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rich squince

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  1. E9f7f71e16b0da64af26f2b29a53ee79

    When care pathways fragment: a blog by Claire Cox

    rich squince commented on Patient Safety Learning's article in Care pathways
    Excellent. And to add: the absence of patient voices in design and evaluation of services and all learning and action and its implementation in response to safety incidents ( weaknesses structurally also built in to HSSIBs own processes at all levels- compared to attempts by its pilot HSIB) means the patient pathway is not centred or understood or worked for. Inevitably fragmentation and reputational focus worsens these dynamics and nothing is conceived to mitigate these knowb risks. Patients continue to fall between greater dangerous cracks in a system not designed to what is needed. This is even worse for all discriminated against groups. This can be put in the framework of systemic epistemic exclusion and harm , embedded, reinforced, developed and never ecamined. Even within this occurs just within services eg maternity, the consequences of this are horrific and continuing, scandalous, significantly avoidable if only....
  2. E9f7f71e16b0da64af26f2b29a53ee79

    The epistemic exclusion of harmed patients in the patient safety field: A call to action from Richard von Abendorff

    rich squince commented on Patient-Safety-Learning's article in Patient engagement
    Some wise words relevant to epistemic exclusion: 'What do you think of scribes, tutor?' said the King to his tutor. 'Some of them are good, some of them are bad,' said the King's tutor. 'Fair enough,' said the King. 'No,' said the tutor, 'not fair enough.' 'How do you mean?' said the King. 'As I said,' said the tutor, 'some of them are bad,' 'Well,' said the King, 'if they're bad, they're bad. So what? If they're bad, no will bother to read them.' 'And that's where you're wrong,' said the tutor, ' a bad scribe is not a scribe who writes badly. A bad scribe is a scribe who makes us look bad.' 'Ah,' said the King, 'I hadn't thought of that. So is there anything we should do about these bad scribes?' 'Yes,' said the tutor. 'What?' said the King. 'Kill them,' said the tutor. 'O,' said the King, 'won't people object?' 'Of course,' said the tutor. 'So what do we do about that?' said the King. 'We say they were enemy soldiers,' said the tutor, 'and we're allowed to kill them.' 'Ah yes,' said the King, 'that makes sense.' 'Glad you see it that way,' said the tutor. ~ Michael Rosen
  3. E9f7f71e16b0da64af26f2b29a53ee79

    The epistemic exclusion of harmed patients in the patient safety field: A call to action from Richard von Abendorff

    rich squince commented on Patient-Safety-Learning's article in Patient engagement
    Exclusion of narratives, a form of censorship, is common in many public sector settings as well as the wider media. So I commend PSLHUB for giving space for discussion of this phenomenon. Further I note the current HSSIB Board has no patient voice embedded in it. Clearly other agendas take priority. I understand this was determined by Number 10 when the body became arms length. Hence also institutionally arms length from patient voices and with many corporate and medically established figures and their fingers at the centre.
  4. E9f7f71e16b0da64af26f2b29a53ee79

    Collaborating for safety: We need to make space for each other

    rich squince commented on Stephanie O'Donohue's article in How to engage for patient safety
    Excellent. I would add others: epistemic exclusion( 'we are experts ');Also where trauma means criticism of whole system it cannot be accepted (read https://blackwells.co.uk/bookshop/product/9781541602953?gC=5a105e8b&gclid=CjwKCAjwq4imBhBQEiwA9Nx1Bm3D3359eYA8MqVfgsgoh5JPPRBzq60mOKmcKZqgAlm_I8nuyQ0cexoCmNkQAvD_BwE ) also: interest ( professional, system, financial, personal, political, historical) meaning challenge is not possible because of implications. also 'othering'- patholigising , blaming, individualising. All linked. Solution: Patient inclusion, leadership, empowerment, centering. No one dares do this!
  5. E9f7f71e16b0da64af26f2b29a53ee79

    Patients who experience harm provide stories, but who will really engage with their insights and opinions?

    rich squince commented on rich squince's article in Patient stories
    HSIB Reccs made to NHSE and actions to ICBs but the latter do not have to respond to action suggestions. Who will chase up their local ICBs? The family should!
  6. E9f7f71e16b0da64af26f2b29a53ee79

    Will lessons be learned? An analysis of the systemic failures in the East Kent Maternity report

    rich squince commented on Patient Safety Learning's article in Trust investigations
    Damning on what not being done. Only solution is patient centred harm reporting and investigation and patient leadership at governance, culture and implementation level. All other internal system fixes will not do. For example
  7. Content Article

    Patients who experience harm provide stories, but who will really engage with their insights and opinions?

    rich squince posted an article in Patient stories
    This constructive commentary reflects on two recent related publications, the Healthcare Safety Investigation Branch (HSIB) report, Variations in the delivery of palliative care services to adults, and an article from Sarcoma UK, Family insights from Dermot’s experience of sarcoma care. Drawing from these publications, Richard, brother-in-law of Dermot, gives a family perspective, calling for a more open discussion around how we can improve palliative care and sarcoma services, and why we must listen and act upon family and patient experience and insight.
  8. E9f7f71e16b0da64af26f2b29a53ee79

    Patient Safety Commissioner Annual Report 2022-23 (July 2023)

    rich squince commented on Patient Safety Learning's article in England
    A patient voice directly and indirectly expressed through a HSIB national report https://sarcoma.org.uk/news/sarcoma-uk-supports-hsib-recommendations-on-variable-and-inequitable-palliative-care-in-england/
Registered address: Patient Safety Learning, China Works SB203, 100 Black Prince Road Vauxhall, London, SE1 7SJ

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