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Moral Injury - when families are let down under the pretence of due process and the greater good

This week saw the publication of an article in the Health Service Journal by social scientist and patient safety activist Josephine Ocloo: 'Bereaved families have been used as pawns in a political game.' Josephine describes the painful journey of families being invited to become part of the Learning From Death Programme and reliving painful experiences around the death of a loved one as part of the collation of evidence to realising that actions that were promised have been repeatedly delayed with little perspective of progress. While COVID-19 is being blamed it is clear that the problems started well before the pandemic.

Neil Greenberg defines moral injury ' as the psychological distress that results from actions, or the lack of them, which violate someone’s moral or ethical code'. Moral injury was initially described in military personnel after ethical catastrophes in Vietnam and other theatres of war but the concept can be easily expanded to healthcare. With the pressures of COVID-19 sub-optimal care is expected - but the upset that this can cause to bedside clinicians might be significant. Importantly moral injury is distinct from burn-out: it is not just 'working too much' but witnessing during work something that seems fundamentally out of order and morally wrong.

The principle of moral injury might be equally applied to bereaved relatives and friends of patients who have come to harm while under the care of the health service. Moral injury is not a mental illness - but it can exacerbate other conditions and has many commonalities with Post-Traumatic-Stress-Disorder. The pseudo-engagement with families, rightly decried by Ocloo as tokenism adds further injury to deep grief.

Importantly the paper by Ocloo in the Health Service Journal comes within days of a report from the Cambridge based THIS Institute to look at the impact of policy interventions in the early 2000s to improve openness of NHS institutions. Data from surveys and interviews leads Graham Martin and co-workers to conclude 'that for NHS staff, and for people in acute hospitals, experiences of openness may have improved noticeably since the publication of the public inquiry [into Mid-Staffs]. For users of community mental health services, however, our analysis suggests that experiences may in some cases have become worse.' At best a lukewarm endorsement of the policy impact and at worst a confirmation that too little has been achieved over the last 20 years.

What is needed to achieve real change? Too many attempts have been fruitless, frustrating and without measurable changes in the outcomes. If this is 'corporate protectionism' as Ocloo states then it might need more profound changes in the way that the corporations are governed and their power is handled by those leading them. In the meantime patients and their relatives are left waiting.

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