Steve Turner

Something happened this week which reminded me how important a public inquiry into the circumstances and aftermath following the death of Robbie Powell is for us all, and for patient safety in general.

I watched the ITV docudrama 'The Pembrokeshire Murders'

In this programme it was twice mentioned that Dyfed Powys Police had previously been found to be institutionally incompetent. In my opinion, the script implied (unintentionally) that it was the media who found the Dyfed Powys Police institutionally incompetent.  In fact it was an  inquiry into the handling of the Robbie Powell case by Avon and Somerset Police that made the finding of institutional incompetence. I was saddened to see this apparent misrepresentation.

The Robbie Powell case is the landmark case on patent safety that too few people know about.

Important patient safety learning was lost in the cover up after Robbie's Death. I agree with the English & Welsh Health Ombudsmen and support the call for a public inquiry.

#robbieslaw 

It's great to see people like Raymond recognised. There are many like Raymond helping keep patients & residents safe in all health systems across the world. 👍🙏

#OneTeam 🌏 

It will be important to see examples of this in action. 

• Staff praised for speaking out
• Changes made as a result
• People who victimise those who speak out for patients held to account
• NHS returners who spoke out in the past welcomed back

Otherwise it's just words...

Click on the attachment (above) to download the interactive pdf, which has clickable links. 😀

A great initiative, simple and effective which in will share with my prescribing colleagues, locally and nationally.

Thank you.

Great post, picking out the key issues.

I wonder what people would want in the person specification and job description for a Patient Safety Commissioner

Will there be a public consultation on this I wonder?

This could really help in engaging everyone and bringing in all perspectives.

Some visual reminders of what matters most:

Really useful, thank you.

This structured model of working needs to be spread to all  areas.

Here's a 2 minute video on the history and current status of Duty Of Candour in UK Healthcare, which I use in my teaching work.

Comments welcome:

#dutyofcandour

#robbieslaw

#TeamNHS

#TeamPatient

Great vlog on consent, illustrated by real examples & current gaps. Showing the international commonalities & highlighting the problem of variation across hospitals.

Times have changed. I remember in the 1980s when I trained as a nurse in large teaching hospital there were some consultants who did not tell patients their diagnosis if they had cancer. This, I'm sad to say, was accepted as 'their way of working'.

• Would this be acceptable today?
• Are we less paternalistic or has paternalism ended?
• Who decides how much information to give to patients?

Here is Cornwall Council's Response to the Safeguarding Report:

https://www.cornwall.gov.uk/council-and-democracy/council-news-room/media-releases/news-from-2020/news-from-november-2020/statement-in-response-to-the-safeguarding-adults-review-on-the-former-morleigh-group/

Interesting, and there are some useful contributions in the A to Z.

My concern over the work of the National Guardian Office remains the same.

I believe it's potentially a good idea to have local Freedom to Speak Up Guardians, as long as they are part of a variety of ways to encourage openness, transparency and promote patient safety. Because #FTSU Guardians report to the Trusts this leads to a conflict interest and potential for the role to be misused. I have seen this in action.

I have concerns about the National Guardian Office and the way it operates. Early on I tried to engage with the people involved and was ignored. 

I believe three things are missing and this omission makes the Freedom to Speak Up process as it stands  potentially dangerous:

1.The lack of open discussion about whistleblowing, which is what happens when speaking up fails. We have to use the word 'whistleblowing' when it's appropriate not euphemisms.

2. The failure to involve patients & the public, as equals, at the heart of the Speak Up activities and process. Inexcusable.

3. The emphasis on good news stories and failure to speak openly about deep seated problems. I think an organisational psychologist may have lot to say on this.

I'm no expert here, just someone who has seen the damage that can done to patient care if everyone's views are not valued and listened to. Here's my short blog on whistleblowing:

Quote

Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve.

https://www.smore.com/v7svc

I'm interested to find out when the results of the evaluation study of the scheme, carried out by Liverpool John Moore's University, will be published?

I've asked NHSI. Had no reply so far.

If anyone has any update on this is be interested.

I believe this scheme can help some people. It's a step in the right direction in my view.

I have reservations about the coaching aspect though. Many whistleblowers are well respected clinicians and able to sucessfully manage their own careers in a non-toxic environment. They were simply trying to do their job properly when they became 'whistleblowers' and, what was a patient safety issue, suddenly became an employment issue. It's the isolation and blacklisting that they can suffer that's the problem. I'm not sure how this can be overcome.

Steve