Patient-Safety-Learning

The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using a standardised, system focused methodology, into maternity events, including 237 maternal deaths. Pulmonary embolism (PE) remains one of the leading causes of direct maternal deaths in the UK, resulting in 1.5 deaths per 100,000 maternities from 2019-2020. This webinar will explore the findings from MNSI's investigation into maternal deaths following pulmonary embolism. Speakers: Dr Charlotte Frise Dr Louise Page Stephanie Smith Register for the webinar

The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using a standardised, system focused methodology, into maternity events, including 237 maternal deaths. This webinar will explore national patterns and safety recommendations from deaths in England in the first trimester of pregnancy. Speakers: Dr Charlotte Frise Dr Louise Page Dr vidya Sundar Register for the webinar

The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. This webinar will explore the findings from MNSI's investigations into first trimester deaths in England from venous thromboembolism associated with hyperemesis. Speakers: Dr Charlotte Frise Dr Louise Page Chandrima Biswas Kirsty MacLennan Register for the webinar

The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. This webinar will explore a thematic analysis of safety investigations into Sudden Unexplained Death in Epilepsy (SUDEP). Speakers: Dr Charlotte Frise Dr Louise Page Joanna Girling Emily Barrow Register for the webinar

The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. This webinar will explore learnings following maternal deaths secondary to HLH and consider learning points for future clinicians and investigators. Speakers: Dr Charlotte Frise Dr Bethan Goulden Dr Louise Page Clare Luby Register for the webinar

Patient Safety Learning and retired urology consultant Peter Duffy have launched a new interview series, ‘Speaking up for patient safety’. Peter is an NHS whistleblower and Chair of the Healthcare Working Group at WhistleblowersUK. The series looks at how people who speak up in healthcare are treated by organisations, leaders and regulators, and how this acts as a barrier to staff raising patient safety concerns. In each interview, Peter and Patient Safety Learning’s Chief Executive Helen Hughes talk to someone who has spoken up about patient safety in healthcare, or who works to help staff raise concerns. In this blog, Peter and Helen explain the concepts of speaking up and whistleblowing and outline why creating a safe environment for speaking up is vital for patient safety. They share why they decided to produce the interview series and outline the impact they hope giving people who have spoken up a platform to share their experiences and insights will have. You can follow the interview series on the hub and by subscribing to the series YouTube podcast. "After I lost my own career as a direct consequence of whistleblowing, I found myself unemployed and prematurely claiming my NHS pension many years before I had ever anticipated stepping away from full-time work. As well as the personal cost, it meant that the unsafe care I reported went unchanged and opportunities to make care safer for patients were lost. It left me determined to prevent the same kind of catastrophic consequences and cover-ups happening to the next generation of patients and healthcare professionals, a cause that Patient Safety Learning is also committed to." Peter Duffy "I hear stories like Peter’s so often, it’s a pattern that is repeated across healthcare all the time. We need to expose the unfairness of doctors, nurses and other healthcare professionals being required to raise concerns, and then being vilified when they do so. The horrendous impact on their lives and careers when the system closes in on them is something we desperately need to address. Staff need to feel safe to share their genuine concerns and insights—and these must be listened to and acted upon to improve patient and staff safety. It’s vital we explore how we can make changes to legislation, leadership and management and culture so that we can stop this awful cycle repeating itself." Helen Hughes We decided to collaborate on a series of interviews that would draw together the voices of some of the people who have spoken up for safety and found themselves treated poorly by the organisations and systems they were trying to make safer. Speaking up, whistleblowing and patient safety People working in healthcare will sometimes see things at work that cause them concern. They might notice a situation or action that is causing or could cause harm to a patient, staff member or the public. For example, they might see a patient safety incident that isn’t dealt with properly or a risk that is not being taken seriously. They may witness dishonest behaviour, bullying, harassment or discrimination. When someone reports their concerns with the aim of making things better or stopping something from going wrong, they are ‘speaking up’. In some cases—but not all—when someone speaks up, it is also defined as ‘whistleblowing’. Although the two terms are often used interchangeably, whistleblowing refers to the sharing of ‘protected disclosures’ which have a specific legal definition, as outlined in the Public Interest Disclosure Act 1998 (PIDA).[1] Whistleblowing always involves a concern that is in the public interest to raise and might relate to a criminal offence, health and safety risks, failures to carry out legal obligations, a miscarriage of justice, or an attempt to conceal and cover up any of these things. PIDA was designed to offer some protection from retaliatory action for whistleblowers. However, many whistleblowers report that the reality of their experience was that there was little to protect them from retaliatory grievances and disciplinary action by their organisation’s management. The repercussions of speaking up act as a significant barrier to people sharing concerns about patient safety. Healthcare staff often fear that they will lose their career and that it will affect their work and personal lives if they step out and speak up. Many people decide it just isn’t worth the risk. But speaking up and whistleblowing are vital to improving patient and staff safety and standards of care. By raising concerns, staff offer their organisations opportunities to learn from things that could go or are going wrong, and mitigate risks. In addition, all registered healthcare professionals have a professional duty of care to raise concerns. Many people we interview in this series make the same comment; that in speaking up, they were just doing their job. For these reasons, it is vital to create a culture where staff feel safe and supported to fulfil their obligations to raise concerns without fear that it will affect their career prospects, working life and personal wellbeing. Creating this kind of environment contributes to what is sometimes referred to as ‘psychological safety’. While there are currently measures in place to encourage and support staff to speak up, they clearly aren’t working effectively—despite so many regulators, potential targets and available sanctions in the NHS, individual and organisational scandals in healthcare just keep happening. Candour, ethical behaviour and honesty are key things we need in place to maximise patient safety in the healthcare system. The importance of first-hand experience and insights Peter’s experience of speaking up is one of many that clearly demonstrates that the current system of regulation and safeguarding is not effective. We decided to start this interview series because we believe it’s time to identify and deal with the cultural and organisational issues that make it difficult for people to raise concerns about patient safety issues. The national NHS Staff Survey results tell us that too many healthcare staff are nervous to speak up when they see unsafe care or inappropriate behaviour. In spite of slight progress in some areas, 37% of all staff who responded still feel unsafe to speak up about concerns—that’s about 260,000 people. Almost 50% said they were not confident that their organisation would address concerns raised.[2] It’s so important that we hear the voices of people who have gone through the difficulty of speaking up or whistleblowing as they have unique and highly valuable insights. Their experiences of internal investigations, complaints processes and employment tribunals demonstrate that the systems that are supposed to support people who speak up often neglect their needs. The reasons for this include pressure from organisational leaders, a culture of not wanting to hear bad news and prioritising organisational reputation above patient and staff safety. It’s vital that we understand the cost individuals have paid for taking action that they believe to be right and that their professional standards require. During the series we speak to experienced and committed healthcare professionals who have received threats, abuse and gaslighting from their employers. Some have lost their careers as a result and many describe the significant impact on their work life, private life and health. The interviews are informal and although the interviewees will have a rough idea of where the discussions are likely to lead, we challenge and explore their opinions. Our aim is to draw out the details that might help us better understand the nature and extent of specific issues—from threats and retaliation from other staff to human resources practices and employment tribunals. We start each conversation by inviting our guest to share their own experience of whistleblowing or speaking up, or of working with people in that space. We discuss the consequences for whistleblowers, as well as for patients and families, when organisations fail to respond well to staff who raise concerns. We then invite each guest to reflect on any areas for learning that can be drawn from their experience and make suggestions of ways to better protect both NHS staff and patients. In some interviews we look at whether healthcare regulators and the legal system are appropriately designed or equipped to protect whistleblowers and staff who speak up, as well as the public interest. Amplifying voices for change If enough healthcare staff, patients, families and motivated members of the public take notice of the issues we’re raising, then the pressure for change can only increase. Our hope is that we can convince leaders across the sectors that real, profound and lasting progress will be in the best interests of all of us. We’d like to see changes to the way that safeguarding and whistleblowing are viewed within our political, judicial and regulatory systems. But to achieve this, we need to see more urgency from those who have the power to make real change. We are seeing some examples of positive movement, but this remains slow and patchy and there is resistance to change from parts of the legal profession and healthcare leaders. Towards the end of last year, the Secretary of State for Health and Social Care, Wes Streeting MP, launched a new consultation on government proposals to regulate health service managers, ensuring they follow professional standards and are held to account. As part of this announcement, he stressed the Government’s commitment to protect whistleblowers by introducing regulation for managers and enforcement measures to tackle managers who “silence whistleblowers or endanger patients through misconduct.”[3] We welcome this commitment, and Patient Safety Learning will be responding to the consultation. However, these words need to be accompanied by prompt and decisive action, or the gap between what many NHS organisations say to employees about speaking up and whistleblowing and what happens in practice will remain. The statistics that estimate the worrying extent of avoidable harm in the UK [5] need action right now, not in a year, or five, or ten. We believe any drive to bring these awful figures down needs to include a relentless focus on safeguarding, speaking up and accountability. Get involved If you have spoken up about unsafe care or have been a whistleblower in healthcare or social care, we would love to hear from you about your experience. You can: contribute to our community conversation (you’ll need to sign up first) comment on any hub post (you’ll need to sign up first) contact us at [email protected] and we can share your story anonymously. You can find information about organisations that offer support and guidance for staff about speaking up and whistleblowing on the hub. Listen to the interviews Helené Donnelly in conversation with Peter Duffy and Helen Hughes Martyn Pitman in conversation with Peter Duffy and Helen Hughes Jayne Chidgey-Clark in conversation with Peter Duffy and Helen Hughes Gordon Caldwell in conversation with Peter Duffy and Helen Hughes Bernie Rochford MBE in conversation with Peter Duffy and Helen Hughes Beatrice Fraenkel in conversation with Peter Duffy and Helen Hughes Chelcie Jewitt in conversation with Peter Duffy and Helen Hughes Michael Swinn in conversation with Peter Duffy and Helen Hughes Rebecca Wight in conversation with Peter Duffy and Helen Hughes Related reading Key themes emerging from our ‘Speaking up for patient safety’ interview series The whistleblower playbook References 1 UK Government. Public Interest Disclosure Act 1998. Accessed 11 December 2024 2 NHS Staff Survey. NHS Staff Survey National Results 2023. Accessed 11 December 2024 3 Department of Health and Social Care, UK Government. New protections for whistleblowers under NHS manager proposals. 24 November 2024 4 J Elgot and D Campbell. Managers who silence whistleblowers ‘will never work in NHS again’, vows Streeting. The Guardian. 27 June 2024 4 J Illingworth, A Shaw, R Fernandez Crespo et al. National State of Patient Safety 2022: What we know about avoidable harm in England. Institute of Global Health Innovation, Imperial College London, 2022

In this interview series, NHS whistleblower Peter Duffy and Patient Safety Learning’s Chief Executive Helen Hughes explore how the healthcare system responds when its staff raise concerns about patient safety. In each episode, Helen and Peter interview someone who has spoken up about patient safety issues in healthcare organisations, or who works to help staff raise concerns where they see unsafe care. In this interview, Peter and Helen speak to Helené Donnelly OBE, who spoke up about unsafe care she witnessed while working as a nurse at Mid Staffordshire NHS Foundation Trust. Helené contributed as a witness to the inquiry led by Sir Robert Francis KC into failings at the trust and was also an advisor in the Freedom to Speak up Review in 2015, where she called for the creation of Freedom to Speak Up Guardians in the NHS. Helené explains why she decided to raise concerns about the quality of nursing care at Stafford Hospital A&E and describes the bullying and threats she received from other staff as a result. She discusses with Peter and Helen the barriers that still prevent staff speaking up today and what can be done to create a more open and responsive culture in teams and organisations. Helené highlights the need to reform how human resources departments respond to staff raising concerns and the vital role of embedding speaking up and organisational culture in the curriculum of all healthcare professional training courses. Subscribe to our YouTube podcast to keep up to date with the latest episodes. View a transcript of this interview Read a blog from Peter and Helen about the interview series