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Found 441 results
  1. Content Article
    This year’s World Patient Safety Day on Sunday 17 September 2023 focused on engaging patients for patient safety, in recognition of the crucial role that patients, families and caregivers play in the safety of healthcare. This webinar provided an opportunity for those involved in patient safety to hear from patient safety leaders and discuss the opportunities and barriers to increased patient engagement. It was co-hosted by the Patient Safety Commissioner for England and the charity Patient Safety Learning.
  2. Content Article
    The Speak Up™ Campaign includes a large selection of resources produced by The Joint Commission (US-based) to encourage patients to speak up and be active participants in their healthcare. These resources are free and can be used by stakeholders that want to promote the Speak Up message. You will find resources about speaking up: about your care against discrimination at your telehealth visit for new parents for safe surgery for your mental health to prevent serious illness. The Joint Commission website also includes information about using Speak Up in your organisation.
  3. Content Article
    In this opinion piece for the BMJ, Partha Kar, NHS England National Specialty Advisor for Diabetes, shares his observations on why leaders fail to speak out on things that clearly aren't good for patient care. He identifies five key reasons: Keeping the job Fear Rhetoric about 'the bigger picture' The idea that 'I'll be rewarded' Genuine belief that the issue isn't real Partha highlights that speaking up about issues needs to become the norm if we are to see a culture shift in healthcare. Leaders need to be at the forefront of this, using their privilege to bring about change.
  4. News Article
    A not-for-profit health system in Maine has threatened legal action against a 15-year-old boy for shedding light on alleged patient safety issues in the paediatric ward of one of its hospitals. Samson Cournane, a student at the University of Maine, started a petition (Patient Safety in Maine Matters) advocating for an investigation into Northern Light Eastern Maine Medical Center last year, claiming conditions at the hospital were unsafe. Mr Cournane’s mother, Dr Anne Yered, had previously been fired from the hospital after reportedly voicing safety concerns to the hospital’s CEO and president in 2020. In the petition, Mr Cournane said his mother was threatened by hospital staff after raising concerns, with one hospital manager going so far as to show up in her backyard to confront her. Dr Yered subsequently claimed she was wrongfully terminated. Mr Cournane then began pushing for an investigation into the hospital, outlining problems in the petition, which was addressed to US Representative Jared Golden. He alleged that the medical director of the paediatric intensive care unit (ICU) — a former colleague of his mother’s — finished just one year of a three-year critical care fellowship, and implied other hospital employees may be scared to come forward with safety concerns. Read full story Source: The Independent, 4 September 2023
  5. Content Article
    This Newsnight report looks at the case of Rebecca Wight, an advanced nurse practitioner who raised concerns about a colleague at at Manchester’s Christie cancer hospital and felt her treatment by Trust management as a whistleblower was poor. She is now taking The Christie to an employment tribunal for constructive dismissal. The video also features an interview with Helené Donnelly, a nurse who tried to raise the alarm more than 100 times at Mid Staffs and went on to be a key witness in the subsequent Francis inquiry. She calls for failing NHS managers to be struck off, highlighting that a decade on from one of the worst failings in NHS history, those raising concerns were still not being listened to.
  6. Content Article
    A recent report found that a third of female surgeons have been sexually harassed at work. In this opinion piece, Dr Liz O’Riordan speaks out about the abuse she suffered from male colleagues while working for the NHS. She describes her experiences, highlighting that incidents of sexual harassment are common amongst female surgical trainees who fear speaking out as it may affect their careers. She also draws attention to the fact that it is not just an issue amongst surgeons, but that many other healthcare professionals experience inappropriate sexual comments and behaviour while at work.
  7. Content Article
    As awareness of the importance of psychological safety in the workplace increases, there is a corresponding increase in the number of psychometric tools, applications and services that attempt to measure psychological safety. This post on the blog Psychological Safety outlines some helpful principles for organisations to apply when choosing a psychometric tool. It lays out the following key principles, stating that in choosing a psychometric tool, we should ensure that we understand the methods and algorithms the tool uses. it’s usable and accessible for everyone. it’s secure. people retain ownership of their own data. the questions and statements actually correlate with psychological safety. it doesn’t make assumptions based upon majority culture. the tool doesn’t create perverse incentives.
  8. Content Article
    Derek Richford’s grandson Harry died in November 2017 at just a week old. Since Harry’s death, Derek has worked tirelessly to uncover the truth about what happened at East Kent Hospitals University Foundation Trust (EKHUFT) to cause Harry’s death. His efforts resulted in a three-week Article 2 inquest that found that Harry had died from neglect. In addition, the Care Quality Commission (CQC) successfully prosecuted the Trust for unsafe care and treatment and Derek’s work has contributed to a review into maternity and neonatal care services at EKHUFT. In this interview, we speak to Derek about how EKHUFT and other agencies engaged with his family following Harry’s death. As well as outlining how a culture of denial at the Trust affected his family, he talks about individuals and organisations that acted with respect and transparency. He highlights what still needs to be done to make sure bereaved families are treated with openness and dignity when a loved one dies due to avoidable harm.
  9. 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.
  10. Content Article
    In 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.
  11. News Article
    The government is to investigate claims an ambulance service covered up details of the deaths of patients following mistakes by paramedics. It follows the Sunday Times report that North East Ambulance Service (NEAS) withheld information from coroners. Labour's shadow health secretary Wes Streeting described the alleged cover-up as "a national disgrace". Health minister Maria Caulfield said she was "horrified" and there would be a further investigation. The newspaper reported that concerns were raised about more than 90 cases and whistleblowers believed NEAS had prevented full disclosure to relatives of people who died in 2018 and 2019. Speaking in the House of Commons, Mr Streeting asked why the regulator - the Care Quality Commission (CQC) - had failed to take action. Ms Caulfield said that while both the NEAS and the CQC had both reviewed the allegations, further investigation was required. The minister said non-disclosure agreements have "no place in the NHS", adding: "Reputation management is never more important than patient safety." Read full story Source: BBC News, 23 May 2022
  12. News Article
    Quinn Evie Beadle died in 2018. Her parents later found out that the “kind, caring” 17-year-old had been failed by a paramedic at the scene of her death — and that the ambulance service altered documents to try to stop them finding out the truth. The teenager, who dreamt of becoming a medic but suffered poor mental health, was found after she hanged herself near her home in Shildon, Co Durham, on the evening of 9 December 2018. The paramedic who attended the scene made basic mistakes, and made no effort to clear her airway or continue with basic life support — despite the fact her heart was still active. But instead of attempting to learn lessons, bosses at the North East Ambulance Trust (NEAS) set out to prevent the family learning what happened. They changed a key witness statement given to the coroner at her first inquest, removing references to mistakes the paramedic had made and inserting the claim that any life support offered would “not have had a positive outcome”. They also withheld from the coroner a key piece of evidence — a reading from a heart monitor — which demonstrated Quinn’s heart activity. It is thought Quinn’s death could be one of more than 90 cases in the past three years in which the NEAS failed to provide families with the whole truth about how their relatives died. Senior managers repeatedly withheld key evidence from coroners about deaths linked to service failures, an internal report shows. In some cases, bosses doctored or suppressed evidence to cover up failures by staff. An independent report into a small number of the cases, including Quinn’s, raised by whistleblowers found that, as in her case, statements were changed or suppressed and pieces of key evidence not disclosed. Read full story (paywalled) Source: The Sunday Times, 22 May 2022
  13. News Article
    Nurses from across the country are heading to Washington, D.C., and Nashville, Tenn., this week to march for better working conditions and to show support for nurse RaDonda Vaught. Ms. Vaught, 38, was convicted of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 after overriding an electronic medical cabinet as a nurse at Vanderbilt University Medical Center in Nashville. Her case has spurred a national outcry from nurses who argue the ruling sets a dangerous precedent for the profession and will discourage nurses from speaking up about errors. Ms. Vaught's sentencing is scheduled for 13 May in Nashville, and she faces up to eight years in prison. Hundreds of nurses are planning to march in Nashville the day of the hearing to show their support for Ms. Vaught and to fight for better protection for nurses against criminal prosecution of errors. "We expect a large number of people to show up … just to show our strength in numbers and hope that the judge takes this into consideration and makes it slightly better by not sentencing her to any prison time," said Erica, a Las Vegas-based hospice nurse who is attending the sentencing. Read full story Source: Becker's Hospital Review, 13 May 2022
  14. News Article
    A former medical director on the Isle of Man, who lost her job when she questioned decisions made on the island during the COVID-19 pandemic, has won her case for unfair dismissal at an employment tribunal. The hearing, which began in January, heard how Dr Rosalind Ranson was victimised and dismissed from her role after making 'protected disclosures' as part of her efforts to persuade the Manx Government to deviate from Public Health England (PHE) advice in the early stages of the pandemic. Dr Ranson, who had extensive experience as a GP and as a senior medical leader in the NHS in England, was appointed to her post as the island's most senior doctor in January 2020 with the aim of tackling what she identified as a disillusioned medical workforce, failings in management, and a bullying culture. She was soon called on to provide expert medical advice and guidance on how the Isle of Man’s health system should respond to the spread of COVID-19. In March, Dr Ranson channelled concerns from the island's doctors that the advice from PHE was flawed, and that a more robust approach should be taken to stem the spread of SARS-CoV-2. That included closing the island’s borders – a move that was initially ignored. Dr Ranson became concerned that her medical advice was not being heeded and that it might not be being passed on to ministers by the then Chief Executive of the Isle of Man’s Department of Health and Social Care (DHSC), Kathryn Magson, who was not medically qualified. The tribunal heard that because Dr Ranson had "blown the whistle" when she spoke out, she was sidelined and eventually dismissed unfairly. Read full story Source: Medscape, 11 May 2022
  15. News Article
    A trust chief who blew the whistle on her predecessor’s ‘aggressive’ behaviour and lack of interest in patient safety says it was the hardest thing she has had to do in her career. Janelle Holmes, who is now chief executive of Wirral University Teaching Hospital Foundation Trust, was among four Wirral University Teaching Hospital Foundation Trust senior executives who wrote to regulators in 2017 about the behaviour of the trust’s then CEO David Allison. They said he would react with “dismay and aggression” to concerns being raised about service quality, and staff were afraid to speak up as a result. The intervention led to Mr Allison’s departure and a subsequent independent investigation found “deep systemic cultural issues”. Mr Allison always denied his behaviour was inappropriate. In an interview with HSJ, Ms Holmes talked of the difficulties in taking those actions, and the subsequent efforts to overhaul the trust’s culture. She said: “From a personal integrity perspective, it was the right thing to do…and I [also] felt I had a personal responsibility to make it right afterwards. “But yes, it was the most difficult thing I’ve ever had to do.” She said: “I remember watching Sir David Dalton (the ex-Salford CEO) probably more than 10 years ago… say ‘we are harming patients’.. it was like ’you can’t say that’. “But actually [there was a] complete sea change and [it became] an organisation where [speaking out] was the right thing to do. That’s the only way you can ensure you’re delivering good quality high standard services. If you’re acknowledging mistakes happen, you’re learning from them, you’re correcting things… I think that then starts to shape how our clinicians and staff feel. Read full story (paywalled) Source: HSJ, 12 May 2022
  16. News Article
    The Doctors’ Association UK (DAUK) has expressed its support for the Whistleblowing Bill launched in Parliament last week, with its first reading in the House of Commons by Mary Robinson MP, Chair of the All Party Parliamentary Group for Whistleblowing. DAUK urged people to tweet their MP to show their support for the Bill. DAUK Chair Dr Jenny Vaughan said: "Healthcare staff need to be able raise patient safety issues all of the time. We’re trained to do that, expect it, point this out as best we can. But sometimes poor safety arises because of the way we are told to work. Then, it can be just as hard for staff to speak up as it is for anyone else, because we can also be threatened, sanctioned, isolated, ignored and bullied. "Blowing the whistle for us means saving lives, in the end. But we stand to lose as much as anyone. DAUK has supported many doctors who have been made to suffer because they spoke out, and there are many more who feel they should but are afraid to. That is why this Bill is so important. For all staff within healthcare. And most of all, for patients - the public. Stopping the greater harm for the greater good.” The most important changes in the private members bill, led by Baroness Kramer would: Require disclosures to be acted upon and whistleblowers protected. Provide criminal and civil penalties for organisations and individuals failing to do so. Establish a fully independent parliamentary body on whistleblowing, and provide easy access to redress. Read full story Source: Medscape UK, 26 April 2022
  17. News Article
    A trust board has backed the medical director who oversaw the dismissal of a whistleblower in a case linked to patient deaths. Portsmouth Hospitals University Trust told HSJ John Knighton had the full support of the organisation when asked if he faced any censure over the wrongful dismissal of a consultant who raised the alarm about a surgical technique. Jasna Macanovic last month won her employment tribunal against the trust with the judge calling its conduct “very one-sided, reflecting a determination to remove [her] as the source of the problem”. The judgment found that the disciplinary process Dr Knighton oversaw was “a foregone conclusion” and as such had broken employment rules. The nephrologist was twice offered the opportunity to resign with a good reference, once during her disciplinary hearing and again on the day the outcome of that hearing was delivered. The trust told HSJ nothing in the judgment suggested Dr Knighton should face any action about his conduct and none had been taken. It said there were no reasons to doubt his credibility or probity. The trust did not respond when asked if any apology had been offered to Dr Macanovic. A spokesperson said: “We are committed to supporting colleagues raising concerns, so they are treated fairly with compassion and respect.” Read full story (paywalled) Source: HSJ, 13 April 2022
  18. News Article
    Criticism of NHS managers over the treatment of whistleblowers has been reignited by Donna Ockenden’s damning review of maternity services at Shrewsbury and Telford Hospital Trust. Her findings come seven years after the “Freedom to speak up?” report from Sir Robert Francis QC, which found that NHS staff feared repercussions if they blew the whistle on poor practice. He recommended reforms to change the culture and support whistleblowers. The Public Interest Disclosure Act 1998 makes it unlawful to subject workers to negative treatment or dismiss them because they have raised a whistleblowing concern, known as a “protected disclosure”. But critics say little has changed since the Francis review. According to Protect, a whistleblowing charity, 64% of those contacting it for advice said that they had been victimised, dismissed or forced to resign. Shazia Khan, founding partner at Cole Khan Solicitors, says that instead of being afforded protection, whistleblowers are “targeted as a form of retaliation by trust senior management and disciplined on trumped up charges to shut them down”. Those seeking to vindicate their rights before an employment tribunal, Khan adds, will often be “priced out of justice” by well-resourced NHS trust lawyers who at public expense “deploy a menu of tactics” to defend cases. When Peter Duffy, a consultant urologist at University Hospitals of Morecambe Bay Foundation NHS Trust, reported on allegedly unsafe practices by colleagues in 2016, he was demoted, falsely accused of financial irregularities, and threatened with a six-figure adverse costs order by Capsticks, the hospital’s law firm. “All my witnesses dropped out after the medical hierarchy told them that the department might be dissolved if the case went badly,” Duffy says, which meant there was no one to rebut the trust’s evidence. Read full story (paywalled) Source: The Times, 7 April 2022
  19. News Article
    Less than half of staff at scandal-hit Shrewsbury and Telford Hospital NHS Trust feel they can speak up about concerns, according to a staff survey, as a damning report warned serious problems persist in maternity care. Shrewsbury and Telford Hospital Trust is one of the worst-performing trusts on the latest national survey of staff for the NHS. It comes after Donna Ockenden, who chaired a review into maternity failures at the trust, said her “biggest concern” was that staff had been told not to share concerns with her inquiry. Ms Ockenden told The Independent her biggest concern was “that ordinary staff on the ground are telling me they were advised not to cooperate with the Ockenden review”. The NHS staff survey, published on Wednesday, showed just 49% of staff at the trust reported they would feel safe enough speaking up about concerns in 2021 – down from 53% in 2020. Meanwhile, just 34% of staff said they feel their concerns would be addressed if there were to speak up. The trust is one of the worst three hospital trusts in the country when it comes to rising care concerns, the figures show. Only United Lincolnshire Hospitals NHS Trust and Barking, Havering and Redbridge University Hospitals NHS Trust performed worse. Read full story Source: The Independent, 31 March 2022
  20. News Article
    A whistleblower who worked at a hospital trust where hundreds of babies died or were left brain-damaged says there was "a climate of fear" among staff who tried to report concerns. Bernie Bentick was a consultant obstetrician at the Shrewsbury and Telford NHS Trust for almost 30 years. "In Shrewsbury and Telford there was a climate of fear where staff felt unable to speak up because of risk of victimisation," Mr Bentick said. "Clearly, when a baby or a mother dies, it's extremely traumatic for everybody concerned. "Sadly, the mechanisms for trying to prevent recurrence weren't sufficient for a number of factors. "Resources and the institutionalised bullying and blame culture was a large part of that." More than 1,800 cases of potentially avoidable harm have been reviewed by the inquiry. Most occurred between 2000 and 2019. Mr Bentick worked at the Trust until 2020. He said from 2009 onwards, he was raising concerns with managers. "I believe there were significant issues which promoted risk because of principally understaffing and the culture," he said. He also accuses hospital bosses of prioritising activity - the number of patients seen and procedures performed - over patient safety. "I believe that the senior management were mostly concerned with activity rather than safety - and until safety is on a par with clinical activity, I don’t see how the situation is going to be resolved," he said. Read full story Source: Sky News, 27 March 2022
  21. News Article
    The chief executive of one of England’s most prestigious private hospitals has lost her employment tribunal claim that she was dismissed for whistle blowing over patient safety issues. Aida Yousefi ran the Portland Hospital in central London from January 2017 until her dismissal in December 2019 on two counts of gross misconduct. She was also in charge of The Harley Street Clinic and a specialist cancer centre. Ms Yousefi’s argument that she was removed after raising concerns about the patient safety was rejected by central London employment tribunal in a judgment published last week. The judge instead ruled that while other senior staff had raised patient safety concerns over cost-cutting, there was no evidence that Ms Yousefi had done so. In their judgment the tribunal panel said: “In oral evidence the claimant further accepted that, as CQC-registered manager, if patient safety concerns were not being dealt with she should have raised it with CQC. She did not do so at any point during her employment.” Staffing concerns were raised by The Harley Street Centre chief nursing officer Claire Champion and others. However, the tribunal heard evidence that doing so could be frowned upon by senior management at HCA International. The tribunal was shown an email from then vice president of financial operations at THSC and the Portland Enda O’Meara saying “Frankly – we are starting to piss some very senior people off in appearing that we can’t [make savings]. We can’t always cite patient safety. Because the response will always be other facilities are doing it”. Another email from Mr O’Meara said: “Please don’t cite ’patient safety’ unless you truly believe it to be the case. This term is particularly sensitive and nothing winds them up more”. Read full story (paywalled) Source: HSJ, 28 March 2022
  22. News Article
    A senior medic has won a whistleblowing case after judges ruled she was dismissed after raising concerns about a new procedure her department was using. An employment tribunal found consultant nephrologist Jasna Macanovic was fired from Portsmouth Hospitals University Trust in March 2018 after telling bosses a dialysis technique called “buttonholing”, which had been “championed” there, was potentially dangerous. The trust’s case was that the way she had gone about raising concerns had made for an untenable working environment in the Wessex Kidney Centre. The process saw a Care Quality Commission complaint, an independent investigation and multiple referrals to the General Medical Council. Employment Judge Fowell said: “The plain fact is that after over twenty years of excellent service in the NHS, Dr Macanovic was dismissed from her post shortly after raising a series of protected disclosures about this one issue. It is no answer to a claim of whistleblowing to say that feelings ran so high that working relationships broke down completely, and so the whistleblower had to be dismissed.” Dr Macanovic resigned from the regional renal transplant team in July 2016 when she discovered two incidents had occurred that “had not been reported by either surgeon” and felt that one of the surgeons had misled the medical director over the issue, the tribunal heard. In an email sent after the resignation meeting, Dr Macanovic said the practice was considered inappropriate by the vast majority of experts in the field and that no other renal unit in England was using it. The case exposes some worrying governance, both within the trust and between it and the Care Quality Commission, with which the issues were raised in 2016. When the CQC asked the trust for more information the unit’s clinical director responded that in his view that the deaths and infections were not due to the buttonholing. The CQC made no further enquiries and wrote back saying “they were satisfied that there were no safety concerns and that appropriate governance had been followed”. Read full story Source: HSJ, 24 March 2022
  23. News Article
    NHS England is trying to force a prestigious cancer trust to publicly apologise to a group of whistleblowers, after being ‘shocked’ by the way it responded to a review into their concerns. As HSJ reported in January, an external review into The Christie Foundation Trust supported multiple concerns which had been raised by staff about a major research project with pharma giant Roche. The review had also noted how 20 current and former employees, some of whom were “long-standing, loyal, senior staff”, had described bullying behaviours and felt they had suffered detriment because they spoke out. In response to the review, trust chair Christine Outram and chief executive Roger Spencer issued a bullish report listing numerous “inaccuracies” and characterised the concerns as being limited to a “small number of staff who are dissatisfied or aggrieved”. It did not thank the staff for raising the issues, nor apologise for the experiences they had. However, HSJ has now learned that NHSE is trying to ensure the trust issues a public apology. At a meeting with some of the whistleblowers on 11 February, David Levy, medical director for NHSE North West, said he was “shocked” and “frankly a bit angry” at the trust’s response, saying it reflected badly on the organisation, HSJ understands. Read full story (paywalled) Source: HSJ, 9 March 2022
  24. News Article
    The Royal College of Nursing (RCN) has designed a 'Raising Concerns toolkit', which includes information to help members navigate the process of escalation, from identifying a potential concern through to formally reporting it to senior colleagues. It’s been designed to help members decide when to escalate a workplace issue and includes a flowchart to support them in deciding what, when and how to report concerns. The toolkit outlines the types of concerns that might be raised such as staffing and patient safety, a lack of support or training, as well as cultural or criminal issues. It supports nursing staff to understand the importance of remaining factual, staying neutral and keeping records of events. RCN Deputy Director of Nursing Eileen Mckenna said: “We know that raising a concern at work isn’t easy, but it safeguards nursing staff and can provide learning opportunities. Our Raising Concerns toolkit can be used by nurses, nursing associates, students and health care support workers in the NHS and independent sector to help them through the process of escalating an issue. “All workplaces that employ nursing staff should have a culture of safety and focus on system learning, not individual blame in the event of a mistake being made. We will always support members who challenge unsafe practices, processes or conditions at work in the interests of their own safety and that of patients. It’s an important skill that promotes psychological safety, a positive learning environment and wellbeing.” Read full story Source: RCN, 2 March 2022
  25. News Article
    A former consultant gynaecologist has told how he raised concerns over bullying, unsafe practices and a "dysfunctional culture" ahead of a report into a maternity scandal. Bernie Bentick, who worked at Shrewsbury and Telford Hospitals Trust (Sath) for almost 30 years, has spoken publicly about maternity care at the trust for the first time. Sath is at the centre of the largest inquiry in the history of the NHS into maternity care, which is expected to report next month. An official investigation is examining the care that 1,862 families received. Mr Bentick says he told senior management several times about a deteriorating culture at Sath. “I was increasingly concerned about the level of bullying, of dysfunctional culture, of the imposition of changes in clinical practice that many clinicians felt was unsafe," Mr Bentick told BBC's Panorama. "If the resources had been made available to employ adequate numbers, to provide safe levels of care in accordance with national guidelines, then the situation may have been profoundly different.” Mr Bentick went on to say that though some “cursory” investigations were launched into his complaints, he believed the trust responded in a way that tried to “preserve the reputation of the organisation.” Read full story Source: Shropshire Star, 23 February 2022
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