Staff ‘rebuked’ for raising safety concerns despite patient deaths

Staff were ‘rebuked’ for raising safety concerns at a trust where the incorrect use of chemotherapy has been linked to patient deaths, HSJ has discovered.

In 2020, East and North Hertfordshire Trust identified higher-than-expected mortality rates among its ovarian cancer patients. An external review, obtained by HSJ, found chemotherapy may have contributed to the deaths of four patients in 2019 and 2020 whose comorbidities had not been adequately considered.

The serious incident investigation was undertaken by a team from specialist cancer trust The Christie. This identified issues including a “reluctance of staff to escalate safety concerns” and “poor consideration” of patient fitness levels in pre-treatment assessments.

The review said: “Many clinical decisions were driven from a senior individual member of the team, rather than a team-based decision-making model.”

“Some members of the MDT [multidisciplinary team] did not feel empowered to escalate issues around SACT [systemic anticancer therapy] assessments, with some staff stating that they felt that they were rebuked for escalating out-of-range blood test results.”

The review said decisions over treatment were not driven by protocol or multidisciplinary team input as part of general practice.

It added: “In the absence of a psychologically safe working environment, over time the above described behaviours became embedded in practice and were therefore less likely to be challenged.”

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Source: HSJ, 27 September 2024