17 January 2023: Closing Statement, Andrew Bragg

The first of the core participants who is not involved with a recognised legal representative was next to give his closing statement. Andrew Bragg gave a brief overview of how he came to be infected through contaminated blood. He was involved in a serious road traffic accident in Norway. Back in the UK he continued to be treated by the NHS. The surgical removal of a pin meant he needed blood transfusions. Years later he became sufficiently unwell to require medical attention. Eventually, he was diagnosed with Hep C, with a damaged liver and secondary health issues. Initially, he was refused anti-viral treatment and was made to feel not welcome at hospital due to his HCV status. A trial opportunity allowed access to the Interferon/Ribavirin protocol, and this achieved a sustained viral response. As a chemical engineer, a scientist, and an auditor he was able to apply his skills as they relate to the Inquiry. From this experience he has written a brief final submission with three recommendations.

 

He has observed the NHS under these circumstances. He noted a lack of SOPs (standard operational procedures), such as simple checklists. There have been incidents of seeing gaps in communication between individuals which he picked up on. The specialists are sometimes coming together, but they are not working as teams. It would also appear that the NHS does not have a way of learning from mistakes. It is not a “learning organisation” in his opinion. Mr Bragg is appalled by the lack of openness and the suppression of whistleblowing. It seems like the NHS can bully and intimidate anyone who wishes to raise concerns. This is a matter of leadership failure. Organisations need to take responsibility. It needs to “own” its weaknesses as a starting point for change. There are many examples of the NHS covering up what they got wrong by denying people access to key information.

 

The recommendations are generic, but they are certainly applicable to what happened in relation to infected blood. Recommendation One is to create a statutory responsibility for all NHS employees to report serious injury or death during treatment when that injury or death may have been preventable. 10% of patients are harmed while under the care of the NHS. 4% of deaths in the NHS are avoidable. This seems to be just accepted as how it is. There are already statutory instruments which apply in industry, but also in healthcare settings. He particularly mentioned RIDDOR. It would not just relate to staff, but patients could also make reports. In Mr Bragg’s working world this approach had extended to reporting “near miss” incidents.

 

Recommendation Two is to establish a body to receive reports of incidents, investigate them and monitor the implementation of needed changes. There is a new body, the Healthcare Safety Investigation Branch, but this is likely to operate at a higher, more strategic level. The new body must be locally facing.

 

Recommendation Three is to establish a system of regularly monitoring all individuals who have been diagnosed with HCV, to implement best practice and achieve early identification of potential complications. (Presumably, this applies to those who have achieved a sustained viral response since most will have been through anti-viral treatment.)