Summary
This case story is illustrative based on a range of examples of real events. NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. As you read about this incident, please ask yourself:
- Could this happen in my organisation?
- Who could I share this with?
- What can we learn from this?
Content
Key points:
- To highlight the influence of workplace culture on clinical decision-making and its potential impact on patient safety.
- To demonstrate the roles and responsibilities of senior leaders.
- To emphasise the need for clear and structured communication within the multidisciplinary team (MDT).
- To underline the importance of self-awareness and recognition of personal and professional limitations to reduce the risk of harm.
- To understand the role of clear, well-defined escalation pathways in supporting timely senior involvement and safe clinical care.
- To highlight importance of undertaking a holistic maternal assessment.
NHS Resolution case study: Workplace culture and escalation (14 January 2026)
https://resolution.nhs.uk/wp-content/uploads/2026/01/Workplace-Culture-and-Escalation.pdf
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