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Content ArticleChris Elston, Patient Safety Education Lead, University Hospital Southampton, shares with the hub his Trust's Patient Safety Incident Response Framework (PSIRF) frequently asked questions. Please feel free to adapt and share at your own organisation.
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Content Article
On 18 August 2023, Lucy Letby was found guilty of murdering seven babies and convicted of trying to kill six other infants at the Countess of Chester Hospital. Looking ahead to the forthcoming independent inquiry into this case, Patient Safety Learning, reflecting on the inquiries of the past, sets out some key patient safety themes and issues that should be considered as part of this.- Posted
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News Article
Female surgeons sexually assaulted while operating
Patient Safety Learning posted a news article in News
Female surgeons say they are being sexually harassed, assaulted and in some cases raped by colleagues, a major analysis of NHS staff has found. The Royal College of Surgeons said the findings were "truly shocking". Sexual harassment, sexual assault and rape have been referred to as surgery's open secret. There is an untold story of women being fondled inside their scrubs, of male surgeons wiping their brow on their breasts and men rubbing erections against female staff. Some have been offered career opportunities for sex. Nearly two-thirds of women surgeons that responded to the researchers said they had been the target of sexual harassment and a third had been sexually assaulted by colleagues in the past five years. Women say they fear reporting incidents will damage their careers and they lack confidence the NHS will take action. It is widely accepted there is a culture of silence around such behaviour. Surgical training relies on learning from senior colleagues in the operating theatre and women have told us it is risky to speak out about those who have power and influence over their future careers. Read full story Source: BBC News, 12 September 2023 Related reading on the hub: Breaking the silence: Addressing sexual misconduct in healthcare Calling out the sexist and misogynist culture within healthcare: a blog by Dr Chelcie Jewitt, co-founder of the Surviving in Scrubs campaign GMC's Good medical practice 2024 -
Content ArticleResearch published in the British Journal of Surgery demonstrates that sexual harassment and sexual assault are commonplace within the surgical workforce and rape happens. This report from the Working Party on Sexual Misconduct in Surgery is a call to action, with a series of recommendations, for healthcare institutions to face up to the shocking reality of sexual misconduct within their organisations. Further reading: Sexual harassment, sexual assault and rape by colleagues in the surgical workforce, and how women and men are living different realities: observational study using NHS population-derived weights Calling out the sexist and misogynist culture within healthcare: a blog by Dr Chelcie Jewitt, co-founder of the Surviving in Scrubs campaign GMC's Good medical practice 2024
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Content ArticleThis research examined sexual misconduct occurring in surgery in the UK, so that more informed and targeted actions can be taken to make healthcare safer for staff and patients. A survey assessed individuals’ experiences with being sexually harassed, sexually assaulted, and raped by work colleagues. Individuals were also asked whether they had seen this happen to others at work. Compared with men, women were much more likely to have seen sexual misconduct happening to others, and to have it happen to them. Individuals were also asked whether they thought healthcare-related organizations were handling issues of sexual misconduct adequately; most did not think they were. The General Medical Council (GMC) received the lowest evaluations. The results of this study have implications for all stakeholders, including patients. Sexual misconduct was commonly experienced by respondents, representing a serious issue for the profession. There is a widespread lack of faith in the UK organizations responsible for dealing with this issue. Those organizations have a duty to protect the workforce, and to protect patients. Further reading: Breaking the silence: Addressing sexual misconduct in healthcare Calling out the sexist and misogynist culture within healthcare: a blog by Dr Chelcie Jewitt, co-founder of the Surviving in Scrubs campaign GMC's Good medical practice 2024
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Content Article
Near misses or great catches? A blog by Emma Walker
Patient Safety Learning posted an article in In health care
After attending a recent Patient Safety Management Network session, Emma Walker reflects on reporting on near misses. -
Content ArticleIn this article in the Scotsman, former whistle blower, Iain Kennedy, writes about the culture of fear and blame in Scotland's NHS and how NHS staff must feel free to speak up about problems that affect patient safety.
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News Article
Execs accused of ‘bullying culture and misuse of power’
Patient Safety Learning posted a news article in News
Former commissioning chiefs have been accused of presiding over a ‘culture of bullying’ at the predecessor organisation to Norfolk and Waveney Integrated Care Board, as part of a legal claim from a former employee. The accusations, which have been made in an employment tribunal case, relate to former chief executive Melanie Craig and other former executives at what was then Norfolk and Waveney Clinical Commissioning Group. Ms Craig now leads Suffolk Community Foundation, a local voluntary sector organisation. The claims have been made by a former long-standing assistant director for mental health services, Clive Rennie, who has claimed unfair dismissal. However, the integrated care board said it disputes the claims and is defending the case. In a witness statement to the tribunal, which began this week, Mr Rennie alleges there was an “authoritarian and dictatorial style of management” and described a “culture of bullying and misuse of power that had emerged under the leadership of Melanie Craig and which included the executive team”. Read full story (paywalled) Source: HSJ, 6 September 2023 -
News Article
NHS staff to be asked about sexual harassment for the first time
Patient Safety Learning posted a news article in News
NHS staff will be asked if they have experienced sexual harassment or inappropriate behaviour in the workplace for the first time. In a letter, NHS England chief delivery officer Steve Russell said the upcoming annual staff survey would include the following question: “In the last 12 months, how many times have you been the target of unwanted behaviour of a sexual nature in the workplace? This may include offensive or inappropriate sexualised conversation (including jokes), touching or assault.” Mr Russell said the anonymous answers to the new question would “help us understand the potential prevalence of sexual misconduct in your organisation and inform further action to protect and support staff across the NHS”. It comes as NHSE launches the health service’s first sexual safety charter to help protect staff from harassment and inappropriate behaviour. The charter is an agreement comprising 10 pledges, including commitments to provide staff with clear reporting mechanisms, training, and support from managers. Read full story (paywalled) Source: HSJ, 6 September 2023 -
News Article
Trust told it ‘lacks skills or integrity’ to carry out suicides review
Patient Safety Learning posted a news article in News
A senior clinician has raised fundamental concerns about a trust’s probe into dozens of suicide cases, which was sparked by his allegations that staff had tampered with the notes of a patient. Cambridgeshire and Peterborough Foundation Trust announced in July there would be an internal review of 60 suicide cases dating back to 2017. But a key whistleblower told HSJ he fears it could be a “whitewash” and it should be carried by an external, independent investigator rather than led by the trust. The suicides review was prompted by allegations staff had added a care plan into the patient record of Charles Ndhlovu, a day after the 33-year-old had died by suicide in 2017. The allegations, not contested by the trust, were based on the findings of an internal investigation in 2021 of the trust’s conduct around Mr Ndhlovu’s case. Read full story (paywalled) Source: HSJ, 6 September 2023 -
Content ArticleIn this article for Health Services Insight, NHS consultant David Oliver examines why most comments on articles in the Health Services Journal (HSJ) are posted anonymously. He highlights that this tendency towards anonymity from commenters who are clearly in influential, senior NHS posts, indicates that the culture in the NHS management community, from NHS England down, is one that makes most people fearful of saying anything in their own name in case of reprisal. He also points out that a culture where people are afraid to make comments and criticisms in their own name is in conflict with the Nolan Principles of 'selflessness', 'integrity', 'objectivity', 'accountability', 'openness', 'honesty' and 'leadership' that senior NHS managers and officials are supposed to be guided by.
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Content ArticleIn the wake of the conviction of Lucy Letby, a neonatal nurse who has been found guilty of the murder of seven babies and attempted murder of six babies, the focus of the nation is on the multiple tragedies that the families have faced, the healthcare staff who tried to blow the whistle, and safety issues in hospitals. NHS England has responded to the conviction by stating that trusts should look at whistleblowing policies, that those unfit to hold directorships should not be appointed, and with that well worn phrase “lessons will be learned.” But will they? In this BMJ opinion piece Alison Leary, professor of Healthcare and Workforce Modelling at London South Bank University, looks at why the NHS has failed to learn lessons from patient safety tragedies spanning the last fifty years. She highlights that unlike other safety critical industries, healthcare is still wedded to concepts that effectively deny the complexity of work and the social structures that surround work. This includes a failure to see the value in retaining experienced staff and a hierarchical approach to the value of work. She also outlines that more focus should be placed on management listening, rather than on staff having to find the courage to speak up when they have concerns: "When workers are listened to and constructive dissent is encouraged and normalised, along with the reporting of incidents, there is little need for whistleblowing. A workforce that must resort to whistleblowing is a symptom of poor safety culture."
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News Article
NHS ‘a long way’ from being ‘proactive’ on safety, watchdog warns
Patient Safety Learning posted a news article in News
Integrated care systems (ICSs) should factor patient safety into all their operational and financial decisions, the Healthcare Safety Investigations Branch’s chief investigator has urged. Rosie Benneyworth, who was appointed as interim chief investigator last summer, said other safety-critical industries made decisions on the basis of a “triad” of operations, finances and safety. She said the NHS needed to be “more proactive” to take action before things go wrong. Dr Benneyworth said in an interview with HSJ: “I think it’s fundamental that ICSs put safety at the core of everything they do. And I don’t think operational decisions or financial decisions should be made without considering the implications for safety.” Dr Benneyworth – a former GP and commissioner – also spoke about whistleblowing in the wake of the Lucy Letby scandal, saying national organisations should “lead the way” on being proactive over safety and supporting whistleblowers. Major cultural problems were uncovered at HSIB several years ago, while NHSE has been under the spotlight in recent weeks for implementation of the “fit and proper person” test for board members. “I think it’s very difficult as national organisations to tell providers what they should [be] doing, if we’re not doing it ourselves,” Dr Benneyworth said. She added: “What we need is a much more proactive approach to safety, where we actually identify those things that could go wrong and take action before they do go wrong." Read full story (paywalled) Source: HSJ, 5 September 2023 -
Content ArticleThis is an oral statement given to the House of Commons by the Secretary of State for Health and Social Care, Steve Barclay MP, to update on the Lucy Letby statutory inquiry.
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Content ArticleIn this interview for Times Radio, Sir Robert Francis KC, who led the 2010 inquiry into failures in care at Mid Staffordshire NHS Foundation Trust, discusses the benefits and disadvantages of statutory and non-statutory inquiries. In light of Lucy Letby's conviction for the murder of seven babies under her care while she worked as a NICU nurse, he also talks about how poor organisational culture can lead to staff covering up patient safety concerns.
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News Article
Whistleblowers sacked by NHS fear no change after Lucy Letby case
Patient Safety Learning posted a news article in News
NHS clinicians who were sacked after blowing the whistle about avoidable patient deaths say they fear lessons from the Lucy Letby murder trial have not been learned and the case will make no difference to their own claims for unfair dismissal. They say hospital bosses are still more concerned about reputation than patient safety, despite what emerged in the Letby case about the tragic consequences of ignoring consultants who first raised suspicions about her killing babies. Mansoor Foroughi is appealing against his dismissal by University Hospital Sussex NHS trust in December 2021 after raising concerns about patient deaths. Mansoor Foroughi, a consultant neurosurgeon, was sacked by University Hospital Sussex NHS trust (UHST) in December 2021 for allegedly acting in bad faith when he raised the alarm about 19 deaths and 23 cases of serious patient harm that he said had been covered up in the previous six years. Those deaths and at least 20 others are now being investigated by Sussex police after allegations of medical negligence. Foroughi, whose appeal against his dismissal is due to be held in the coming months, told the Guardian: “I don’t think mine or anyone’s chances of success has increased [after Letby], and only a change in the law will do that.” Read full story Source: The Guardian, 1 September 2023 -
Content Article
During the pandemic, reports of abuse directed at doctors’ surgery staff and community pharmacy teams across West Yorkshire have increased. In response, the West Yorkshire Health and Care Partnership has launched a new insight driven campaign called ‘leaving a gap’ to make people think about the consequences of abusive behaviour. Co-produced with staff and patients, the campaign recognises that services are extremely busy, and it can be frustrating for people accessing care. The campaign reminds people we’re all here to help each other and the importance of all round understanding and kindness. A series of striking images created as part of the campaign aim to make people think about the gap that will be left if staff leave their role due to abuse. Please share the 'Leaving a gap' campaign message by displaying it in your public spaces, publishing it on your website and via social media. You can use the assets provided on this page to help; there are A4 and A5 size posters as well as social media images, a website banner and hero image and an animated video you can download. -
Content ArticleThe case of Lucy Letby, who was convicted of the murder of seven babies and attempted murder of another six in August 2023, has shocked both the public and the healthcare community. In this BMJ editorial, independent investigator Bill Kirkup and James Titcombe, Chief Executive of Patient Safety Watch, outline how the failure to listen to healthcare professionals raising concerns in the case may have contributed to further deaths. They highlight that when doctors at the Countess of Chester Hospital had concerns that they were seeing more deaths than expected, managers failed to take seriously their instinct that there might be a specific underlying cause. The doctors were even pressured into apologising to Letby. They argue that in spite of efforts by the NHS to create a culture where it is safe for staff to speak up about concerns, whistleblowers are still often ostracised and threatened when they highlight patient safety concerns. The article calls for health organisations to adopt the voluntary charter around candour currently being signed by police services and other bodies, pending the implementation of the proposed Public Authorities (Accountability) Bill, which would place a much-needed enduring duty of candour on NHS staff and organisations.
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Content ArticleThe majority of safety failures in the NHS are caused by bad systems not by malicious or incompetent staff, writes Steve Black in this HSJ opinion piece. The Letby case has provoked plenty of discussion of the way the NHS handles safety critical issues. But there were some hints that the way the case was handled was too typical of how the NHS thinks about safety issues both culturally and procedurally. One part of the issue is how the system resists ideas that work elsewhere, the other is how the standard approach to problems makes learning hard and vastly increases the expense of handling safety errors.
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News ArticleWhistleblowers who first revealed a toxic environment at one of England's largest NHS trusts say they do not believe crucial changes will be made. In a letter, they said families who suffered due to management failings at University Hospitals Birmingham (UHB) "have every reason to feel let down". Investigations have been examining UHB after staff told the BBC a climate of fear put patients at risk. The letter was written by three doctors to the Labour MP For Birmingham Edgbaston, Preet Gill, who is heading a cross-party reference group on the trust. In their letter, the consultants raise concerns about the appointment from within the trust of new chief executive Jonathan Brotherton and feel the management team remains largely unchanged. "More than six months have elapsed since we spoke to you of the need to repay the debt owed to those UHB staff, patients and their families who have suffered as a result of the board's serious failings," they wrote. "They now have every reason to feel let down." Read full story Source: BBC News, 29 August 2023
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Content ArticleTwo years after his 13-year-old child died needlessly in hospital, Paul Laity reflects on life without her. Martha Mills died of septic shock due to a series of serious failures in her care after she injured her pancreas in a cycling accident. Her father Paul talks about the ongoing pain of grief, and the additional burden of knowing that Martha's death was preventable, caused by the complacency of her doctors and a culture in the hospital that meant consultants were reluctant to ask expert advice from paediatric ICU. "Martha’s avoidable death was unusual in that the prime causes weren’t overwork or a lack of resources, but complacency, overconfidence and the culture on the ward. What upsets me most was that the consultants – a different one most days – took a punt that she was going to be OK over the weekend. No one assumed responsibility; they hoped for the best rather than playing safe. Was everything done for Martha that could have been done? Emphatically not. It’s very hard to live with this knowledge. But just as hard is the recognition that I, too, didn’t do enough." Further reading ‘We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death (The Guardian, 3 September 2022) Prevention of Future Deaths Report: Martha Mills (28 February 2022)
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News ArticleMore than half of NHS staff believe bosses would ignore whistleblowers amid fresh concerns hospitals could be covering up potential scandals following the Lucy Letby case. New national figures seen by the The Independent reveal that in the majority of hospitals, most doctors and nurses do not believe their concerns would be acted upon if they were raised with senior managers. It comes after The Independent revealed that NHS bosses accused of ignoring complaints about Letby were the very same people later appointed to act on whistleblower concerns at the hospital where she murdered seven babies and tried to kill six more. Several doctors who worked alongside her during the killing spree say they attempted to raise the alarm with hospital managers – only to have their pleas ignored. They believe the lack of action by bosses resulted in more babies being killed, stating managers who failed to act were “grossly negligent” and “facilitated a mass murderer”. In nearly three-quarters of general hospitals – such as the Countess of Chester where Letby worked – fewer than half of staff believed their trust would act on a concern, according to results from the latest NHS staff survey. Read full story Source: The Independent, 27 August 2023
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News Article
‘Insecure’ junior medics ‘crying every day’ in ‘chaotic’ department
Patient-Safety-Learning posted a news article in News
Delays in patient care and a lack of consultant support have left junior medics fearing for their mental health, an NHS England investigation has discovered. Junior doctors described haematology services delivered from University Hospitals Birmingham’s Heartlands Hospital as “chaotic”. Their concerns are raised in a report by NHS England Workforce, Training and Education (formerly Health Education England). UHB’s haematology service has been under scrutiny since 2021, when HSJ revealed whistleblower concerns over patient safety, including a series of blood transfusion’ never’ events. The WTE team visited UHB in April. As a result, the haematology service is now subject to the General Medical Council’s enhanced monitoring regime. This means intensive support is given to trainees and the trust to improve medical training. UHB’s obstetrics and gynaecology department is also under enhanced monitoring. The WTE report warns that consultants working across multiple sites left trainee medics at Heartlands without sufficient support and supervision. Most conversations with consultants were via telephone, leaving juniors feeling “unsupported and insecure”. The report stated: “Trainees described the workload … as chaotic and some reported the stress … was affecting their mental health… Some reported they do not feel valued, and the panel heard examples of people crying every day. Most described their roles as 100 per cent service provision… [they] reported very limited learning opportunities overall.” Read full story (paywalled) Source: HSJ, 24 August 2023 -
Content ArticleIn this blog post, Charlotte Augst looks at the impact of the Lucy Letby conviction on views of patient safety and accountability. The case has brought debates about patient safety into the mainstream media and public consciousness, and rather than focus simply on one extreme case, she believes it is important to look into common patterns in the NHS that lead to harm. She highlights that while such an awful case—where a healthcare professional caused deliberate harm to the most vulnerable patients—is shocking, it is also rare. She outlines a need to focus on the systemic issues that are resulting in repeated harm to patients, particularly in maternity services. Patients continue to be harmed because of rifts between management and clinical staff, the inability of the healthcare and regulatory system to really listen to patients, systemic discrimination and cognitive bias. Charlotte argues that while we may find ourselves focusing on the character of a nurse who committed such heinous crimes, we need to pay equal attention to the normalised behaviours and attitudes that harm patients and take place every day throughout the NHS.
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Content ArticleIn this letter, Rob Behrens, the Parliamentary and Health Service Ombudsman, calls on the Secretary of State for Health and Social Care, Steve Barclay MP, to prioritise improving patient safety in the wake of the Lucy Letby trial.
