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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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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.
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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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Content ArticleFollowing the Lucy Letby case, letters to the Times discuss workplace rights and safety in hospitals. Keith Conradi, former chief investigator, Healthcare Safety Investigation Branch, highlights a current NHS workforce too frightened to raise safety concerns, working in a toxic and bullying culture, where the predominance of HR approaches undermine the culture of safety. And Andrew Harris, professor of coronial law, William Harvey Research Institute, Queen Marys University London, writes that there is a duty on medical practitioners to report the circumstances of a death and not to limit disclosure to avoid investigation. In his letter he questions whether medical examiners across the country are acting independently of their trusts and properly notifying such cases.
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Content ArticleWe now know that Lucy Letby is a murderer, responsible for the deaths of seven babies and the attempted murders of six more. But as unimaginable as her crimes were, this verdict raises as many questions as it answers. Letby was not working in a vacuum. Could the killings at the Countess of Chester Hospital NHS Foundation Trust have been stopped sooner? Did organisational failures cost the lives of babies who could have been protected? The timeline gives us a clue, writes Minh Alexander, a retired consultant psychiatrist and NHS whistleblower, in this Guardian opinion piece. In June 2016, Letby’s hospital trust commissioned a review of neonatal care by the Royal College of Paediatrics and Child Health after “concerns about increasing neonatal mortality”, which oddly did not feature a case-note review. This prevented detailed examination of the deaths, which should have been the prime objective. The college reported “extremely positive relationships” among staff but “remote” relationships with executives. Astonishingly, the college’s report seemingly did not explicitly acknowledge a possibility of deliberate harm. Nevertheless, the college raised concern that not all deaths were followed by postmortem investigations – as they should have been, according to guidelines – and that where postmortems did take place, they did not include systematic blood tests and toxicology. It noted concerns from obstetrics staff about four unexpected deaths. In the coming days, there will be many questions. Why did it take so long for the hospital to refer matters to the police? Were doctors pressured not to persist with their concerns about Letby? How many trust board members knew there was a possibility of deliberate harm but failed to act?
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Content ArticleBabies would have survived if hospital executives had acted earlier on concerns about the nurse Lucy Letby, a senior doctor who raised the alarm has said. In an exclusive Guardian interview, Dr Stephen Brearey accused the Countess of Chester hospital trust of being “negligent” and failing to properly address concerns he and other doctors raised about Letby as she carried out her killings. Brearey was the first to alert a hospital executive to the fact that Letby was present at unusual deaths and collapses of babies in June 2015. The paediatrician and his consultant colleagues raised concerns multiple times over months before Letby, then 26, was finally removed from the neonatal unit in July 2016. The police were contacted almost a year later, in May 2017. Speaking publicly for the first time, Brearey told the Guardian that executives should have contacted the police in February 2016 when he escalated concerns about Letby and asked for an urgent meeting.
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Content ArticleUnderstanding of the significance of psychological safety has grown over recent years as we see the implications of people not speaking out—a culture that forces people to conceal rather than reveal. Concealing observations, ideas and thoughts can lead to major events that are harmful to organisations as much as individuals. Sometimes, individuals feel it is imperative to speak out somewhere, which leads to whistleblowing. This article looks at how to identify whether a workplace has a psychologically safe culture and how to transform cultures where staff don't feel able to speak up. It describes The Wellbeing and Performance Agenda, which contains six elements for building psychological safety: Transforming managers into leaders Psychological responsibility Sharing responsibility for the future success of the organisation Adaptive and positive culture Intelligent management Safe and resilient individuals
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Community Post
National Patient Safety Syllabus
Jon Holt posted a topic in Professionalising patient safety
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The Academy of Medical Royal Colleges have published the first National patient safety syllabus that will underpin the development of curricula for all NHS staff as part of the NHS Patient Safety Strategy: https://www.pslhub.org/learn/professionalising-patient-safety/training/staff-clinical/national-patient-safety-syllabus-open-for-comment-r1399/ Via the above link you can access a ‘key points’ document which provides some of the context for the syllabus and answers to some frequently asked questions. AOMRC are inviting key stakeholders to review this iteration of the syllabus (1.0) and provide feedback via completing the online survey or e-mailing Rose Jarvis before 28 February 2020. I would be interested to hear people's thoughts and feedback and any comments which people are happy to share which they've submitted via the online survey- Posted
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Community PostI am interested in what colleagues here think about the proposed patient safety specialist role? https://improvement.nhs.uk/resources/introducing-patient-safety-specialists/ https://www.independent.co.uk/news/health/nhs-patient-safety-hospitals-mistakes-harm-a9259486.html Can this development make a difference? Or will it lead to safety becoming one person's responsibility and / or more of the same as these responsibilities will be added to list of duties of already busy staff? Can these specialist be a driver for culture change including embedding a just culture and a focus on safety-II and human factors? What support do trusts and specialists need for this to happen? Some interesting thoughts on this here: https://twitter.com/TerryFairbanks/status/1210357924104736768
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Does your employer praise staff and patients for reporting safety concerns?
PatientSafetyLearning Team posted a topic in Whistle blowing
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A question posed by a delegate at our Patient Safety Learning conference 2019: 'Does your employer praise staff and patients for reporting safety concerns?' Tell us about your experiences of how reported concerns are received. Does it differ depending on whether they are raised by staff or patients? Are there any examples of great practice you can share where people are really praised for raising patient safety concerns?- Posted
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Community PostA question posed by a delegate at our Patient Safety Learning Conference 2019: 'How can we change the blame culture without blaming others?' What are your thoughts?
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Community PostHi - I was wondering if anyone has used the freedom to speak up (FTSU) guardian service where they work? It is FTSU month in October and I was wondering if anyone had used the service, would they like to answer a few questions. We can post this on the hub, so people can see how the system works and how it felt to raise concerns. This of course would be dealt with strict anonymity, as these issues may be sensitive. Please get in touch!
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Community PostHave you witnessed poor care, reported an incident but you weren't heard or felt unsafe at work? Do you have the courage to speak up? Why should we need 'courage' to speak up at work?
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How does it feel to work in a toxic culture and what impact it has on patient safety
HelenH posted a topic in Bullying and fear
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We know that blame and fear is toxic. It makes working in healthcare unsafe for staff and is a huge barrier to patient safety - staff won’t share what goes wrong if they expect not to be listened to or worse, will be criticised or blamed for errors that are really attributable to unsafe systems. It would be really valuable to better understand how this feels and the impact it has on clinicians and the safety of patients and service users.- Posted
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Content ArticleNHS England commissioned a limited scope independent review into patient safety concerns and governance processes related to the North East Ambulance Service. Chaired by Dame Marianne Griffiths DBE, the review considered the facts surrounding a number of individual cases, reviewed the processes surrounding coronial investigations and reviewed the seven previous investigations and reviews undertaken by the ambulance service to determine if they were sufficient to fully understand and resolve issues.
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Content ArticleThe role of Freedom to Speak Up Guardians is to support staff working in healthcare raise concerns about their workplace. In this report, the National Guardian’s Office provides an overview of the latest annual speaking up data, summarising the themes and learning from information shared by Freedom to Speak Up guardians.
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Content ArticleIn this article, Roger Kline looks at the responsibility of Board members in speaking up and responding to concerns raised about patient and staff safety concerns.
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Adverse incidents arising from suboptimal healthcare are a major cause of worldwide morbidity and mortality. Arriving at an understanding of the conditions under which adverse incidents occur has the potential to improve the safety of healthcare provision. Staff working in the NHS have been contributing their experiences via a narrative data capture platform – SenseMaker – to help gain contextual insights on a wide range of topics under exploration by the NHS Horizons team. This blog by Rosanna Hunt (Senior Associate, NHS Horizons) in collaboration with Lizzy MacNamara (Junior Research Consultant, The Cynefin Co.) and Taj Nathan (Consultant Forensic Psychiatrist, Cheshire & the Wirral Partnership Foundation Trust) describes how the SenseMaker® platform could be used to extract staff experiences on the topic of patient safety incidents both reported and unreported by staff, and the facilitated conversations that would be needed to transform the data into actionable insights and commitment to change. -
Content ArticleAn article from Roger Kline on the failure of many NHS organisations to create a climate where it is safe for staff to speak up. Roger reflects on the recent report published by the National Guardian’s office which summarises the results from the NHS staff survey completed by over 600,000 staff and highlights the story of a senior manager who tried to speak up and the consequences that followed. Further reading: Still not safe to speak up: NHS Staff Survey Results 2022 (Patient Safety Learning blog)
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Why didn’t you report it? A blog by Emma Walker
Patient Safety Learning posted an article in Good practice
A minor accident makes Emma Walker reflect on the safety culture of the NHS. -
Content ArticleAn NHS consultant who was sacked after whistleblowing says it was because he raised concerns that “normal birth” ideology was putting the lives of women and babies at risk. Martyn Pitman, a respected obstetrician and gynaecologist, became a whistleblower to prevent “avoidable disasters” in NHS maternity care, but it cost him his career. Pitman lost his job last month after more than 20 years as a consultant at Royal Hampshire County Hospital in Winchester. His bosses cited an “irretrievable breakdown in his relationship with management”. His dismissal caused outrage from hundreds of former patients and doctors’ leaders, who say it highlights an NHS culture of “punishing those who dare to speak out”.
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Content ArticleBackground to the independent review by Lewisham and Greenwich into Dr Chris Day's whistleblowing case.
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Content ArticleThe NHS Staff Survey is an essential tool for assessing the experiences and opinions of NHS workers in Trusts in England. It also provides valuable insights to help understand the speaking up culture in the NHS. In this report the National Guardian’s Office analyse the results of the 2022 NHS Staff Survey, focusing on questions relating to speaking up.
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Content ArticleThe NHS in England has largely relied on a human resources trilogy of policies, procedures and training to improve organisational culture. Evidence from four interventions using this paradigm—disciplinary action, bullying, whistleblowing and recruitment and career progression—confirms research findings that this approach, in isolation, was never likely to be effective. Roger Kline proposes an alternative methodology, elements of which are beginning to be adopted, which is more likely to be effective and to positively contribute to organisational cultures supporting inclusion, psychological safety, staff well-being, organisational effectiveness and patient care.
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Content Article
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. Stephen talks to us about his time as turnaround Chair of Mid Staffordshire NHS Foundation Trust, how NHS boards can ensure they live their values and why creating a safe space to share concerns improves patient safety.
