Mistakes

Another day. Another prisoner released by mistake (and then found), Another Minister jumping up and down. Another Tory ex-Minister demanding someone is sacked.

But

Human beings make mistakes. Especially human beings working in grossly underfunded services

Forget the fake outrage of Tory Ministers whose party stripped he entire justice system of any semblance of reasonable funding.

Ignore the embarrassed outrage of Labour Ministers who never make a mistake themselves (coughs).

Let’s start with some wisdom from patient safety which has had to grapple with “incidents” for many years. American safety expert Rick Brenner suggested the following algorithm as a guide to understanding where accountability (not blame) might lie:

Step one. Did he person alleged to have caused the “incident” set out to cause the incident?  If not, move to ……..

Step two. Was the judgement of the persons alleged to have caused the “incident” impaired in some way such as though drink, drugs, family illness, domestic violence and so on. If not, move to…….

Step three. Did the person alleged to have caused the “incident” deliberately breach a Safe Operating Procedure? If not, go to………

Step four. Might someone else, with similar skills and training. in the same role, under the same conditions, have also caused a similar “incident”.

If so, then this was probably a system failure not an individual failure.

Mistakes in the release of prisoners are happening “all the time” and are symptomatic of the chaos within the system, the chief inspector of prisons Charlie Taylor has warned. He says prisoners being released early, in error or even late is an “endemic problem” now that needs to be fixed by prison service leaders..

“I think it’s very easy to throw an individual at Chelmsford under the bus for this, but this is a systemic problem and the prison service needs to take some responsibility as well for failing to fix this issue, which has got much, much worse in the last couple of years.”

So what actually happened?

The prison officer at HMP Chelmsford who mistakenly released Hadush Kebatu was apparently suspended. It is unclear if he or she still is. The mistaken release appears to have arisen from "human error", the justice secretary told the Commons.

Really?

The Government rushed out new tougher better rules. Hmmmm

Then Justice minister Alex Davies-Jones summoned prison chiefs for a meeting and a team of digital experts had been tasked with overhauling the “archaic” paper-based system of prisoner records.

So it is systematic problem. The BBC reported that a clerical error by a court had led to his release, as he was listed as receiving a suspended sentence, rather than one in custody.  So, it is not just “mistakes” within prisons but the wider system.

Charlie Taylor continued “Where there are big changes in policy, as we’re seeing very regularly at the moment, that they make sure there’s enough resource going into prison so they can make those changes without dropping the ball, as they spectacularly have in this case.”

Parallels with healthcare?

All this may feel familiar to NHS staff where blame overrides learning as inquiry after inquiry tells us.

In a report for NHS Resolution several years ago we summarised the approach that research signposts as the most effective response to the risk of “incidents”. https://www.scribd.com/document/817836134/NHS-Resolution-Being-Fair-Report We wrote

“This requires us to improve our learning about how day-to-day care is delivered, how it feels to work for frontline staff,  and ways in which they need to adapt and adjust what they do to keep patients safe.

“This means learning how care is delivered, not how we imagine it is delivered, but exactly how it is done on a day-to-day basis. It requires us to improve our learning about what is working well and what doesn’t go as planned or expected.

Underpinning this learning is a culture which is kind, respectful and which enables people to speak out openly, and to share issues, concerns and ideas without judgement.

This, in turn, uses that knowledge to help people redesign the workplace; for example, systems of work, the way equipment is placed and stored, the infrastructure and staffing needed, and processes of how care is delivered.

The mindset should always be to design systems that support the individuals within those systems to work safely. It also, importantly, includes learning about how people behave and what supports safer behaviours and decision making. This includes understanding the significant links between the health and wellbeing of staff and safer practice If safety is both a state where as few things as possible go wrong and a state where as much as possible goes right ,then organisations and leaders need to:

• be mindful of the potential for things not to go as planned; to understand the potential for risk and harm; and to take steps to prevent and minimise the impact

• seek to learn when things don’t go as planned; learn so that things can be changed to the system and change things to help people work safely

• seek to learn from the day-to-day and from when we get it right in order to replicate this and optimise what we know we already do well.

Ask the people who do the work every day and discover how the world looks from their point of view – both staff and patients People should be seen as the solution to harness, not the problem to blame.

Ministers seem to think the answer is to announce that “a team of digital experts” had been tasked with overhauling the “archaic” paper-based system of prisoner records. https://www.standard.co.uk/news/politics/david-lammy-times-radio-government-robert-jenrick-police-b1256785.html

Why on earth do Ministers (and not just those responsible for prisons) think they can crack the problem without addressing culture and resources – both of which were wrecked by the previous Government?

They can’t.