Title: Avoidable deaths in Britain's National Health Service - a systems-thinking informed analysis using data garnered from government agencies, representative bodies, private canvassing and public inquiries

Authors: Simon Ashley Bennett

Addresses: Civil Safety and Security Unit, University of Leicester, LE1-7QA, UK

Abstract: Medical error kills significant numbers of patients around the world. There are circa 150 avoidable patient deaths each month in the UK. This paper uses systems-thinking to reveal the causes of medical error and avoidable death in the National Health Service (NHS). It is concluded that such problems emerge from a web of factors that include defensiveness, careerism, bullying, target-chasing, under-funding, cost-cutting, overstretch and inefficient legacy capital. Efforts to transform the NHS into a learning organisation, in which errors and malpractice are reported, have been thwarted by intimidation, undermining and bullying. The culture of the NHS may reasonably be described as pathogenic. If it is to become a learning organisation in which risk is managed proactively, the NHS must transform its organisational culture, much as aviation has done. The aviation industry's safety journey teaches that detoxification takes decades of sustained effort and that change is a top-down process.

Keywords: National Health Service; NHS; avoidable deaths; systems-thinking; pathogenic culture; aviation.

DOI: 10.1504/IJHTM.2020.116787

International Journal of Healthcare Technology and Management, 2020 Vol.18 No.1/2, pp.95 - 110

Received: 25 Mar 2020
Accepted: 07 Sep 2020
Published online: 02 Aug 2021 *

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