The West Suffolk Independent Review published yesterday indicates that safety concerns were ignored and the hunt for an anonymous whistleblower was "flawed" and "ill-judged".

https://www.england.nhs.uk/east-of-england/wp-content/uploads/sites/47/2021/12/west-suffolk-review-081221.pdf

This Review was commissioned following widely reported events arising from an anonymous letter that was sent in October 2018 to the relative of a patient who had died at the West Suffolk NHS Foundation Trust (the Trust). 

The 225 page report contains important learning and highlights the need for an open culture in the NHS and an end to a culture of avoidance, denial and victimisation of those who speak out for patient safety.

This report highlights the need for cultural change and raises several key points:

• The importance of real and empowered clinical leadership.
• The importance of NHS leaders being self-questioning, open to criticism and to listen to staff.
• The importance of leaders understand the value of dissent and disagreement. 
• Where concerns and criticisms appear or do turn out to be misguided, the need for NHS leaders to avoid jumping to any conclusion that the individual raising them is simply making trouble.

Edited 10 December, 20214 yr by Steve Turner

Hi Steve, I’ve just finished reading the Exec Summary and have been tweeting the key learnings identified within it. Shocking. I’ll add 
 

 

Key learning 1: ‘Staff who do Speak Up may not always be right, but that should not matter. Important patient safety concerns would be less likely to be raised if staff feared being wrong and facing disciplinary action (or simply being castigatedasatroublemaker)’

Key Learning 2: ‘The approach to FTSU by NHS organisations continues to develop. Those responsible for its operation … may need further support in some important areas. eg understanding the importance of separating FTSU from performance and disciplinary matters’

Key Learning 3: ‘ It is also important that all NHS organisations are aware of and have implemented the May 2018 Guidance for NHS Boards. This requires them, where concerns raised are wholly or in part about members of the Board, to inform the Trust’s FTSU Guardian in confidence’

Key Learning 4: ‘ It is important that the culture of the organisation & the leadership environment & approach allows for individuals to feel comfortable with the various checks and balances operating effectively – such as challenge from their Boards’

Key learning 5:  ‘If clinical leadership is to have any real meaning, senior executives need to allow clinical leaders to be respected participants in the decision- making and management process.’

Key Learning 6: ‘. However difficult, leaders need the ability to get over whatever personal discomfort they may feel and appreciate the potential value of the advice being offered. If it turns out to be correct, then the matter in question can be addressed and everyone will be better off as a result. NHS leaders need to value those who raise concerns. They also need to be seen to be even-handed in their approach.’ 

Key Learning 7:  ‘Where concerns and criticisms appear or do turn out to be misguided, NHS leaders must avoid jumping to any conclusion that the individual raising them is simply making trouble.’

Key Learning 8: ‘There can be particular difficulties for Medical Directors who are in the sometimes awkward position of being part of the overall corporate Trust management, but at the same time seen by their colleagues as one of the consultant medical body’

Key Learning 9: ‘an apparent reluctance to raise a Datix.. In the best NHS organisations, there should be a high level of incident reporting combined with low levels of harm to patients and risks to patient safety. Datix reports help to identify and address patient safety risks.’

KL 10: ‘The need for an open culture in which staff understand the importance of incident reporting, confident that all will be dealt with fairly, is one that applies to all NHS organisations. A culture where staff feel the need to keep their heads down has to be addressed.’

Key Learning 11: ‘ Had the management focus been upon the question of Why rather than Who, it would have helped to foster a culture where those who have what they believe to be a legitimate patient safety concern feel free to express it through an appropriate channel.’

Key Learning 12: ‘In a service in which clinicians are routinely told if it is not written down it did not happen it is simply not acceptable for management colleagues to regard themselves as exempt from such strictures.’