Sam

The Learn from Patient Safety Events (LFPSE) service is the NHS's new system for the recording and analysis of patient safety events. Very little research had been done before to understand the best ways to make sure patients, service users and their families can give their views on safety incidents, for the whole NHS to learn from. Learning from patients’ experiences and how they feel about the care they have received is known to be a very good way to make healthcare services better. However, getting the right information from people in the right way, and making sure the right NHS staff see it and can act on it, is difficult to do. This Show and Tell outlines the research completed to understand how we can do this better through the introduction of the LFPSE service. Audience: This is a publicly open event for anyone interested in understanding the work that NHS England has completed into understanding the best ways to make sure patients, service users and their families can give their views on safety incidents, for the whole NHS to learn from. Speakers: Lucie Mussett Patient Safety Lead & Senior Product Manager for the Learn from patient safety events (LFPSE) service Hope Bristow – Senior User Centred Designer (Informed Solutions) Natasha Hughes – User Researcher (Informed Solutions) Register

This two-day King's Fund conference aims to explore how the current strain on services makes listening to people more difficult but even more important, at a time when public satisfaction with the NHS is at an all-time low. Join us to hear about how you can make sure building in the user voice is routine and core to the business of the health and care system, not just ‘a nice to have’. Conference sessions will: discuss how the NHS and social care cannot deliver quality unless listening to patients and carers, and acting on their feedback, lies at the heart of its culture.   provide learning on how to listen well and what meaningful engagement with people and communities looks like. Gain insight into the findings from the Fund’s project on understanding integration with the HOPE (Heads of Patient Experience) network by working with six sites on an action learning piece. Learn about how health and social care decision-makers cannot overcome challenges and answer long-term questions alone - such as how the system will address the deep inequalities and how it can adapt to provide the joined-up, efficient care that people want and gives them more control – public input is crucial. Join peers to share learning on grasping this opportunity to finish building a culture where listening to patients, service-users, and communities is everyone's business.   Register

This free online event is an exciting opportunity to hear nursing workforce expert, Professor Alison Leary MBE, speak on the subjects of safe caseloads in community nursing. Professor Alison Leary PhD RN FRCN is Chair of Healthcare & Workforce Modelling at London South Bank University and Director of the QNI’s International Community Nursing Observatory. We will also hear from Cathy Woods and representatives of the software company Yarra, on the Use of E-CAT software for Monitoring Caseloads. The E-CAT product for district nursing is an electronic tool which supports caseload analysis and audit. Underpinned by a bespoke dependency tool and based on a methodology validated by the University of Ulster, the tool looks at caseload variables at all levels, from caseload holder to commissioner and facilitates caseload benchmarking and performance management. The tool has been implemented in all five health trusts in Northern Ireland providing a significant regional evidence base. We will be able to hear about the experience of using E-CAT in Northern Ireland from the NI Public Health Agency. Register

Agenda and registration

Last year, our helpline advisers dealt with an average of two calls a day relating to complaints – could the caller complain about what had happened? How to complain? Who to complain to? This event is for patients and carers who would like answers to some basic questions about complaining about care. Solicitors Chris James and Josh Hughes from law firm Bolt Burdon Kemp will be joining our Chief Executive Rachel Power in this online event. Between them they’ll: Help people understand the NHS complaints process, including its limitations Describe how to get the most out of making a complaint Explain were the distinction can lie between poor service and a claim in negligence. Register

The Safe Anaesthesia Liaison Group (SALG) Patient Safety Conference will be held virtually this year on Thursday 23 November 2023. The first session will include engaging lectures around the current work of SALG, and the second session will focus on topical issues in relation to a selected group or society (yet to be announced). There will be a prize session for accepted abstracts, with a poster section and oral presentations. This online conference is being organised by SALG co-chairs, Dr Peter Young from the Association of Anaesthetists, Dr Felicity Platt, Royal College of Anaesthetists The day will provide valuable knowledge for doctors engaged in clinical anaesthesia, pain management and intensive care medicine, and who have an interest in improving patient safety. Register

This conference focuses on patient involvement and partnership for patient safety including implementing the New National Framework for involving patients in patient safety, and developing the role of the Patient Safety Partner (PSP) in your organisation or service. The conference will also cover engagement of patients and families in serious incidents, and patient involvement under the Patient Safety Incident Response Framework published in August 2022. This conference will enable you to: Network with colleagues who are working to involve patients in improving patient safety. Reflect on patient perspective. Understand the practicalities of recruiting Patient Safety Partners. Improve the way you recruit, work with and support Patient Safety Partners. Develop your skills in embedding compassion and empathy into patient partnership. Examine the role of patients under the new Patient Safety Incident Response Framework (PSIRF). Understand how you can improve patient partnership, family engagement and involvement after serious incidents. Identify key strategies for support patients, their families and carers to be directly involved in their own or their loved one’s safety. Learn from case studies demonstrating patient partnership for patients safety in action. Examine methods of involving patients to improve patient safety in high risk areas. Self assess and reflect on your own practice. Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register **Five free places for hub members. Email [email protected] for code**

AHSN are launching new resources to help patients participate fully in Structured Medication Reviews with Shared Decision Making. During this lunchtime webinar, you will learn about: The importance of shared decision making when undertaking Structured Medication Reviews with patients. How our new range of free, evidenced-based resources can support and help prepare patients invited for a Structured Medication Review with their GP, pharmacist or other healthcare professional. The resources are available in a range of formats and languages from the AHSN Network website: Resources to support patients having a Structured Medication Review – The AHSN Network. Event programme: Professor Tony Avery, GP and National Clinical Director for Prescribing, NHS England, will present on key strategic and policy drivers and highlight why Structured Medication Reviews and shared decision making are crucial in tackling problematic polypharmacy and unnecessary medicines and lead to better patient outcomes. Clare Howard, Clinical Lead AHSN National Polypharmacy Programme, will share findings from the AHSN pilot to test the patient-facing resources ahead of national rollout. Partner organisations showcasing co-creation and development of the resources with patients: David Alldred PhD, FHEA, FRPharmS, Professor of Medicines Use and Safety, Leeds University & NIHR Yorkshire and Humber Patient Safety Research Collaboration Daniel Okeowo, MPharm, MRPharmS, Doctoral Training Fellow, NIHR Yorkshire and Humber Patient Safety Translational Research Centre Graham Prestwich, Patient Representative and Innovator, Me and My Medicines Gemma Donovan, Medication Behaviours: Are Your Medicines Working? This will be followed by a panel discussion and Q&A Register

The 15th annual HSJ Patient Safety Congress brings together more than 1000 attendees with the shared goal of advancing the national agenda for patient safety across health and social care. In this blog, Samantha Warne, the hub's Lead Editor, captures some of the key highlights and messages from day one of HSJ’s Patient Safety Congress. How can we reset on safety and thrive in today’s healthcare environment? Shaun Lintern, longstanding Chair of the Patient Safety Congress and Sunday Times Health editor, opened the Congress by reflecting on the current state of the country and the healthcare service, highlighting the challenges that winter approaching will bring, the recent scandals, ongoing police inquiries, Lucy Letby, crumbling roofs and workforce problems, and asked the question: How can we reset on safety and thrive in today’s healthcare environment? Closed cultures and restrictive practices Putting mental health at the forefront of the agenda, along with the theme from this year’s World Patient Safety Day, ‘engaging patients for patient safety’, the Congress began with a heart breaking but powerful patient story from Sharon Clarke, mother of Ryan. Ryan is autistic and was detained for 17 years in mental health units despite no crime being committed. Ryan had to mix with violent offenders, spent 3 years in solitary confinement, was at times heavily medicated and at one point was restrained by nine members of staff where he broke his hand. It took years of campaigning to finally get Ryan out, but Ryan is now thriving and happy in supported living. But this is not an isolated case. There are 2000 people with autism and learning disabilities who are currently detained. The Government has said numerous times that they will get them out but it was only Sharon’s tenacity that changed things for Ryan. A panel discussion followed on how we are letting vulnerable patients in closed cultures down. Professor Joy Duxbury, Professor of Mental Health at Manchester Metropolitan University, spoke about how the over-reliance on restrictive practices when supporting vulnerable people who become distressed is an ongoing and serious concern. Joy highlighted the charity, Restraint Reduction Network, which is working towards reducing reliance on restrictive practices. We also heard from Chris Dzikiti, CQC’s director of mental health, who said that the watchdog is meeting with chairs and CEOs of providers to ensure they are demonstrating leadership in tackling closed cultures following a series of high-profile scandals. He said clear action plans must be shown to inspectors assessing services, particularly where poor practices have been identified. He told the event: “If ever we’re going to change the culture of services we need our leaders to be counted on. I say to leaders, CEOs and chairs, if you honestly wait for CQC to come and tell you what’s wrong in your organisation then something’s wrong.” Regulation of NHS board members and managers? Next on the agenda was Aidan Fowler, National Director of Patient Safety at the Department of Health and Social Care, who gave an update on the Patient Safety Strategy. He cautioned against the ‘false hope’ of trying to achieve ‘zero harm’ from healthcare, describing it as unachievable. He told delegates: “The dream of zero harm is appealing. It’s what we all want. But it’s unachievable in reality, it’s unmeasurable [and] it carries risk.” Aidan said what is really meant is eliminating “avoidable harm”, but also described this as “problematic”. He stressed the ambition should be to reduce harm to minimal levels, but said the notion that any provider could claim they had no harm for period of years was “hard to credit”. He also highlighted the recent Martha’s rule as an example of how healthcare will work with and amplify the family/patient voice and empower people when there is a concern. Aidan was asked whether NHS board members and managers should be regulated, amid calls for this in the wake of the Lucy Letby scandal. He said: “I think there are pros and cons to regulation… What I would say is that you just have to be cautious that you do not lead to a disbarring process without the developmental side of regulation, and the support side of regulation. For staff, to support them to do a good job. “We have seen that there is a gap in patient safety training for boards, which we need to work on, for them to understand and to encourage them to talk about it more.” Speaking about lessons from the Letby case more widely, Aidan told the congress there was a danger in patient safety of “looking in the rear view mirror”, and said leaders needed to move to a system where concerns “are sensed in real time” and responded to “at first sign of any concern”. On the panel was Dr Rosie Benneyworth, Healthcare Safety Investigation Branch’s interim chief investigator, and she told the Congress that she felt managers should be regulated, but that it was the wrong question we are answering. “I do not think regulation of managers will stop another Lucy Letby… I do not think we should be jumping on regulation of managers because of Lucy Letby,” she said. “However, I think regulation done well can drive up standards, it can lead to improvements, and it can also make sure that there is an oversight on the national level of people working in the system”. “Managers are vital in healthcare and are as equally important to a person’s healthcare as a doctor and a nurse.” Putting patients and family at the centre One of the streams for the first day was ‘Putting patients and family at the centre’, looking at the gap between aspiration and reality and what we can do to bridge that gap. In the first session of this stream we heard from Dr Dawn Benson and her son Michael, in one of the most touching and inspiring presentations of the day. Michael has cerebral palsy and learning impairment due to avoidable harm at birth. Michael spoke about the ‘social model’ of disability, which is the understanding that disability is something that is created by society. This is because disabled people face barriers that stop them from taking part in society in the same way as non-disabled people. Michael spoke about the patient’s need to be empowered and how healthcare professionals need to listen to the patient. Dawn reflected on how she would have liked to meet the healthcare professionals involved in Michael’s birth to hear how the event had impacted their lives. She rejected the term ‘second victim’ for staff, as she said as a mother she was the second victim, but she said staff were ‘third victims’ and that were multiple victims in a patient safety event. She also described what she felt ‘good’ family involvement looked like, highlighting the ability to ask questions, being an active participant, not wanting compassion but respect, and acknowledging that not everyone has the interpersonal skills needed in an investigation and that organisations need to make sure the right people with the right skills are doing it. The session ended with a powerful statement from Michael when asked what he thought about the people involved in his birth: “They are only humans, but they do make mistakes, but they must learn from their mistakes, if not they shouldn’t be in the job”. Perceptions of working with harmed families The last session of the morning in the ‘putting patients and family at the centre’ stream was from Rosi Reed and Dorit Braun, from Making Families Count. Making Families Count aims to improve outcomes for families affected by serious harm and traumatic bereavements in health and social care services and offers peer support, training, information, advice and guidance. This session examined the misconception that all families want is someone to blame and the perceptions of working with harmed families. Rosie and Dorit highlighted three key things that families want: Openness and honesty – to know the complete and total truth. Parity – to be treated as an equal partner in any investigation Remediation – to know what will happen as a consequence of learning from the investigation. Making Families Count have recently developed in partnership with NHS Trusts, the ‘Compassionate Communication, Meaningful Engagement handbook’ for all NHS staff which aims to improve collaboration with patients, their families and carers following a patient safety event. Dorit and Rosi both shared their personal stories of the death of a family member. Dorit described her daughter-in-law who died during a psychotic episode having been discharged the previous evening. You can read more on Dorit’s story in a blog Dorit shared with the hub: Safer outcomes for people with psychosis. Using her experience, Dorit spoke about the Making Families Count project, Life Behind the Cubicle. The project is working in partnership with Oxford Health NHS Foundation Trust service users, families and carers, and clinicians to develop and test an eLearning resource to enable professionals to properly engage families and friends in a care pathway for someone with an acute mental health episode. Patient Safety Management Network Over lunch, attendees used the opportunity to speak to the presenters, meet others working in patient safety and share ideas, including at the Patient Safety Management Network stand. The Patient Safety Management Network, created in June 2021 and hosted on Patient Safety Learning’s hub, is an innovative voluntary network for patient safety managers and everyone working in patient safety. You can join the Network by signing up to the hub today. If you are already a member of the hub, please email [email protected]. Not one size fits all In the afternoon we heard from Sarah Tilsted from the Patients Association, Professor Mahendra Patel, chief executive at the Centre for Research Equity, and Dr Habib Naqvi from NHS Race and Health Observatory in a session on how health inequities and discrimination are impacting patients and families. Sarah spoke about the lived experience advisory panel, Patient Voices Matter (PVM). Although from varied backgrounds, the themes coming out of the group were common, no matter what their background, religion, ethnicity: these were lack of accessibility to healthcare, communication difficulties, lack of personalisation. Sarah highlighted six principles of patient partnership, including that services and systems make sure patients are fully informed in a way that patients can access and understand, and that inequalities are recognised and appropriate approaches adopted for different patient groups and communities, identifying and meeting their specific needs. Professor Patel and Dr Naqvi discussed how research must be more representative and how to make sure people from different disabilities, ethnicities and religions are recruited for research and trials. If we don’t get patient communities involved at the clinical trial stage, this lack of clinical representation means medications and medical devices will not be fit for purpose. Dr Naqvi gave the examples of pulse oximetry during Covid and the drawbacks when using pulse oximetry on darker skin, and a trial that showed a cancer drug behaved differently in black patients. He also told us how the NHS Race and Health Observatory are working on projects such as jaundice testing, closing the gap in maternal mortality and increasing representation in a clinical trial in breast cancer. Families just want the truth The final session in the ‘putting patients and family at the centre’ stream was from Dr Josephine Ocloo and David Smith. They shared their own personal experiences of loss and how they became involved in the National Learning from Death’s programme. They highlighted the four key themes that families want, which echoed what Rosie and Dorit had said earlier in the day: Independence and accountability. Honesty and compassion. Equality. Leadership and culture change. David and Josephine spoke about the importance of open and honest conversations with those people involved when a patient dies of avoidable harm. Josephine highlighted the key principles that bereaved families and carers should expect after the death of someone in NHS care and voiced her frustration that these principles haven’t been embedded in organisations and that there needs to be a cultural change. She spoke of a current culture of protecting the reputation and entity of an organisation and how the regulators are failing us and that they need to hold corporate organisations to account. The power of an apology The first day of the Patient Safety Congress finished with the James Reason Lecture, this year from Marina Cantacuzino, Founder of the Forgiveness Project. Marina has spent 20 years learning about how people recover and heal, and examines the power of sincere apology and its relationship to forgiveness. This was a fitting end to a day filled with inspiring and at times harrowing personal stories of loss, campaigning for justice and the need for change.