First Do No Harm: key recommendations

 In this article, she continues the discussion around the Cumberlege Review, First Do No Harm, highlighting the key recommendations and calling for a long overdue overhaul of safety reporting systems.

The Cumberlege Review, First Do No Harm identified three particular sets of historical circumstances which caused disasters, pain and years of suffering for patients. These three areas were reported in some detail last month.1 This article will now focus on the overarching themes of the report, which are an equivocal set of recommendations, to try to unscramble the complexities of patient safety reporting and monitoring for patients and healthcare professionals. The Report2 investigated what had happened in the case of three seemingly avoidable disparate situations – the history of which go back to the 1950s:

The Cumberlege team were horrified by the stories told by women (and most of the victims were women) of constantly being fobbed off by the healthcare system, who did not want to listen to their stories of pain and suffering. The review looks at not just what happened in the three individual cases but how the healthcare system reacted as a whole, and how that response can be made more robust, speedy and appropriate.3 The Report comments that they found the  healthcare system to be “disjointed, siloed, unresponsive and defensive” to the patients affected by these issues. The team identified that the systemic problems run very deep. Baroness Cumberlege also noted that: “