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As an agency scrub nurse, I was booked to work out of London in a private clinic. This was to work two nights and two days in theatres. It was my very first agency shift. On the way to the theatres, escorted by a porter, I slipped on the stairs whilst holding on to the rails and fell, sustaining a right dislocated shoulder. I had it relocated in A&E in a local NHS hospital and was given entonox and morphine. I returned to London the next morning – the taxi fare of £220 was not covered by the clinic. I have now been unemployed for many weeks due to the injury. The Agency left it to me to handle the compensation with the hospital and the Union could not help as I did not have a photo of the stairs or other evidence of steps being wet, etc. Therefore, I will get zero compensation. Health and Safety at the hospital said I tripped over my own feet and I should have held on to the rails. When I told them that I had actually gripped the rails as it is my habit to do this anyway – they said I "should have gripped the rails tighter"! My argument is if everyone using the stairs is required to grip tightly to the rails, where are the signs to tell them to do this? The hospital said a Riddor (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations) was unnecessary. The Health and Safety Executive (HSE) accepted my Riddor report online and promised to tell the hospital of their responsibility to report my injury. So I urge my Agency colleagues, to be careful. If you are badly injured, ensure you or someone on your behalf takes photos so your Union can help you. Also ask your Agency about injury compensation before you accept shifts. If you are on a permanent contract in the NHS or a private clinic and just doing the odd agency shift, you can get quick treatment and sick leave pay for your injury. However, if like me, you are on bank shifts, you get no sick leave and NHS treatment for your injury is painfully slow. I suggest investing in health insurance – I will be doing that now. Above all, please be safe wherever you work, and extra vigilant when using steep stairs and also stairs with edges that are not non-slip covered. And most importantly, always remember to "HOLD TIGHTLY TO THE RAILS"!

WHO's definition of an After Action Review and resources Guidance for After Action Review After Action Review infographic 3 minute video explaining the AAR practice as promoted by WHO, including the definition, the different methodologies and available resources. After Action Reviews and simulation exercises

Problems related to the care home and the company were known well before the Panorama expose in 2016. When the Panorama programme was aired it resulted in immediate closure of one home and all the homes which were operated by Morleigh being transferred to new operators. The Review includes reports of abuse against residents; residents being left to lie in wet urine-soaked bedsheets; concerns from relatives about their loved ones being neglected; reports of there being insufficient food for residents, no hot water and no heating; claims that dozens of residents were sharing one bathroom. Here's a summary of the report's findings: More than 100 residents had concerns raised more than once. More than 200 safeguarding alerts were made for individuals but only 16 went through to an individual adult safeguarding conference. More than 80 whistleblower or similar reports were made concerning issues that put residents at risk. 44 inspections were undertaken at Morleigh Group homes in the three-year period, the vast majority identifying breaches. There was a period of at least 12 months when four of the homes had no registered manager in place. During the three-year period reviewed the police received 130 reports relating to the care homes. A spokesperson for Cornwall Council said: “We have different procedures and policies in place and have invested time, money and staffing into making sure that we can respond better when concerns are raised.'' “One of the problems was that all the partners had their own policies and procedures but they weren’t integrated. That is probably one of the key issues that we have now addressed.” “The assessment is so different now and the organisations are working much more closely that it reduces the risk dramatically.'' This is an important and long-awaited review. This situation echoes other care home scandals across the UK. I urge everyone to read the full report and reflect on the real root causes of the problem, which I believe go well beyond failings in inter-agency policies and communication. What would your action plan be? How would you monitor it?