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Showing results for tags 'Organisational culture'.
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News Article
Family hit a 'brick wall' seeking justice for baby
Patient Safety Learning posted a news article in News
The grandfather of a baby who died at a hospital that was fined over failings in the delivery has spoken of his five-year fight for justice. Derek Richford was speaking as an independent report into baby deaths at the East Kent Hospitals Trust will be released this week. He said he "came up against a brick wall" while searching for answers over the death of grandson Harry Richford. An inquest into Harry's death at Margate's Queen Elizabeth the Queen Mother Hospital in 2017 found it was wholly avoidable and contributed to by neglect. Coroner Christopher Sutton-Mattocks said the inquest, which was finally held in 2020, was only ordered due to the family's persistence. The following year the trust was fined £733,000 after admitting failing to provide safe care and treatment for mother Sarah Richford and her son following a prosecution by the Care Quality Commission (CQC). Mr Richford said: "To start with we felt fairly alone and we felt like we were coming up against a brick wall. "The trust were refusing at that time to call the coroner. They were reporting Harry's death as 'expected'. "We didn't contact anyone other than the CQC just to say 'look there's been a problem here'." He said at a meeting with the trust, more than five months later, "we suddenly realised that there were a huge [number] of errors". Mr Richford told the BBC: "It took me about a year to come up with all the detail I needed and to speak to all the right people." He said the family then spoke to the Health Safety Investigation Branch who found there were issues. Mr Richford also tracked down a "damming" report by the Royal College of Obstetricians and Gynaecologists (RCOG). "In the end it was like peeling back the layers of an onion, and the more you took off, the more you found," he said. Read full story Source: BBC News, 18 October 2022 -
News Article
‘Obfuscations and failures’ in trust’s handling of death, damning review finds
Patient Safety Learning posted a news article in News
There were ’obfuscations, difficulties and failures’ in a scandal-hit trust’s handling of a baby’s death, a damning review has found, although it cleared the organisation’s former chair of ’serious mismanagement’. A fit and proper person review into the conduct of former Shrewsbury and Telford Hospital Trust chair Ben Reid, who left in August 2020, has been published by the board. The report follows complaints about Mr Reid’s conduct from the family of baby Kate Stanton-Davies, who died in the trust’s care and whose case – alongside that of Pippa Griffiths – sparked the original Ockenden inquiry. In March 2022, the final Ockenden report into maternity services at Shrewsbury found poor maternity care had resulted in almost 300 avoidable baby deaths or brain damage cases in the most damning review of maternity services in the NHS’s history. Report author Fiona Scolding KC said she does not believe Mr Reid “lied” or acted unethically in his handling of complaints from the family and therefore this does not disqualify him from holding office within the terms of such a review. However, the report is highly critical of the trust, with Ms Scolding concluding it is “undoubtedly true” the provider had not dealt with Kate’s father Richard Stanton and her mother Rhiannon Davies in an “open and honest” way in respect of their daughter’s death. Read full story (paywalled) Source: HSJ, 13 October 2022 -
News Article
Outstanding air ambulance team 'go the extra mile'
Patient Safety Learning posted a news article in News
An air ambulance service has been praised by inspectors for providing an "outstanding level of care". The Care Quality Commission (CQC) carried out checks on the Essex & Herts Air Ambulance Trust (EHAAT) in August and September. The report said patients felt "truly respected and valued as individuals" and described teamwork as "exemplary". Ben Myer, EHAAT head of clinical delivery, said "everyone worked so hard to make the desired result a reality". The service provides emergency care and transport in Essex and Hertfordshire, and surrounding areas when needed. As well as being rated outstanding overall, the charity was also rated outstanding for being safe, effective, caring, responsive to people's needs - and being well-led. Jane Gurney, EHAAT chief executive, thanked the local community for supporting the service, and issued a personal thank you to "each team member across the charity, whatever their role, all of whom work so hard every day to uphold these high standards". Read full story Source: BBC News, 12 October 2022 -
News ArticleAn ambulance service rated ‘inadequate’ by the Care Quality Commission has set out a wide-ranging improvement plan, including ‘civility training’ for senior leaders and ensuring board members hear a mix of ‘positive and negative’ stories from patients and staff. South Central Ambulance Service has been moved into the equivalent of “special measures” by NHS England, in the wake of the Care Quality Commission report in August which criticised “extreme positivity” at the highest levels of the organisation. This means 3 out of only 10 dedicated ambulance service trusts in England are now in segment four of NHSE’s system oversight framework, the successor to special measures. The other ambulance services in segment four are East of England and South East Coast. In a damning inspection report published in August, the care watchdog said that leaders were “out of touch” and staff had faced a “dismissive attitude” when they tried to raise concerns. One staff member told inspectors: “When sexual harassment is reported it seems to be brushed under the carpet and the person is given a second chance. Because of this, a lot of staff feel unsafe, unsupported and vulnerable when coming to work.” An improvement plan summary published at the start of last month included a large number of priorites and actions, including to “ensure [a] mix of positive and negative patient/staff stories are presented to [trust] board meetings” – an apparent attempt to address CQC concerns that its positive outlook could feel “dismissive of the reality to frontline staff”. Read full story (paywalled) Source: HSJ, 11 October 2022
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News Article
Number of NHSE whistleblowers tripled in 2021-22
Patient Safety Learning posted a news article in News
The number of concerns reported by NHS England staff through the freedom to speak up process almost tripled last year, the organisation’s latest board papers have revealed. There were 152 cases received by the internal freedom to speak up guardians in 2021-22 compared to 56 in 2020-21. This year 54 cases were received in quarter three alone. The most common concerns are related to allegations of bullying and harassment. These accounted for nearly 40% of the total. People and team management concerns accounted for a third of FTSU cases. Within the latter, there were sub-themes of breakdown in relationships, failure to offer role models and sanctioning or ignoring poor culture. This week’s report also set out the NHSE FTSU guardian’s next steps. These include appointing a lead guardian, finalising a strategy and continuing to engage with Health Education England and NHS Digital staff as they are brought into NHSE next year. Read full story (paywalled) Source: HSJ, 7 October 2022 -
News ArticleHospital authorities in Wales have been accused of attempting to cover up failings in the delivery of a baby born with significant brain damage. Gethin Channon, who was born on 25 March 2019 at Singleton Hospital, in Swansea, suffers from quadriplegic cerebral palsy, a severe disability that requires 24/7 care. There were complications during his birth, due to him being in an abnormal position that prevented normal delivery, and he was eventually born via caesarean section. An independent review commissioned by Swansea Bay University Health Board (SBUHB), which manages Singleton Hospital, found “several adverse features” surrounding Gethin’s delivery that were omitted from or “inaccurately specified” in the hospital’s internal report. The investigation, carried out by obstetrician Dr Bill Kirkup, said SBUHB had “significantly” downplayed the “suboptimal” care received by Gethin and his mother, Sian, and had erroneously attributed his condition to a blocked windpipe. It also suggests that amendments were retrospectively made to examination notes taken by staff during the course of Ms Channon’s labour. The family said that SBUHB, which was flagged by national inspectors in the months after Gethin’s birth due to “concerns” over its ability to deliver “safe and effective” maternity care, had “covered up” the failings in their case. SBUHB said it had been “working tirelessly” with the family to investigate and address their concerns, and that it would be inappropriate to comment on specific allegations as the process was ongoing. Read full story Source: The Independent, 2 September 2022
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News Article
‘Appalled’ NHSE director orders safety review at all providers
Patient Safety Learning posted a news article in News
The NHS’ mental health director has branded abuse exposed at a city inpatient unit as “heartbreaking and shameful” and ordered a national review of safety across all providers. In a letter to all leaders of mental health, learning disability and autism providers, shared with HSJ, Claire Murdoch responded to BBC Panorama’s exposure of patient abuse at the Edenfield Centre run by Greater Manchester Mental Health FT by warning trusts they should leave “no stone unturned” in seeking to eradicate and prevent poor care. An investigation by the programme found a “toxic culture of humiliation, verbal abuse and bullying” at the medium-secure inpatient unit in Prestwich near Manchester. In response, Ms Murdoch said the mindset that “it could happen here” must be at the front and centre of national and local approaches, adding that trusts which already adopt this outlook are most likely to identify and prevent toxic and closed cultures. She also urged all boards to urgently review safeguarding of care in their organisations and identify any immediate issues requiring action now, such as freedom to speak up arrangements, complaints, and care and treatment reviews. A separate national probe into the quality of inpatient care is due to launch imminently. Read full story (paywalled) Source: HSJ, 30 September 2022 -
Content ArticleThe US Roadmap to Health Care Safety for Massachusetts sets five goals that will be reached through a sustained, collective state-wide effort among provider organisations, patients, payers, policymakers, regulators, and others.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) facilitated a half-day event on 17 March 2023 to ask how healthcare can understand and start to manage the risk of staff fatigue. Listen to a recording of the event.
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Content ArticleSafety culture, in formal social-scientific terms, is an object of knowledge. As such, it is part of a larger discursive practice of accident prevention, together with other objects like technical failure and human error. This study examines safety culture as an object in the discourse of accident prevention based on the Foucauldian approach.
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Content ArticleThe NHS Resolution Just and learning culture charter has been developed as a resource to support the creation of a person-centred workplace that is compassionate, safe and fair when care in the NHS goes wrong. Most of the time, care received by patients in the NHS is safe. Sometimes, even with our best intentions, things can go wrong. When things go wrong, support, care and understanding for everyone involved must be a priority. At no time is there an excuse for incivility, bullying and harassment within the NHS. We accept the evidence that the NHS will provide safer care and be a healthier place to work if we address all of the components of a learning organisation and this underpins our charter. The hope is that this charter will act as a tool to help organisations take a consistent approach towards staff in relation to incidents and errors.
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Content ArticleHow can improvement-led delivery enhance the quality of outcomes for our patients, communities and our health and care workforce? In April 2022, Amanda Pritchard requested a review of the way in which the NHS, working in partnership, delivers effectively on its current priorities while developing the culture and capability for continuous improvement. Led by Anne Eden, NHS Regional Director South East, with a steering group chaired by Sir David Sloman, Chief Operating Officer, NHS England, the review team co-developed 10 recommendations with health and care leaders that have been consolidated into three actions.
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Content ArticleThis BMJ Leader article from Roger Kline looks at how to tackle structural racism in the NHS, discussing psychological safety and inclusion, and the role leaders need to play.
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Content ArticleMany healthcare leaders are governed by deep-set habits, behaviours and lessons learned over many years in an environment that was much less complex than today's. This creates barriers to success, perpetuating the challenges that we strive to overcome. The author of this article, published by NHS providers, argues that before we can adopt new habits, behaviours and processes, we have to "unlearn" the lessons of old.
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Content ArticleThe ‘No Blame Culture’ being adopted by the NHS draws attention from individuals and towards systems in the process of understanding an error. This article in the Journal of Applied Philosophy argues for a ‘responsibility culture’, where healthcare professionals are held responsible in cases of foreseeable and avoidable errors. The authors argue that proponents of No Blame Culture often fail to distinguish between blaming someone and holding them responsible, They examine the idea of ‘responsibility without blame’, applying this to cases of error in healthcare. Sensitive to the undesirable effects of blaming healthcare professionals and to the moral significance of holding individuals accountable, the authors argue that a responsibility culture has significant advantages over a No Blame Culture as it can enhance patient safety and support medical professionals in learning from their mistakes, while also recognising and validating the legitimate sense of responsibility that many medical professionals feel following avoidable error, and motivating medical professionals to report errors.
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Content Article
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This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Jonathan talks to us about the importance of leadership in creating a safety culture and the role of Patient Safety Learning in fostering collaboration and establishing standards for patient safety. -
Content ArticleAqua recently convened a selection of expert panellists to a round table discussion, chaired by Professor Ted Baker, to consider ‘what does safety look like at a system level?’ and discuss the key issues and help support the development of Integrated Care Systems. This report captures the key themes covered in this discussion.
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Content ArticleIf a manager approaches your desk, do you feel a sense of anxiety? If your team wants to challenge an idea or offer a different perspective, do they feel free to speak up? These are both examples of psychological safety - or a potential lack thereof - in the workplace. Organisations have focused heavily on mental health and well-being at work over the last few years, but many still lack an awareness of psychological safety, how it can impact your team and the consequences of an unsafe culture. This article looks at how you can measure and improve psychological safety.
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Content ArticleImperial College Healthcare share a poster on their strategic goals and their values and behaviours.
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Content Article
Kindness in healthcare website
Patient Safety Learning posted an article in Good practice
This 'Kindness in healthcare' website is the home for ‘conversation for kindness’, which is a monthly meeting that was set up in the summer of 2020 by a group of colleagues and friends working in healthcare across Sweden, the UK and the USA. The initial purpose of getting together was to have some time together to continue some initial conversations around kindness, and to explore its role at the ‘business end’ of healthcare. As the conversation has developed, interest in this work has grown and it now has contributors from almost 30 different countries across the globe. The monthly virtual call takes place the 3rd Thursday of every month (6-7pm GMT) and its focus is on listening, learning, thinking differently and mobilising for action It's an open culture of sharing of resources, energy and ideas. -
Content Article
In this blog, Steve Turner reflects on why genuine patient safety whistleblowers are so frequently ignored, side-lined or victimised. Why staff don't speak out, why measures to change this have not worked and, in some cases, have exacerbated the problems. Steve concludes with optimism that new legislation going through Parliament offers a way forward from which everyone will benefit.- Posted
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Content Article
In this article, published in the Future Healthcare Journal, Helen Hughes, Chief Executive of Patient Safety Learning, reflects on how avoidable harm continues to occur, ten years on from the Francis report into major patient safety failings at Mid Staffordshire NHS Foundation Trust. She describes an implementation gap—where safety concerns and issues highlighted in inquiries and reviews are not being translated into improvements in patient safety. The article outlines some of the key barriers to implementation and suggests what needs to change to ensure we truly learn lessons from patient safety scandals such as Mid Staffordshire. -
Content Article
NHS Employers: Improving staff retention (April 2022)
Patient Safety Learning posted an article in Culture
As organisations navigate the ongoing impact and fallout of the COVID-19 pandemic, they must focus on strengthening the supply of our highly valued workforce and ensure that both new and existing staff are supported and encouraged to remain. In partnership with NHS England and NHS Improvement, NHS Employers has refreshed their retention guidelines. There are two main objectives for this guide: first, ensuring it continues to draw on the latest learning and innovation from the COVID-19 pandemic, which has forced employers to critically re-examine how to retain NHS staff. Second, ensuring it supports the ambitions set out within the NHS People Promise, so that employers can work to make this a lived reality for all NHS staff. To help achieve these objectives, this guide explores the experiences of organisations NHS Employers has worked with on retention. -
Content ArticleAqua recently convened a selection of expert panellists to a round table discussion, considering ‘What does safety look like at a system level?’. The round table was chaired by Professor Ted Baker, who led the discussion around the key issues facing Integrated Care Systems and how we can help support their development.
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Content ArticleThis plan from NHS England sets out how the NHS will make maternity and neonatal care safer, more personalised, and more equitable for women, babies, and families. NHS England has engaged a wide range of stakeholders who supported the development of this plan. This includes women and families who have used or are using maternity and neonatal services, members of the maternity and neonatal workforce, leaders and commissioners of services, NHS systems and regional teams, and representatives from Royal Colleges, charities and other organisations.
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