HelenH

Key Learning 8: ‘There can be particular difficulties for Medical Directors who are in the sometimes awkward position of being part of the overall corporate Trust management, but at the same time seen by their colleagues as one of the consultant medical body’

Key Learning 7:  ‘Where concerns and criticisms appear or do turn out to be misguided, NHS leaders must avoid jumping to any conclusion that the individual raising them is simply making trouble.’

Key Learning 6: ‘. However difficult, leaders need the ability to get over whatever personal discomfort they may feel and appreciate the potential value of the advice being offered. If it turns out to be correct, then the matter in question can be addressed and everyone will be better off as a result. NHS leaders need to value those who raise concerns. They also need to be seen to be even-handed in their approach.’ 

Key learning 5:  ‘If clinical leadership is to have any real meaning, senior executives need to allow clinical leaders to be respected participants in the decision- making and management process.’

Key Learning 4: ‘ It is important that the culture of the organisation & the leadership environment & approach allows for individuals to feel comfortable with the various checks and balances operating effectively – such as challenge from their Boards’

Key Learning 3: ‘ It is also important that all NHS organisations are aware of and have implemented the May 2018 Guidance for NHS Boards. This requires them, where concerns raised are wholly or in part about members of the Board, to inform the Trust’s FTSU Guardian in confidence’

Key Learning 2: ‘The approach to FTSU by NHS organisations continues to develop. Those responsible for its operation … may need further support in some important areas. eg understanding the importance of separating FTSU from performance and disciplinary matters’

Key learning 1: ‘Staff who do Speak Up may not always be right, but that should not matter. Important patient safety concerns would be less likely to be raised if staff feared being wrong and facing disciplinary action (or simply being castigatedasatroublemaker)’

Hi Steve, I’ve just finished reading the Exec Summary and have been tweeting the key learnings identified within it. Shocking. I’ll add 
 

It’s very kind of you to share your experience with us. How absolutely awful, it’s shocking to hear. The staff ‘appeared kind and caring’ was such a telling phase. From what you outline, they must have seen how much pain and distress you were in. I agree with you, we must ensure that women are provided with the information and support they need, so that women don’t experience such avoidable pain. The guidance is there, it needs to be followed. 
 

Thank you again and sending you my very best wishes. Helen 

Thank you.

You must be so relieved. It's great to be able to promote a 'good news' outcome. 

Thank you so much for posting. I’m so pleased it worked out really well for you and the staff sound fabulous.
 

Have you thought about sharing on  CareOpinion too? It’s a great site for giving positive feedback that shared directly with the staff concerned. 

Thank you for posting. I’m really pleased it worked out well for you and your health is good. Such a relief.
 

It would be awful if women are put off having a necessary procedure because of fear of pain. But as you say, the percentage of women who do experience severe pain is very high. 
 

I don’t know the evidence base for the Drs statement that women who have an injection have higher pain scores. Does anyone reading this post have more information on this? 

Sobering example and very good advice. Would you mind us turning this into a blog? @Patient Safety Learning

Hi all,

I've a personal experience which I'll share, but it has to be un-attributable.

After 5 cancellations of surgery over the last 18 months (partly Covid, partly building maintenance and partly because there were no post surgery ICU beds available), my friend/family member was told that they were being referred to a specialist hospital, relatively nearby. No explanation was given as to whether this was a matter of clinical urgency, capacity or another factor. Within a few weeks, they were phoned up by the specialist hospital and told that the referral should never have been made and they were not accepting it. My friend/family member was then told that they had to go back to the referring hospital, tell them that the referral wasn't being accepted and that the surgery needed to be rescheduled. 

All of this information was presented in a manner of irritation that the specialist hospital had been inconvenienced. It was also made clear  that it was the patients' responsibility to communicate with the referring hospital and 'sort this mess out.' There was no suggestion that my friend/family member's GP might be involved and could/should be able to be supportive, nor was there any indication of what impact this could have on surgery waiting time and her deteriorating health.

This may have happened at any time, but we suspect that the huge backlog and capacity constraints have had an impact on the availability of treatment, clinical prioritisation and patient communication.

Is this an isolated incident?

Please share if you have an experience as a patient or member of staff trying to deliver safe and effective care.

Thanks so much for taking time to share your experience. Glad it worked out well for you. 
 

That’s an excellent idea, the ‘dry run.’ Is that widely available, I wonder? I’m sure colleagues will let us know! 

Thank you for sharing your ghastly experience. It drives us @Patient Safety Learning to support the wonderful campaigners that have been exposing this obscenity, affecting so many women. I hope we can deliver the change needed to stop this. Women should not be exposed to this pain. It’s avoidable. I’m so sorry that you suffered in this way, the pain and the betrayal. Helen 

Hi Helen,  thank you for sharing your horrible experience with us. I hope that you are able to receive the care you need without fear or pain.
 

We are working closely with @Katharine Tylko and her wonderful colleagues at CAPH. They also have a FB group where women are sharing their stories too. https://m.facebook.com/story.php?story_fbid=1564972663700527&id=193342597530214

We will not stop until these significant patient safety concerns are addressed. You might find our latest blog on this issue of interest. https://www.patientsafetylearning.org/blog/minister-acknowledges-patients-concerns-about-painful-hysteroscopies-but-will-action-be-taken
 

Thanks again. Personal testimonies really help drive home the need for urgent action. Take care and best wishes, 

Helen 

This is absolutely not correct. 

From the NICE guidance ‘Do not exclude people from referral to a multidisciplinary assessment service or for further investigations or specialist input based on the absence of a positive SARS‑CoV‑2 test (PCR, antigen or antibody).’

https://www.nice.org.uk/guidance/ng188/chapter/3-Investigations-and-referral

Please see a jointly produced leaflet by us and the RCGP 

People have said that they have found this helpful in discussing with the GP. Hope it helps. If it does, can you let us know? 
 

Best wishes

Helen 

and @Stephanie O'Donohue

Hi Michelle,

we’ve a few of those on the hub, should be searchable. Any problem, just let us know @Patient Safety Learning

I met with the CEO of an Australian company this week and they have a tool that hasn’t yet been used in healthcare. It is a 10 minute survey that looks at: health and well being;  safety systems; safety leadership; safety engagement. It’s called the Health and Safety Index. It looks pretty impressive. I’ve been thinking that it would be good to get a few pilots in healthcare on it and they’re keen. If you’re interested, do let me know and I’ll make the introductions healthandsafetyindex.com.au 

@Steve Turner An excellent blog, thank you. Very powerful concluding thoughts: 

Given the annual expenditure on medicines with the benefits and risks involved in their use, it seems surprising to me that the art and science of prescribing medicines receives so little attention in investigation reports, and from public bodies.

I believe patients, the public and healthcare practitioners need to be aware of the Prescribing Competency Framework and why the framework must be applied in practice, used in clinical supervision and CPD, and why we must all speak out if we believe it is not being followed.

At present it appears that, since the demise of the National Prescribing Centre, no national body is picking up on this need for more awareness, training and education specifically related to prescribing. I believe that patients are being harmed and lives may be being lost as a direct result of this gap in learning.

I do hope that your blog and discussion drives the change needed. 

Hi Carrie, I’m at a meeting with the CIEHF this afternoon and will raise the general point with them, how needle phobic patients are being supported. They may wish to include in any guide and advice. 

I’d have thought that the main contact for personal support should be your GP.

Hope that helps, best wishes, Helen 

Hi Carrie, Good question. Maybe submit to the CIEHF so they can include this in their work? https://www.linkedin.com/posts/noorzamanrashid_the-economist-on-twitter-activity-6750290388721926144-h8XV/ Helen

Hi Carrie,

I wonder if you shared your concerns with your GP they could provide you with information and support - including ensuring that the vaccination is given to you in a way that avoids any distress. 

Best wishes, Helen

That sounds fascinating and valuable. Might you write a blog for us on your work? Maybe reflections on the impact of your work at Leeds, Birmingham and Glasgow ? Helen 

Do contact me on helen@patientsafetylearning.org if you'd like to follow up.