system errorBureaucratic systems are like the worst kind of artificial intelligence.

They are programmed to protect themselves and have no empathy or humanity as a counter balance.  Why would they – they are simply self-serving machines.

You could take almost any organisation, but for argument let us take the health service.  The system is dysfunctional.  Good in many respects and sometimes excellent, it is incapable of critical analysis, so any error or mismanagement is just perpetuated by the system.

There could be a number of triggers for change, but the system has them all covered.

Internal:  When members of staff speak out about unsafe practices they become whistle blowers and the system knows just how to contain this attack.  First discredit the individual in order to discredit the message.  Conduct a witch hunt to unearth false evidence and drive the person to resignation through stress related illness.  Enemy of the system eliminated.  For detail you can look at the accounts of David Drew, NHS consultant at Walsall Manor Hospital for over 19 years.

Or Gary Walker CEO of United Lincolnshire Hospitals NHS Trust  Or Dr. Raj Mattu or Dr. Kim Holt the whistle blower from the Baby P case.

And here in the case of David Sellu, we see that evidence was hidden in order to scapegoat a notable surgeon for the death of a patient caused by system failure.

But of course the system never fails and is never at fault for the system has in-built mechanisms to shift the blame and cover the truth.

External:  When a service user makes a complaint then the self-protection control system moves in to suffocate any emerging threat.   This comment to a Telegraph article published on 27th January 2013 explains how.

“The problem is the burden of proof
Comment on Telegraph article 27 January 2013 by “romeolima”
Today 07:52 AM
@nautonnier. This is a long comment from me but I hope people will read it.  I absolutely agree with your sentiment but the problem is the burden of proof. Before the police can investigate, complainants often have to go through a tortuous multi-layered system that allows an internal investigation into an incident by the hospital itself without the complainant or their legal representatives being allowed to question the witnesses. Staff do not have to swear or affirm and their version of events frequently reads like a novel. Notes go ‘missing’ (this is a common event) and staff are ‘helped’ to make statements by their legal department although this is meant to be a process without lawyers on both sides. Hospital legal departments often regard this as a ‘dry run’ of a possible court case and can prepare their defence whilst obstructing the availability of medical data to the police, should they be involved, the complainants and their legal team. There is no organisation of any credibility that can carry out an investigation into an individual complaint even if this is about a patient death. The Ombudsman has proved ineffective and the system is such that the hospital already has prior knowledge of the details of the complaint as the complainant must have already gone through the hospital system prior to reaching the Ombudsman. It’s a terrible catch 22.
In no other area is one party allowed to have complete control over evidence that might prove the complainants allegation while the other party has to beg for access to information. Almost all the Incident Reporting Protocols that I have read say that in the event of any incident that all notes, statements etc should be immediately captured electronically but this wealth of material, which cannot be altered, is almost never made available to the complainant. In all cases of death the Coroners Officer would appear to be the proper person to immediately seize and hold originals of all patient records whether paper or electronic while a decision to proceed to an Inquest or not is being made. In my own family’s case, the notes were held at the hospital’s litigation department for nearly six weeks before the Coroner requested a copy. This is highly unsafe as an evidential chain and we have never received all the material requested and are fairly certain that the Police would be told that material was missing and therefore the Crown Prosecution Service could not proceed.”

Regulation:  Regulation of NHS is so complex that in a recent PASC inquiry no-one in authority was able to answer the simple question ‘Who is ultimately responsible?’   The Health Service Ombudsman is the only organisation which will investigate individual complaints, but this body will not make judgement on legal breaches due to its ‘lay person’ status, so don’t expect decisions based on the NHS Constitution; irrelevant.  When policy or procedures are breached these are just guidelines.

 The Ombudsman is the system’s greatest ally, catching all the leakage from the

phase one close down.  

Government:  Those in government feign surprise when scandals hit the headlines.  They use complex processes like public inquiries to kick the can down the road and any promise of reform is mere lip-service until the heat dies down.  Government is part of the system, protected by the system and the greatest beneficiary of the system.  Turkeys just don’t vote for Christmas.

Media:  Just not interested.  Our free press are tightly controlled and the news you hear is carefully selected by the system, for the benefit of the system.

So there we have it.  System rules OK and don’t think for one moment anything you do will ever change that.