The response considers each of the 96 recommendations made in the report, and is designed to help the Department of Health put the recommendations into practice and improve patient safety.
Dr Ray Nethercott of the Royal College of Paediatrics and Child Health, said:
“Our greatest sympathy goes to the bereaved families who have endured incredible suffering. We owe it to them to consider Justice O’Hara’s report and recommendations in detail and work with the relevant bodies to minimise the risk of such a tragedy happening again.
“I work with colleagues who wake up every morning wanting to do the very best for the children they treat. Nobody wants these tragedies to happen. But when they do, it’s only right that we admit to mistakes and look closely at what went wrong, why, and who is accountable. I recognise now more than ever that healthcare delivery is extremely complex, it is incumbent on us all to seek ways to make it easier to understand and to much more clearly describe who has accountability when mistakes are made.”
The response supports the vast majority of O’Hara’s recommendations and points to resources that have been developed to enhance patient safety, improve transparency and tighten up reporting in the years since the deaths occurred. The response says:
- Honesty and transparency within the health system is vital.
- We propose the establishment of a new Board which would hold Trusts and civil servants to account for systemic failings.
- Children, young people and parents/carers should be invited to co-design services and shape models of care.
- Sufficient time must be allocated for training and learning for healthcare professionals.
- There should be increased use of E-health to enhance patient safety.
- There is a need to ensure the continued local provision of the surgery of childhood in line with the Federation of Surgical Speciality Associations guidance (2018) on the local delivery of surgery in childhood.
- There are nuanced differences between ‘responsible’ and ‘accountable’ – and these need to be properly considered.
Dr Nethercott said:
“As Justice O’Hara says, there have been many positive changes to practice over the last 20 years, but there is still more we can do. The lessons learned and the improvements that these tragic cases have prompted will have a far reaching impact.”
The group has made an open offer to the Department of Health to work with them to implement the recommendations of the Inquiry report – stressing that patient representation is vital.