• For the future, the former Health and Social Care Secretary Jeremy Hunt had already instituted a review by Professor Sir Norman Williams which has recommended vital changes to the system for regulating healthcare professionals.

    The recommendations are:-

    • Strip the GMC of its right to appeal MPTs’ decisions on a doctor’s fitness to practice.  (However, the Professional Standards Authority will retain its right of appeal.)
    • Reflective notes by doctors and nurses will not be able to be used by regulators, GMC/NMC in fitness to practice cases (no mention of protecting those notes from use by the police, Courts and lawyers)
    • There is to be a clearer understanding of where the threshold lies for bringing gross negligent manslaughter cases.  The emphasis would be on very poor performance rather than honest mistakes (there is no detail of how this can be achieved)
    • The role of medical examiners is to be extended with experienced clinicians examining all deaths not referred to a Coroner( In April it was reported Medical Examiners will no longer be independent but based in acute hospitals and will not cover community mental health or primary care deaths.)

    These proposed changes reflect the deep concern about the effect on clinicians’ ability to learn from mistakes following recent Court rulings and it is hoped to support the promise that the NHS will support them to learn rather than seek to blame.

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