HelenH

Well said Kathy. Some of this is resourcing but much of this is prioritisation that doesn’t put patient and staff safety as a core purpose. Lessons must be learned

‘There are not any showers for nurses at work.’ Outrageous. We have to care for staff. No staff safety, no patient safety 

Great that Royal Free have recognised the necessity of supporting staff at this very difficult time. Wondeful that your skills, energey and compassion are being released to support this. Please do keep us in touch with insights into how its all going. I'm sure there's valuable learning that others can benefit from. Best wishes, Helen

James says 'If our understanding of, and our systems for, patient feedback are limited to seeing it simply as data, concerns, compliments, or even stories, then I think we are missing this bigger picture. Feedback is a relationship. It is one way that people receiving a service can express their care, in return, for those who provide it, and for others who will use it. It is an expression of the values of equality and mutuality which lie at the heart of our health service.

Our current approaches to patient feedback recognise little of this – and it is time they did.'

Absolutely. Completely agree

Brilliant as ever @MartinL  I learn so much from your insights and advice.

I wonder whether the NHSI Patient Safety Incident Response Framework will reflect this wisdom? https://improvement.nhs.uk/resources/future-of-patient-safety-investigation/

Thank you.

'it is up to the investigator/team to establish the facts including obtaining information from those involved' Absolutely. One of the challenges that we hear is whether such people/teams have the capacity to respond as you outline. Commitment and knowledge does need to be matched with sufficient resources to investigate, learn and then take action.

Any insights that you have of good practice, we'd love to hear from you - in a blog or sharing policies, SOPs, guidance etc. 

Helen

I think collectively that many have  forgotten that reporting is about learning and taking action to prevent errors and harm. It’s not an activity my it’s own right! It’s also part of caring for and an accountability to staff, saying that we your concerns matter and we’re going to take them seriously. 
 

Danielle, I love your suggestions. We’re going to be collating examples of great practice to share and we’ll start with these! If you’ve more detailed information or would write a blog on what you do and the impact it has, that would be wonderful. helen@patientsafetylearning.org

I've just re-read. Too good a series just to read once. 

My favourite quote on this one is 'Scheduling 12-hour days – well it keeps investigators in work.' Sadly, I think 12 hour shifts are becoming the norm in healthcare. And that excludes the journey to and from work.

Thank you again for your insight, commitment and bravery.

Good questions for Boards., leaders, CQC and Healthwatch  to ask too:

"Are staff allowed to Speak Up and report safety incidents?"

"Are the reports followed up and lessons shared without victimising the person who reported it?"

Staff should be allowed for sure. But ideally they should be encouraged and welcomed.

Helen

Thanks for your insights Sue.

Congratulations and good luck with the role. Will be great for there to be more of you!

Please keep in touch as the role develops, we'd love to hear your journey and reflections for others to learn from.

Helen

Hi David, a very good point. And a general one about the role of NHSI with regard to patient safety and incident reporting. NHSI is leading on replacing the now outdated NRLS. How will this inform learning and action? Will all risks reported be analyses and transparently reported. Will this be accompanied by the insight from Trusts that have responded with improvement action and advice for others #share4safety

What do people think?

@Clive Flashman

Thank you Martin, much rich insight here.

NHS Improvement is developing a new Serious Incident Framework. I do hope that this work reflects on:

'HFs in the first sense is a study of basic processes. Investigations are always about these basic processes – seldom about how someone felt about someone else and about how these senses interacted with the environment, the equipment and the system or method of working.'

There is criticism that current approaches to investigation prioritise 'process over outcome.' Let's hope that changes soon.

Dear anonymous HCA,

Thank you for sharing your experience with us. What a  shocking and distressing account; both for the residents of the home and for yourself. 

Would you be willing to speak with the CQC? Colleagues there have already been very responsive to another whistle blower who contacted us. I'm sure that the CQC would be keen to know the details of the home so that they can follow up. 

Here are links to CQC's site should you or anyone else want to report poor care. https://www.cqc.org.uk/contact-us/report-concern/report-concern-if-you-are-member-staffhttps://www.cqc.org.uk/give-feedback-on-care

It may be that there is a professional regulation concern.  The NMC state that 'they exist to enable better and safer care. One of the ways we do this is by acting when someone tells us they have a concern about a nurse, midwife or nursing associate which could put the safety of patients at risk, or damage the public’s confidence in the nursing or midwifery professions.' ...... and that 'If you feel uncomfortable about contacting the employer, or you don't know who the employer is, or it seems as though the public might be at risk, then we would encourage you to go ahead and make the referral to us.'

https://www.nmc.org.uk/concerns-nurses-midwives/concerns-complaints-and-referrals/making-a-referral-to-us/

I hope that's helpful. With very best wishes,

Helen

Brilliant initiative.

@Claire Cox are there more resources from this Centre we could add to the hub?

'Even with mistakes much more consequential than an airplane meal, many or most people just want to hear someone take responsibility and offer a sincere apology.' True

Great article Kathy.

Would like to know more about the petition and whether this should call for more research too. 

Let's discuss with @Claire Cox  and @Mark Hughesand how we can promote through a discussion on the hub community. We can link to social media to get wider attention to this issue. Can you email me at helen@patientsafetylearning.org to follow up?

That's great to hear @Aston02. Disappointing that you had to use the service but shows why it's needed. Shocked that senior management behaved that way. Was there any follow up with them do you know?

Great post, thank you to East Kent and congratulations on your award. Will be really helpful to keep informed of your progress and the impact that engaging with energetic and committed Ward Managers will have. Helen

Thank you so much for your story. It’s heartening to hear the support you received in what was a difficult tome for you, other staff and especially the family. Does your organisation have guidance/resources that we could share? It would be wonderful if everyone, patients and staff, could have the same experience. 

Does also show the contractual vulnerabilities of bank and locum staff in raising issues. Staff shouldn't have to chose between doing the right thing, their professional responsibilities and their livelihood. I'll write to the GMC, NMC and HCPC on this issue. 

Thanks again to the brave reporter.

Hi @Andrew Ottaway and @Claire Cox

Thanks for the discussion and update Andrew. I think it would be helpful to clarify responsibilities and I will write next week to the FTSUG's office, the CQC and NHSI.  It does appear to be a loophole.

Will keep everyone posted.

Helen

'Absolutely 100%' - I so admire you for doing the right thing in reporting and having the integrity, compassion and commitment to patient safety to do so again. As the Chief Executive of Patient Safety Learning, wife, daughter and mother, thank you. I hope the support you receive in telling your story will help with the distress and anguish this incident has caused you. Thank you for sharing 

Hi @Clive Flashman The link is here

Check out discussion on our community page

thanks Jane. Great presentations at a great conference