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Back to Our Purpose: The Reboot of Safety Partnering with Patients to Improve Diagnostic Safety Incorporating CPPS™ Certification into Academic Curriculum

"We want to be more supportive, compassionate and engaging to patients, their families and staff – and we’re going to improve how we learn from such incidents. This change is in line with NHS England’s Patient Safety Incident Response Framework (PSIRF), the new national policy. The framework supports a focus on understanding how and why incidents happen, rather than apportioning blame, to improve learning and make care safer. We want the public to help shape these changes and design our new approach to patient safety. If you would like to share any experience of having been involved in an investigation at Oxford Health in the past, or want to share your ideas for how things need to change, we would really like to hear from you. You can give feedback anonymously by completing this survey. The information will be used to inform how we improve. Also, if want to share your experience in more detail, please email patient.safety@oxfordhealth.nhs.uk – we can speak to you one-to-one or in group sessions, face-to-face to remotely."

Recommendations Keep the focus on patients: Co-design digital solutions with patients. Run electronic medicines product information (ePI) pilots to validate solutions within a variety of real-life settings and platforms, for example, hospital, community, NHS website and app. Work with patients, pharmacists and HCPs to identify digital ePI use cases, including use cases for HCP-facing medicines information and prompts for interacting with patients. Specifically focus on co-designing solutions for patients who have difficulty accessing information or who have particular needs, such as patients with cognitive or sensory differences, health literacy or digital literacy needs. Co-develop a digital-first approach to provide ePI, ensuring that no patient is left behind. Provide appropriate training for HCPs to help them identify health and digital literacy needs and proactively ensure alternative access where ‘digital exclusion’ is identified. Optimising the impact of technology by: Demonstrating trustworthiness through development of good governance, transparency, privacy and security. Focusing on defining the problem, gathering evidence, and conducting small tests of change. Explore working with NHS England to implement structured ePI and develop standards and funding for a sustainable digital model. Over time, making ePI an integral part of the digital health landscape so that technology providers can build innovative solutions which address the needs identified in this report – establishing the UK as a global leader in this arena. Supporting patients to make best use of ePI as it becomes available. With a multi stakeholder roadmap approach, evolving towards personalised medicines product information, connecting with the electronic health record. Ensure strong connections with regulation & policy setters: Review legislation and regulation to identify potential adaptation in support of patient and carbon-friendly digital first approaches. Strengthen the real-world evidence base to understand how medicines information impacts on patient activation, adherence and outcomes. Obtain government support at the highest level to implement these recommendations.

The National Safety Standards for Invasive Procedures 2 (NatSIPPs 2) are intended to share the learning and best practice to support multidisciplinary teams and organisations to deliver safer care. They consist to two inter-related sets of standards: Organisational standards – clear expectations of what Trusts and external bodies should do to support teams to deliver safe invasive care. Sequential standards – the procedural steps that should be taken where appropriate by individuals and teams, for every patient undergoing an invasive procedure. The flow chart below combines the NatSIPPs 2 sequential standards with the WHO Surgical Safety Checklist to provide a simple visual reminder tool for health and care staff. Its author is Nigel Roberts, Head Theatre Practitioner (Head of Nursing) at Birmingham Women’s and Children’s NHS Foundation Trust, and the flow chart was produced with support from Patient Safety Learning and Dr Annie Hunningher. Are you a healthcare professional interested in learning more about NatSIPPs? On the hub we host the National NatSIPPs Network, a voluntary group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. You can join by signing up to the hub today. When putting in your details, please tick ‘National NatSIPPs Network’ in the ‘Join a private group’ section’. If you are already a member of the hub, please email hello@patientsafetylearning.org.

The review were assured that services at the Trust remain safe and patients and service users should continue to access care as needed with confidence. However, the review found a number of areas of concern, particularly with regards to governance and leadership, culture and staff welfare and has made a series of recommendations for further action. The review was commissioned following concerns raised in December 2022 relating to patient safety, leadership, culture and governance. As part of this response, NHS Birmingham and Solihull (ICB) announced three independent reviews focusing on: Patient safety and governance (Bewick Review) - commissioned by the ICB, overseen by experienced senior independent clinician, Professor Mike Bewick, former NHS England Deputy Medical Director. Well-Led review of leadership and governance – in conjunction with NHS England, using established methodology. Culture - commissioned externally by UHB’s Interim Chair, incorporating findings from above. In order to bring the conclusions and recommendations of these two pieces of work together and provide additional independent assurance, Professor Mike Bewick has been commissioned to support both remaining reviews and also return at a later date to update on progress on implementing the recommendations following this report. In the patient safety review, the independent review team set out two concerns and four groups of recommendations. As part of this, they also make clear that their ‘overall view is that the Trust is a safe place to receive care’. The review team have highlighted the need for better understanding of raised Hospital Standard Mortality Rates, concerns regarding levels of staffing, particularly nursing at Good Hope Hospital. The review also finds that ‘any continuance of a culture that is corrosively affecting morale and in particular threatens long term staff recruitment and retention will put at risk the care of patients’. This was supported by feedback from the Trust’s Medical Staff Committee. The review team make 17 recommendations (available in the full report) across clinical safety, governance and leadership, staff welfare and culture, including: Haemato-oncology: A specific review of mortality should be conducted by an external specialist in this field with support from a governance lead. The terms of reference should include: An independent retrospective review of all the deaths first analysed by Dr Nikolousis to establish any lessons learned Consideration as to whether there an outstanding DoC responsibility relating to this patient cohort All deaths in the year 2021/22 An assessment of how integrated the department is following the merger in 2018 with a focus on how leadership and accountability of the service currently functions. That prospective appointments of senior medical, nursing, and managerial leadership are reviewed with a focus on developing core skills, including those required for leadership, collaborative working methods, professional interaction, and disciplinary processes. In light of the tragic death by suicide of Dr Kumar - Together with HEE, a review of the processes to support doctors in training who are concerned about their mental health, ability to speak up freely about concerns with colleagues and a clear message that they will be listened to. That the concerns of senior clinicians, expressed by the Medical Staff Committee in January 2023, are addressed specifically as part of the Phase 2 cultural review. That the Trust commissions a partner to deliver awareness training on how to identify issues of bullying, coercion, intimidation and misogyny.