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richard vA

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  1. Content Article Comment
    Interesting but I am concerned about the lack of reference to the patient in this evolving variable policy area around harm. My question about your experience relates to 2 key related issues: 1. Is their evidence of real Patient Involvement, indeed co production in some processes 2. Is there evidence, even any data collected and analysed on the outcome for patient and families, their honest full feedback and whether compounded harm has been avoided. I say this has someone who has had experience of the PSIRF context and a sister organisation and concerns expressed here from a patient family perspective https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/from-the-exit-door-of-hsib-challenging-feedback-and-a-health-warning-for-patients-and-families-r10266/#:~:text=Richard von Abendorff%2C an outgoing,become an exemplary investigatory safety
  2. Content Article Comment
    Very interesting. Something I would like to add to the mix for proper consideration to be given to is : My question about your experience relates to 2 key related issues: 1. Is their evidence of real Patient Involvement, indeed co production in some processes 2. Is there evidence, even any data collected and analysed on the outcome for patient and families, their honest full feedback and whether compounded harm has been avoided. I say this has someone who has had experience of the PSIRF context and a sister organisation and concerns expressed here from a patient family perspective https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/from-the-exit-door-of-hsib-challenging-feedback-and-a-health-warning-for-patients-and-families-r10266/#:~:text=Richard von Abendorff%2C an outgoing,become an exemplary investigatory safety
  3. Content Article Comment
    My question about your experience relates to 2 key related issues: 1. Is their evidence of real Patient Involvement, indeed co production in some processes 2. Is there evidence, even any data collected and analysed on the outcome for patient and families, their honest full feedback and whether compounded harm has been avoided. I say this has someone who has had experience of the PSIRF context and a sister organisation
  4. Content Article Comment
    Given my concerns about how Patients and Families are utilised, or not in learning investigations, by even the leading exemplar service i am interested to read this and will feedback my thoughts, as I was one of the patient contributors to the Discovery phase and did comment on this whole project some time ago expressing my views
  5. Content Article Comment
    well put-there is a difference between a complaint and a report of harm in my opinion. , but each deserve full respect, attention and centering pf patients views, for similar reasons. hsib is looking at harm reduction and looking at systemic issues-which patients are well able to engage with if given an opportunity-their efforts should be respected fully
  6. Content Article Comment
    I do hope other comments will be added. The incoming Board requires constructive food for thought as it launches the next stage with theoretically& legally more powers and independence but in a just as challenging context. Learning from tragic deaths of mental health patients requires huge sensitivity, sophistication and patient and family centredness
  7. Content Article
    More information about "From the exit door of HSIB: Challenging feedback and a health warning for patients and families"
    Richard von Abendorff, an outgoing member of the Advisory Panel of the Healthcare Safety Investigation Branch (HSIB), has written an open letter to incoming Directors on what the new Health Services Safety Investigations Body (HSSIB) needs to address urgently and openly to become an exemplary investigatory safety learning service and, more vitally, how it must not contribute to compounded harm to patients and families. The full letter is attached at the end of this page. HSIB as experienced and observed vs HSIB as imagined and described (and not researched!): a patient system perspective Dear Ted and Rosie and all incoming Directors to HSSIB, In 2017 I wrote an open article making demands of HSIB to be patient centred. Six years later, having following HSIB closely, and in some aspects intimately, I write an open letter from a point of despair as HSSIB emerges from HSIB and I end my formal involvement as the patient safety expert from experience on the Advisory Panel. Nothing I say may surprise you, but I hope the incoming executive considers these issues seriously and urgently. I raise it in this public way as I believe if these issues are not transparently and explicitly addressed as a matter of urgency, I cannot assure other patients and families should they become involved with HSSIB. I say this for fear they will experience compounded harm and, related and additional to this (as I will expound below), I have significant concerns about the quality and output of HSIB investigations to achieve maximum impact, utilising the patient and family perspectives. HSSIB must prioritise its development to become exemplary and better than what has gone before (based on evidence) and to also be valuable not harmful for patients and families. Patient safety in England needs a place where trust and faith are restored, with evidence showing it listens, learns and acts by putting patients and their advocates at the centre. The issues can be examined from three perspectives relevant at this juncture: A review of its past work given it has new power. The new governance arrangements coming in to place, but without patient voice at its heart. Various concerns over the last 6 years that cannot be ignored, and a recognition already acknowledged by yourselves, Ted and Rosie, that the patient involvement aspects require more work. My full letter details the experiences I draw upon. I challenge the lack of evidence base and research on HSIB that claim it is truly independent drawing on patient and family perspectives. I do not go in to detail on other publicly shared criticisms of HSSB, but I believe these criticisms cannot be ignored and have not been adequately addressed. I bring to everyone’s attention that the Advisory Panel I was on had no explicit or expected role in even commenting on these types of issues but some members did at times. Given Governance at HSSIB is now being established in a more recognised, explicit and conventional way, I believe the Non-Executive Directors and Executive Directors have a vital role to immediately address these concerns drawing on independent expertise. I challenge the opinion that HSIB has an innovative or patient-centred engagement model. It focuses on the important issues of accessibility and basic, respectful communication with patients and families – something we have seen that has not been done by health bodies. But it does no more than this. This is not exemplar family involvement. The letter relates independence to patient-centredness in a way contrary to how HSIB has worked in the past and refers to the vital need to report authentic accurate accounts of patients. It argues that much work has to be done to avoid bias towards health service perceptions, and to make patients and their advocates more central in all HSSIB processes, from scoping to evaluation. Family involvement is so much more than engagement. And in all these processes, patients need not only empowerment but advocacy and support. If HSSIB does not do this, who will give it the recognition it needs? The letter looks at the relationship between restorative approaches and investigations and how to minimise or, ideally, eliminate compounded harm and to get quality investigations drawing on the valuable insights of families and the patient-led framework that is needed. This itself deserves ongoing research, development and typologisation. Engagement with whistleblowers in the NHS, and indeed within HSSIB, as a starting point to be any kind of exemplary service also requires explicit, transparent, evidence-based attention given HSIB’s previous history of this (and some key issues are identified in the letter). The letter recognises the innovative and challenging role HSSIB takes on and that it cannot shirk from addressing these if it seeks to be truly innovative. However, based on experiences to date, unless HSSIB urgently takes on this challenge, I cannot express any assurance to families who consider participating. I have been a critical friend for a very long time and now can just be a serious critic in making these challenges. One big question remaining is why these limitations still exist after more than six years of HSIB? One issue has to be to move away from a solely or predominantly technocratic and medically centred and medically organised framework. This also requires consideration. Richard von Abendorff, 12 October 2023 Download the full letter here or from the attachment at the end of the page: Open letter to HSSIB.pdf
  8. Content Article Comment
    And may involve listening but no empowered action as I mentioned in recent tweet replies in calls for more mere 'listening :...... ''But what action do you demand after listening? Listening without robust action is tokenistic, falsely raising expectations and is further disempowering and traumatising to patients if not backed up by patient moderated/enhanced outcomes. Ask @BeresfordPeter @DavidGilbert43. Also reply in another related context. Progress in this area is SO slow https://x.com/twitsquince/status/1711552623784988872?t=_KknwvgmS8GR5LwHu_UnNw&s=08
  9. Content Article Comment
    But what action do you demand after listening? Listening without robust action is tokenistic, falsely raising expectations and is further disempowering and traumatising to patients if not backed up by patient moderated/enhanced outcomes. Ask @BeresfordPeter @DavidGilbert43. Also reply in another related context. Progress in this area is SO slow https://x.com/twitsquince/status/1711552623784988872?t=_KknwvgmS8GR5LwHu_UnNw&s=08
  10. Content Article Comment
    Excellent. Please don't forget work & feedback to a @theHSSIB report, additional family insights, role of family feedback and coordination between palliative and oncology services all linked in this article
  11. Content Article Comment
    Can a more accessible link be shared?. I am not on linked in
  12. Content Article Comment
    Great image. Power differential, interests, positioning of placed expertise, status, uni directional process. Captured here. No one listens or is interested ( ok ..we had one response)
  13. Content Article Comment
    NRLS now is LFPSE. Hopefully someone from there can respond. They are currently asking if and how Patients and Families can report events in another blog on this site. Link below. Astounding there is no plan yet and no massive patient consultation process
  14. Content Article Comment
    Where are patients and whistleblowrs? Elephants in the room
  15. Content Article Comment
    What about dealing with managers who protect bad apples and victimise whistleblowrs? Key system reforms needed of this even worse problem IMHO. System coverup is worst issue .As @alexander_minh has argued for years based on masses of data& correspondence2 systemic radical reforms are essential starting point: 1.whistleblowrs protection reform 2.managerial accountability. I add: like @DavidGilbert43 3.empowered patient leadership throughout org. Agree?
  16. Content Article Comment
    This first step is so important..who controls it ia a key concern.
  17. Content Article Comment
    Some excellent patient leadership campaigners have questioned if there is any real empowered embedded patient voice in the whole process. I share the concern. The blog above highlighs need for more than stories. Structural engagement and change needed. It will come about if patients are empowered in the process.
  18. Content Article Comment
    I asked at my one hour session that harmed patient experts by experience are involved in drafting of this key report. Nothing about us without us. I am still seeking assurance
  19. Content Article Comment
    No one currently investigates patient reports of harm from the patient perspective, with a patient eye view & patient interests at heart. They would require both TRUE INDEPENDENCE ( of the reputation protecting NHS Trust involved and also be a fearless challenger, if needed of the existing NHS system and clinical base) AND TRUE WIDE RANGING EXPERTISE ( clinical, human factors, safety & patient need focus), all woth with PATIENT OVERSIGHT ( empowered. Informed. Suitably Rewarded. Co produced in a nutshell). Who can do that? Who will dare do that. It is needed, urgently . Will NHSE patient Safety dare? If you have thoughts: share here. Contact NHS staff above
  20. Content Article Comment
    No one currently investigates patient reports of harm from the patient perspective, with a patient eye view & patient interests at heart. They would require both TRUE INDEPENDENCE ( of the reputation protecting NHS Trust involved and also be a fearless challenger, if needed of the existing NHS system and clinical base) AND TRUE WIDE RANGING EXPERTISE ( clinical, human factors, safety & patient need focus), all woth with PATIENT OVERSIGHT ( empowered. Informed. Suitably Rewarded. Co produced in a nutshell). Who can do that? Who will dare do that. It is needed, urgently . Will NHSE patient Safety dare? If you have thoughts: share here. Contact NHS staff above
  21. Content Article Comment
    Something is happening but it is under radar of too many patients. Where do patient report harm events. No where...still...yet. how can they? I have been made aware of a consultation happening as part of a Discovery Phase for the development of The Learn from Patient Safety Events (LFPSE) service. See below for the information I received: Consultation by NHS England. "Discovery Phase is taking place over around 8 weeks, with the involvement of a Patient Safety Partner recruited through our internal processes. I’ve included an excerpt from the Task Profile we used for recruitment below, which explains more about the phase and its aims. 1. The Learn from Patient Safety Events (LFPSE) service is a new national NHS service for the recording and analysis of patient safety events that occur in healthcare. This utilises new digital technologies to support learning from what does and does not go well, by replacing the National Reporting and Learning System with a new safety learning system. The service introduces a range of innovations to support the NHS to improve learning from the over 2.5 million patient safety events recorded each year, to help make care safer (see ‘How LFPSE will improve patient safety learning’). View this short animation: Introducing the Learn from Patient Safety Events service - YouTube. 2. Patients Safety Partner involvement is important for understanding how best to ensure patients, carers and families can contribute to national patient safety learning and improvement. The LFPSE project team are undertaking a Discovery Phase to understand how Patients and Families can best share their safety experiences within the NHS to help support national learning and improvement. A ‘discovery phase’ is a process that helps to “define the problem” and decide what (if any) work then needs to take place (e.g. designing and building software/applications). 3. The work will involve identifying target audiences (who else do we need to involve in the research?), what needs they are trying to meet (their aims after experiencing a patient safety event), what existing feedback channels or processes there are in place (where do people already go when wanting to share such information and experiences?), and any concerns/issues with current options (what stops people sharing their experiences? What makes it difficult to do? What gets in the way of this being used for learning?). At the end of the discovery phase, we will produce a report that summarises our findings, and makes recommendations for what should happen next. “ We are recruiting patients and families via a number of channels – some directly, like yourself, where they have expressed an interest previously, and some via NHS England’s engagement teams, as well as via CQC. We have reached out to a number of advocacy groups (AvMA, Patients Association, Harmed Patients Alliance, and Care Opinion) to try to get a wide range of views represented, both of patients with experience of harm, and those without. This is important to ensure we design a user-friendly service for “novice” patients, as well as those who understand the landscape of patient safety better. The questions asked will cover things like whether the individual has any personal/family experience of harm; if not, do they know what a patient safety incident is, how they would describe the concept in their own words, where they would go if they had an experience that might involve a patient safety issue, what they would want out of that process, etc. The intention is very much to get a sense of the current state of play, level of knowledge and awareness of issues, terminology, and options open to patients, and to then use that to explore what kind of service will work best to ensure we can gather the learning from patients for use at a national level, whilst also giving patients what they need in terms of feedback/closure etc (which will likely need to happen at the provider level, rather than nationally).' to ask to be involved contact [email protected] or [email protected]
  22. Content Article Comment
    The Learn from Patient Safety Events (LFPSE) service is a new national NHS service for the recording and analysis of patient safety events that occur in healthcare patient reporting of harm. NHS have announced a new Discovery Phase for the development of the LFPSE, which includes engaging patients. This is vital and unknown about, and needs urgent attention. I have already raised my concerns. See below for the information I have received and how to get involved: "Discovery Phase is taking place over around 8 weeks, with the involvement of a Patient Safety Partner recruited through our internal processes – I’ve included an except from the Task Profile we used for recruitment below, which explains more about the phase and its aims. 1. The Learn from Patient Safety Events (LFPSE) service is a new national NHS service for the recording and analysis of patient safety events that occur in healthcare. This utilises new digital technologies to support learning from what does and does not go well, by replacing the National Reporting and Learning System with a new safety learning system. The service introduces a range of innovations to support the NHS to improve learning from the over 2.5 million patient safety events recorded each year, to help make care safer (see ‘How LFPSE will improve patient safety learning’). View this short animation: Introducing the Learn from Patient Safety Events service - YouTube. 2. Patients Safety Partner involvement is important for understanding how best to ensure patients, carers and families can contribute to national patient safety learning and improvement. The LFPSE project team are undertaking a Discovery Phase to understand how Patients and Families can best share their safety experiences within the NHS to help support national learning and improvement. A ‘discovery phase’ is a process that helps to “define the problem” and decide what (if any) work then needs to take place (e.g. designing and building software/applications). 3. The work will involve identifying target audiences (who else do we need to involve in the research?), what needs they are trying to meet (their aims after experiencing a patient safety event), what existing feedback channels or processes there are in place (where do people already go when wanting to share such information and experiences?), and any concerns/issues with current options (what stops people sharing their experiences? What makes it difficult to do? What gets in the way of this being used for learning?). At the end of the discovery phase, we will produce a report that summarises our findings, and makes recommendations for what should happen next. “ We are recruiting patients and families via a number of channels – some directly, like yourself, where they have expressed an interest previously, and some via NHS England’s engagement teams, as well as via CQC. We have reached out to a number of advocacy groups (AvMA, Patients Association, Harmed Patients Alliance, and Care Opinion) to try to get a wide range of views represented, both of patients with experience of harm, and those without. This is important to ensure we design a user-friendly service for “novice” patients, as well as those who understand the landscape of patient safety better. The questions asked will cover things like whether the individual has any personal/family experience of harm; if not, do they know what a patient safety incident is, how they would describe the concept in their own words, where they would go if they had an experience that might involve a patient safety issue, what they would want out of that process, etc. The intention is very much to get a sense of the current state of play, level of knowledge and awareness of issues, terminology, and options open to patients, and to then use that to explore what kind of service will work best to ensure we can gather the learning from patients for use at a national level, whilst also giving patients what they need in terms of feedback/closure etc (which will likely need to happen at the provider level, rather than nationally).' to ask to be involved contact lucie[.]mussett[@]nhs.net or natasha[.]hughes[@]nhs.net
  23. Content Article Comment
    This touches on similar issues and the review is currently forging ahead. Contribute. The patient voice is vital. Read next comment about what NHS is planning. I am concerned it is too little rushed through. Serious empowred co production is needed.. what do others think?
  24. Content Article Comment
    The above is NHS patient safety response to this below. I.am very concerned that the full vital patient voice will not be heard. This is a defining moment.
  25. Content Article Comment
    So sorry to hear. The big question. Who can patients and their families report these harm events to? To get independent expert patient focussed action. No one from my experience. There is a national consultation process needing engaging with. This must be done . Read here and please also share widely. If not now when? See below for the information I received: I’ve included an excerpt from the Task Profile we used for recruitment below, which explains more about the phase and its aims. "Discovery Phase is taking place over around 8 weeks, with the involvement of a Patient Safety Partner recruited through our internal processes – I’ve included an except from the Task Profile we used for recruitment below, which explains more about the phase and its aims. 1. The Learn from Patient Safety Events (LFPSE) service is a new national NHS service for the recording and analysis of patient safety events that occur in healthcare. This utilises new digital technologies to support learning from what does and does not go well, by replacing the National Reporting and Learning System with a new safety learning system. The service introduces a range of innovations to support the NHS to improve learning from the over 2.5 million patient safety events recorded each year, to help make care safer (see ‘How LFPSE will improve patient safety learning’). View this short animation: Introducing the Learn from Patient Safety Events service - YouTube. 2. Patients Safety Partner involvement is important for understanding how best to ensure patients, carers and families can contribute to national patient safety learning and improvement. The LFPSE project team are undertaking a Discovery Phase to understand how Patients and Families can best share their safety experiences within the NHS to help support national learning and improvement. A ‘discovery phase’ is a process that helps to “define the problem” and decide what (if any) work then needs to take place (e.g. designing and building software/applications). 3. The work will involve identifying target audiences (who else do we need to involve in the research?), what needs they are trying to meet (their aims after experiencing a patient safety event), what existing feedback channels or processes there are in place (where do people already go when wanting to share such information and experiences?), and any concerns/issues with current options (what stops people sharing their experiences? What makes it difficult to do? What gets in the way of this being used for learning?). At the end of the discovery phase, we will produce a report that summarises our findings, and makes recommendations for what should happen next. “ We are recruiting patients and families via a number of channels – some directly, like yourself, where they have expressed an interest previously, and some via NHS England’s engagement teams, as well as via CQC. We have reached out to a number of advocacy groups (AvMA, Patients Association, Harmed Patients Alliance, and Care Opinion) to try to get a wide range of views represented, both of patients with experience of harm, and those without. This is important to ensure we design a user-friendly service for “novice” patients, as well as those who understand the landscape of patient safety better. The questions asked will cover things like whether the individual has any personal/family experience of harm; if not, do they know what a patient safety incident is, how they would describe the concept in their own words, where they would go if they had an experience that might involve a patient safety issue, what they would want out of that process, etc. The intention is very much to get a sense of the current state of play, level of knowledge and awareness of issues, terminology, and options open to patients, and to then use that to explore what kind of service will work best to ensure we can gather the learning from patients for use at a national level, whilst also giving patients what they need in terms of feedback/closure etc (which will likely need to happen at the provider level, rather than nationally).' to ask to be involved contact lucie[.]mussett[@]nhs.net or natasha[.]hughes[@]nhs.net

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