rich squince
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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!
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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
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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/
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Collaborating for safety: We need to make space for each other
in How to engage for patient safety
Posted
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!