Steve Turner

Time to act. Time to actually learn lessons. Time to change the law to protect patients.

Time to join the dots and prevent further tragedies.
There is an opportunity to link the planned inquiry, which I agree must be a statutory inquiry, to the current government review of the whistleblowing framework: framework: https://www.gov.uk/government/publications/review-of-the-whistleblowing-framework/review-of-the-whistleblowing-framework-terms-of-reference

This important report highlights the #patientsafety minefield that exists in the UK. It is characterised by a fragmented system with both overlaps and gaps, plus very few opportunities for inter-disciplinary / inter-organisational learning.
Featuring:
- A Patient Safety Commissioner whose remit is limited to medicines and medical devices
- A plethora of organisations that 'don't investigate individual concerns' (including Healthwatch and the Patient Safety Commissioner)
- A lack of genuine patient involvement
- A lack of ownership and leadership at the top
#share4safety #health #healthcare #nhs #socialcare

I'm a nurse. I believe in the principle of 'do no harm' So I don't support this initiative in its current form and advise people to take care if they are thinking of talking to the local guardian. They may be able to help, or they may make the situation worse. It depends on their employer.

The introduction of the National Guardian Office and Freedom to Speak Up Guardians in each NHS trust is problematic.

This initiative has an inbuilt conflict of interest, as the Guardians are employed by the trusts themselves. Whistleblowers who have been failed by local Guardians have shared their experiences that included the disclosure of their identity to hospital management and boards, which resulted in retaliation. I also know of Local Guardians who were not supported and themselves the target of retaliation after supporting whistleblowers.

In addition, the National Guardian Office appears to studiously avoid the word ‘#whistleblowing’ in its material and outputs wherever possible. This adds to the stigma around healthcare whistleblowers and is inexcusable.
 

This potential for harm because the Guardians are employed by the trusts is a #patientsafety issue and something that the National Guardian Office should be addressing. Instead, the NG Office seems impossible to engage, with unless you agree 100% with their views and become one of their 'cheerleaders'. 

Patients deserve better.
 

A useful document from the DHSC. It contains vital information for NHS leaders, board members and educators.

One anomaly stands out, however. The report lists one of the 'substantial measures' introduced in the last decade as 'legal protection for whistleblowers'. I'm at a loss to know what these improved legal measures are?

Thanks for sharing this important summary of the current harmful system for healthcare whistleblowers. I agree 100%, that the current system of governance fails whistleblowers. In fact, it fails everyone. It appears to be set up this way be design, rather than inadvertently.

It's indefensible to have a system whereby the patients and relatives must struggle to have someone independently investigate their concerns, and staff who speak out are victimised and silenced. Even Healthwatch, as I understand it, doesn't investigate individual concerns. You couldn't make this up!

Recently I replied to a HSIB survey asking if they investigated 'systematic problems' and the reply was that they don't. So that limits their helpfulness even more. This blog on HSIB and why it has been stripped of maternity investigations, is also interesting & relevant: https://minhalexander.com/2023/04/26/finally-revealed-the-suppressed-susan-newton-report-on-whistleblowing-governance-at-hsib-nhs-england/ 

Thanks for the comments. These are important points.

I agree that U.S. bounty model of “whistleblowing” rewards would be inappropriate for the UK, and the way in which the Office of The Whistleblower provides independent oversight of whistleblowing will be critical. For me, the strengths of this approach are that it crosses all sectors and will include perspectives from other countries. I hope and expect that the core issues relating to whistleblower victimisation in health & social care will surface as a result, so they be dealt with effectively and patients protected.

For me, the core issues include those related to leadership style & behaviour, nepotism & cronyism, governance, patient and public involvement, accountability, long-term planning, information and record sharing.

If you are interested in patient safety, please read the Protection for #Whistleblowing Bill and assess for yourself the impact this will have, don't rely on someone else's summary of the Bill.

'The Public Interest Disclosure Act [PIDA] fails to address the public interest. PIDA turns patient safety concerns into employment issues. It kicks in after the harm has been done, turning a public interest matter into a costly private dispute. Taking the focus off the core issues. Further harming everyone involved in speaking up.
The Office of the Whistleblower will strengthen existing initiatives and bring them together, emphasising prevention and early intervention by the most appropriate route.
Right now, there is an elephant in the room. Where staff can't, or don't blow the whistle or are ignored or silenced, the onus to expose wrongdoing falls on patients and their relatives who then have no protection under #PIDA. Their concerns are often treated as individual cases and core learning, which would make services safer across the board, are delayed or even lost.'
More information here:

Read the Bill here: https://www.appgwhistleblowing.co.uk/

Here's a summary of the benefits of the Protection for Whistleblowing Bill [HL] comparing it to current law.

Time to examine the root causes of why these reports continue to show that lessons have not been learned. Three areas of concern stand out for me:

1. There is no independent official body that looks at systemic failings in #healthcare in the UK. (I understand that the remit of the Health & Safety Investigation Branch [HSIB] specifically excludes this).

2. There is no clear pathway that triggers major reviews of healthcare failings. (More often than not these shocking reports are prompted by #patients and their families).

3. When staff feel unable to blow the whistle, or are ignored and victimised for doing this, relatives take this on, at great personal cost. (Examples of where staff have not raised concerns or have had their concerns dismissed, include the death of Robbie Powell, Elizabeth Dixon, Oliver McGowan, Claire Roberts and ‘Gosport.)

For too long inexcusable failings have been covered up. It's frequently said that it wasn't because nobody knew about it. It was something that everyone knew about.

In the words of the late Professor Aidan Halligan, we need to 'Run toward problems, especially on a bad day'.

A significant role for the new Patient Safety Commissioner, in my view, will be through reference to improving prescribing competency, as set out in the RPS Prescribing Competency Framework.

A framework which is for ALL prescribers.

When speaking the 'truth to power' & reflecting on medicines' safety this framework is key.

Link: https://www.rpharms.com/resources/frameworks/prescribers-competency-framework 

An opportunity to reflect and act on the (UK) Prescribing Competency Framework:

I believe a review of the corporate governance of #health & #socialcare services in England is needed.
This review need not be a long-winded process. There are many studies and reports available, this is the starting point. Plus, the #NHS constitution for England, which rarely gets a mention.
Sadly, I don't think this will happen. The overriding ethos is to avoid confronting problems that could make the 'great and the good' look bad & break down the widespread rampant cronyism which is holding back the development of services and driving staff away.
#Patients suffer as a result.

#leadership #ethics #accountability #whistleblowing #whistleblower #share4safety

'Almost all whistleblowing creates positive change in the organisation which has its wrongdoing reported. Whistleblowers uncover 43% of corruption, compared to only 19% discovered by paid auditors. Whistleblowers lead to the recovery of enough money to give everyone on the planet, health care, many times over.' - WhistleblowersUK 

I find it shocking that the proposed reforms, listed below, are not already in place:

• patient involvement in complaints investigations
• the establishment of independent investigation bodies
• more meaningful data analysis strategies to uncover and address systemic causes behind recurring complaints.

Perhaps people who are involved with complaints handling, and those who have made complaints can share their experiences?

Good or bad experiences - all will contribute to further learning and help deliver real change.

I am so saddened to read yet another report on failings that, if seen and acted on in isolation, will not lead to the systemic changes that are needed. I agree with the conclusion.

The approach to patient safety needs to change. This is the 'modernisation' our health and social care services desperately need.

No more 'lessons will be learned' statements without follow up, and no more 'sorry-not-sorry' apologies, we need radical patient-led change, transparency, and accountability. 

Thank you for posting this.

The actions resulting from Coroners' prevention of future deaths are vital for patient safety. I look through these reports when preparing clinical education sessions, and have included this link in my medicines and prescribing teaching resource page: https://www.judiciary.uk/subject/alcohol-drug-and-medication-related-deaths/ 

Thank you for posting this.

Coroners' prevention of future deaths reports are important, and the actions resulting from them are vital for patient safety. I look through these reports when preparing clinical education sessions, and have included this link in my teaching resources: https://www.judiciary.uk/subject/prevention-of-future-deaths/ 

Unfortunately, I believe there is an inconsistency in when Coroners make these reports. For example, in the case of the death of Oliver McGowan, where no such report was made. This is a case study I use in my medicines and prescribing teaching work.

I've also come across a press reports of a trust putting pressure on a Coroner not to make a prevention of future deaths report. 

I'm interested in people's views on this. Am I right in thinking that there is an inconsistency in how Coroners use their powers to make prevention of future deaths reports? Are there any other reported examples of trust's trying to put pressure on Coroners?

An important message here. Knowing the reason for the use of a medicine (i.e. its 'indication') is vital for patient safety. 

It's not just pharmacists who need to know the indication for a medicine.

In my clinical practice I've seen problems caused by misunderstandings of what a medicine was prescribed for. Including patients who have been prescribed antipsychotic drugs which they did not know the reason for & which could be making their condition worse. Also, I've come across people who were prescribed antidepressants for pain rather than depression (e.g., amitriptyline which is indicated for both things) who believed they were taking an antidepressant and that it 'wasn't working', not knowing that the dose prescribed for pain is lower than that for depression.

Many medicines have several different indications, also some medicines are used 'off label' (i.e. for purposes that they are not licensed for). This can be confusing to both patients and clinicians alike, especially when trying to build up a list of previous medicines and what they were prescribed for.

I've seen prescribing mistakes made as a result.

An insightful piece, written with objectivity and empathy, highlighting the need for a deeper understanding of why people speak up in healthcare and the consequences for us all when patient safety concerns are dismissed.

All healthcare leaders should read this and reflect on how effective current measures are, and what actions are needed.

Excellent poster. Good to see scientific rigour applied to this safety critical topic. 

In my view, this provides and important and stark contrast to the pseudo-science and waffle produced by the National Guardian Office. 

In my blog there is broken link to the Turn Up The Volume! web page. This is no longer updated, (as I am retiring soon) , however some of the materials may be helpful. Here's the link: https://www.carerightnow.co.uk/turn-up-the-volume-resources-2/

A really helpful article picking up on the key points.

In my recent experience of providing remote 'patient led medicines reviews' I'd also add that this isn't just about Doctors, remote consultations (where appropriate) open up many new possibilities for new ways of working by all clinicians. I use them for my developing work as a Care Navigatior . 

I'm pleased to see the  “remote by default” message challenged. This was such a bad thing to say and harks back to the old way of thinking that technology is the answer to healthcare problems, when it's just a tool. A Secretary of State for Health and Social Care should know this.

Finally it's worth remembering that digital consultations aren't something the NHS has just discovered and is now 'educating' patients on. Many patients have been asking for this for years. This tweet sums it up nicely:

Source : https://twitter.com/NusratMedicine/status/1382641585184210944?s=20

A good article. I agree in principle too with 'raising concerns in the right way', however my experience, and that of many others, is that this isn't always possible.

We need more CEOs like David Carter, and we need to expose CEOs who victimise those who raise genuine concerns.

Robert Darren Powell, a much loved member of a close family, was just 10-years old when he died on the 17th April 1990. Every parent’s worst nightmare, the tragic loss of a child, became Will and Diane Powell’s lived reality. Their acutely distressing grief, was exacerbated because they quickly learned that Robbie’s death was preventable. Little did they know back in 1990 that their pursuit for truth, justice and accountability would span across three decades, cost them in-excess of £300,000 in compensation, and unveil medical negligence, cover-ups and bureaucratic failure. '

The shocking story of a cover up in the UK healthcare system. It is THE landmark case on #DutyofCandour .

As a clinician I am appalled, and support Will Powell in his continuing quest for justice.

Because of the cover up vital learning on #patientsafety , particularly around the care of children and communication with parents, has been missed.

https://www.open.ac.uk/researchcentres/herc/blog/robbie-powell-time-truth-justice-and-accountability

https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/english-and-welsh-ombudsman-set-out-the-case-for-a-proper-public-inquiry-into-the-tragic-death-of-robbie-powell-r3560/?tab=comments#comment-334

https://twitter.com/MedicineGovSte/status/1424353716040343557?s=20

https://www.youtube.com/playlist?list=PLPtuApYs79-6ie3tnwTpONsxjzc5ooG4d

This 'fortress mentality' & similar attitudes have been around for a long time. I'm a strong supporter of the NHS and its core principles. At the same time, having worked in the private sector, for a US company & in Australia, I can also see why people raise concerns about the downsides of so-called 'socialised medicine'.

It's the often mentality that's the problem in my opinion, and this can be reinforced by the leadership and the surrounding bureaucracy. 

Here's an example from some years ago, which I think is still relevant:

I was doing a review of waiting list administration in an NHS  hospital that had a military wing. The civilian consultants had very long waiting lists, the militarily consultants did not. I assumed that was because they had fewer referrals to manage. When I looked into it this, I found it was not the case. So I asked one of the military consultants what they did to successfully manage their waiting list. He said 'it's simple, I look through the list myself every week and if I have a backlog or urgent referrals to be seen I add a clinic and do what's needed'.

Great to see this promoted. I will be using this poster in my Clinical Education work & my clinical practice .

Thank you David Havard, this is really helpful.