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Found 441 results
  1. News Article
    A review into how a reporting error came about has uncovered tension among an ambulance trust’s previous senior leaders, including that its new CEO felt it was ‘the least cohesive team I have ever joined’. Management consultancy Verita was commissioned by London Ambulance Service Trust to carry out a review of how it came to be misreporting category 1 (the most serious) response times. The report, published in board papers on Thursday, said it was caused by a contractor’s programming error going unnoticed and concluded it was “impossible to typify the events of August 2020 as other than an avoidable failure of governance and process”. Daniel Elkeles, who joined the trust as CEO in August 2021, told the review that when he joined the senior team it was “the least cohesive team I have ever joined” and said the organisation was not “psychologically safe” for those who wanted to speak up. Read full story (paywalled) Source: HSJ, 26 May 2023
  2. News Article
    Regulators are probing a series of whistleblowing claims about the leadership culture of a trust which is rated ‘outstanding’ for its management, HSJ has learned. It is understood multiple current and former staff members at Bolton Foundation Trust, including people in senior positions, have been in contact with NHS England and the Care Quality Commission in recent months. The claims include a dramatic worsening in leadership culture at the trust, particularly around the FTSU process and people who speak up being bullied, side-lined and silenced. And investigations and meetings are stage-managed and tightly controlled by executives, with constant “sugar-coating” and positive spin on board reports, and intolerance of people who disagree. Read full story (paywalled) Source: HSJ, 22 May 2023
  3. News Article
    Trainee medics in a troubled maternity department have flagged concerns with national regulators over the safety of patients, it has emerged. Last year the General Medical Council said it had concerns about the treatment of obstetric and gynaecology trainees at University Hospitals Birmingham and placed medics at Good Hope Hospital and Heartlands Hospital under intensive support known as “enhanced monitoring”. The GMC’s review flagged serious concerns about emergency gynaecology cover arrangements and said there was a real risk trainees would become hesitant and reluctant to call on consultant support. In September it placed additional restrictions on training, due to “ongoing significant concerns about the learning environment and patient safety”. Now it has emerged in board papers for Birmingham and Solihull integrated care board that Health Education England, now part of NHS England, and the GMC carried out a follow-up visit to UHB in late March to review progress. Board documents state that “several patient safety concerns [were] reported by postgraduate doctors in training to the visiting team”, with a subsequent feedback letter from HEE urging immediate changes to dedicated consultant time and job plans. Read full story (paywalled) Source: HSJ, 17 May 2023
  4. 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.
  5. News Article
    A world-renowned cancer centre hit by whistleblowing concerns over alleged bullying has been downgraded by the health watchdog. The Care Quality Commission (CQC) told The Christie NHS Foundation Trust in Manchester it "requires improvement" in safety and leadership. A former trust nurse told the BBC leaders had intimidated staff to stop them voicing concerns to inspectors. Rebecca Wight worked at The Christie - Europe's largest cancer centre - from 2014 but quit her role as an advanced nurse practitioner in December, claiming her whistleblowing attempts had been ignored. She told BBC Newsnight the trust had attempted to manipulate the inspection by intimidating those who wished to paint an honest picture. Roger Kline, an NHS workforce and culture expert from Middlesex University Business School, told BBC Newsnight there was a culture at The Christie which was "unwelcoming of people raising concerns". He said: "The trust response is more likely... to see the person raising the concerns as the problem rather than the issues they have raised," adding this was "not good for patient care". Read full story Source: BBC News, 12 May 2023
  6. News Article
    A former top medic on the Isle of Man who was unfairly dismissed has said her career has been "shattered" by her treatment. Rosalind Ranson was the Department of Health and Social Care's (DHSC) medical director from January 2020. She was awarded a record £3.19m in compensation after a lengthy tribunal which ruled she had been unfairly dismissed for whistleblowing. Dr Ranson raised a number of serious concerns about the coronavirus advice on the island that was not being passed on to ministers. She was later marginalised before being dismissed as the island's top medic when the operational services of DHSC transitioned into Manx Care. Dr Ranson said: "For me it is a tragedy that my 35-year career in medicine has come to an end through these circumstances. "I was proud of my professional integrity, my resilience, and my strength to stand up for those that I protected through my work as a doctor." Read full story Source: BBC News, 4 May 2023
  7. Content Article
    Jacqueline McIntosh, Freedom to Speak Up Guardian at Homerton Healthcare NHS Foundation Trust demonstrates how adopting a reactive approach to guardian ring-fenced time, improved worker wellbeing when it's most needed.
  8. 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.
  9. Content Article
    A ‘Just Culture’ aims to improve patient safety by looking at the organisational and individual factors that contribute to incidents. It encourages people to speak up about their errors and mistakes so that action can be taken to prevent those errors from being repeated.  Adam Tasker and Julia Jones are graduate medical students at Warwick Medical School. They wanted to explore doctors’ perceptions of culture and identify ways to foster a Just Culture, so they conducted a qualitative research study at one of the hospitals where they were doing their medical training. We asked them about why Just Culture is important in the health and care system, and what they discovered from their research.
  10. News Article
    The safety of a ward accused of failing children has been rated as inadequate by inspectors. The care regulator warned Kettering General Hospital (KGH) in Northamptonshire over its children's and young people's services. Inspectors' worries include sepsis treatment, staff numbers, dirt levels and not having an "open culture" where concerns can be raised without fear. Since the BBC's first report in February highlighting the concerns of parents with children who died or became seriously ill at KGH, dozens more families have come forward, bringing the number to 50 to date. Inspectors found that "staff did not always effectively identify and quickly act upon patients at risk of deterioration". They said there were sometimes "delays in medical reviews being undertaken outside of normal working hours", highlighting one case where a seemingly deteriorating patient was not seen until three hours after being escalated to the on-call team. Read full story Source: BBC News, 20 April 2023
  11. Content Article
    If 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.
  12. Event
    Dr Leslie Hamilton, assistant coroner and retired cardiac surgeon, will speak about the importance of creating and maintaining a no-blame culture within NHS and independent healthcare organisations. This should help to ensure that people feel able to share and reflect honestly whenever things go wrong in care, so that lessons can be learnt and changes made to improve patient safety. Register
  13. News Article
    A former adviser for the Care Quality Commission (CQC) has called on the regulator to explain what action it has taken against the officials responsible for wrongly dismissing him after he raised whistleblowing concerns. Shyam Kumar, a surgeon who was part of inspection teams in the North West, told HSJ that he had to live with question marks over his reputation for several years. He is furious that a senior CQC official sought to question his honesty and integrity in evidence submitted to the employment tribunal examing his dismisal. The tribunal heard Mr Kumar had raised a number of whistleblowing disclosures to the CQC, including concerns about the lack of appropriate expertise on inspection teams. After a wide-ranging review around its handling of whistleblowing concerns, CQC chief executive Ian Trenholm last week apologised to Mr Kumar for “unacceptably poor treatment” by his organisation, and thanked him for contributing to the review. However, Mr Kumar told HSJ: “I’m glad the CQC has looked at this and finally acknowledged what they did to me was wrong. But I want to know what has happened to the individuals that were responsible.” Read full story (paywalled) Source: HSJ, 6 April 2023
  14. News Article
    The government is actively considering whether to give full legal powers to an independent inquiry investigating the deaths of mental health patients. Roughly 2,000 deaths at the Essex Partnership University NHS Foundation Trust (EPUT) are being examined. The BBC understands Conservative Health Secretary Stephen Barclay is minded to make the inquiry statutory, which would compel witnesses to come forward. Only 11 current and former trust staff have agreed to give live evidence. Melanie Leahy, whose son Matthew died aged 20 while an inpatient at the Linden Centre in Chelmsford, said families were "definitely" a step closer to what they had campaigned for. "We just need it converted [to a statutory inquiry] - it's just delay after delay after delay and we need those powers," she told BBC Essex. Read full story Source: BBC News, 3 April 2023
  15. News Article
    A review of the whistleblowing framework – the laws that support workers who blow the whistle on wrongdoing in the workplace – has been launched by the Government. The review will seek views and evidence from whistleblowers, key charities, employers and regulators. Whistleblowing refers to when a worker makes a disclosure of information which they reasonably believe shows wrongdoing or someone covering up wrongdoing. Workers who blow the whistle are entitled to protections, which were introduced through the Public Interest Disclosure Act 1998 (PIDA). Successive governments have taken steps to strengthen whistleblowing policy and practice. It provides a route for employees to report unsafe working conditions and wrongdoing across all sectors. This was keenly felt during the height of the Covid-19 Pandemic, when the Care Quality Commission and Health and Safety Executive recorded sharp increases in the number of whistleblowing disclosures they received. The review will gather evidence on the effectiveness of the current regime in enabling workers to speak up about wrongdoing and protect those who do so. The evidence gathering stage of the review will conclude in Autumn 2023. Read full press release Source: Gov.UK, 27 March 2023
  16. News Article
    The Care Quality Commission’s follow-up of whistleblowing concerns from health and care staff has been poor and inconsistent, and there is a “widespread lack of competence and confidence” on dealing with race and racism at the organisation, two reviews have found. A “Listening, learning, responding to concerns” review was published by the Care Quality Commission, alongside a linked independent review into how the regulator failed Shyam Kumar, a consultant orthopaedic surgeon in the North West, who was also a CQC specialist professional adviser. The wider review looked at a range of issues including how the CQC deals with racism; how well it listens to whistleblowers in providers; and how it deals with its own staff, including as part of a recent restructure, and its internal “Freedom to Speak Up” process. It followed concerns bring raised, in addition to Mr Kumar’s case, about these issues. Scott Durairaj, a CQC director who joined it last year and led the review work along with a panel of advisers, reported there was “clear evidence, during the scoping, design phase and throughout the review, of a widespread lack of competence and confidence within CQC in understanding, identifying and writing about race and racism”. Read full story (paywalled) Source: HSJ, 29 March 2023
  17. Content Article
    On 24 August 2022, the Employment Tribunal found that Mr Shyam Kumar, a consultant orthopaedic surgeon employed at University Hospitals of Morecambe Bay NHS Foundation Trust (UHMB), had been disengaged from his role as a Specialist Advisor within the Care Quality Commission (CQC) on account of having made “protected disclosures” to the CQC. This means he had raised concerns with CQC about the health of patients and other important issues and had done so in the public interest. The Employment Tribunal found that the fact that he had raised these various concerns with CQC had materially influenced its decision to disengage him. It awarded him £23,000 in damages for injury to feelings, on account of what it described as “the inevitable impact” of CQC’s actions upon Mr Kumar’s reputation among his peers and the shock, confusion and concern it caused to him. The CQC has accepted these findings and apologised to Mr Kumar. CQC’s Chief Executive, Ian Trenholm, issued a public statement on 6 September 2022 about what occurred, including a recognition of the importance of the concerns Mr Kumar raised, the importance of the information raised by staff and the public generally, and the “vital role” played by Specialist Advisors in CQC’s inspections. Following this, Zoe Leventhal KC was appointed by CQC’s Executive Board to carry out an independent review into whether CQC took appropriate action as a regulator in response to the protected disclosures that Mr Kumar made, and whether it dealt appropriately with a sample of other instances where concerns have been raised with CQC.
  18. Content Article
    The concerns that health and care workers and the public share with the Care Quality Commission (CQC) about health and care services are critical to its work. It is also vital that CQC listens to its own staff. This review explores whether there are areas of culture or process within CQC that need to be improved in relation to listening, learning, and responding to concerns. The review focused on these key areas: Organisational findings Reviewing how well we listen to whistleblowing concerns. Reviewing our Freedom to Speak Up policy. Learning from the tribunal case. Reviewing how we listen to our staff. Reviewing the expectations and experiences of people who raise concerns with us.
  19. Content Article
    In this blog, Patient Safety Learning looks in detail at the results of the NHS Staff Survey 2022, focusing on responses relating to reporting, speaking up and acting on safety concerns. It includes the following key points: It is difficult to imagine other safety critical industries would deem these results acceptable. Nearly half of all respondents did not feel confident their organisation would address their concerns about unsafe clinical practice. It is hugely concerning that over 40% of respondents could not say that they would be treated fairly if involved in a patient safety incident. This could significantly undermine the willingness of staff to raise concerns, with significant consequences for patient safety. There needs to be greater urgency to improve the safety culture in the health service. NHS England needs to recognise the scale of this challenge and provide clarity on how it will work with organisations to tackle this. NHS England, working in partnership with the National Guardian and the Care Quality Commission, should bring forward as a matter of urgency robust and specific commitments to drive forward the work of improving the safety culture in the NHS.
  20. Content Article
    This editorial in BMJ Quality & Safety argues that patients' perceptions of their safety should not be dismissed when measuring healthcare safety. The authors argue that a differentiation between ‘feeling safe’, as defined through patient experience, and ‘being safe’, as defined through observation and evaluation using clinical outcomes selected by quality experts, creates a power differential and dynamic that degrades the role and value of patient experiences as valid patient safety indicators.
  21. News Article
    An NHS England investigation into claims of a toxic culture at a hospital trust has been described as lacking transparency and undermining trust. The Parliamentary Health Service Ombudsman also said there were "very serious" patient safety issues at University Hospitals Birmingham (UHB). Criticism is contained in letters seen by the BBC between the ombudsman, the trust and NHS England. The inquiries, commissioned by the Birmingham and Solihull Integrated Care Board and the local NHS, were begun in response to an investigation by BBC Newsnight and BBC West Midlands which heard from current and former clinicians from the trust, who accused it of being "mafia-like". One of England's biggest hospital trusts, UHB has been in the spotlight for months after three probes were started following allegations doctors there were threatened for raising safety concerns. The trust denies this and says its "first priority is patient safety". The ombudsman, however, said he was sceptical about the reviews' transparency and independence. His finding of "very serious" patient safety issues at UHB is based on the trust's response to the ombudsman's recommendations and findings, including a case of an avoidable patient death. Read full story Source; BBC News, 14 March 2023
  22. Event
    Part of Whistleblowers Awareness Week (WBUK). Aims and Objectives: 1. To engage MPs, organisations and policy makers in understanding the consequences of the victimisation of healthcare whistleblowers for patients and the public. 2. To help remove the stigma around the subject of whistleblowing. 3. To inform attendees of the benefits of change and how this links to the Protection for Whistleblowing Bill [HL] and an Office for the Whistleblower. 4. To provide information that will enable attendees to take practical, measurable steps to move the agenda forward and join in with the work of the APPG and WBUK. Speakers: Dr Jenny Vaughan OBE - Doctors’ Association U.K. Cathryn Watters RGN – Whistleblowers and regulation Steve Turner RMN – Patient experience Professor Emmanouil Nikolousis (online) – Cultures of fear Panel members: Mr Chris Day - CQC Director of Engagement Dr Chris Day Dr Chaand Nagpaul CBE Tom Grimes - NHS England Head of Advocacy and Learning (FTSU) Dr Jayne Chidgey-Clark - National Guardian for the NHS More information
  23. Event
    until
    Whistleblowing is barely out of the news. We cannot turn on the TV without a headline or plot that relies on whistleblowers and how badly they are treated. Think about our police, NHS, armed forces, media, banks, corporations - the list goes on... Whistleblowing is good for society and good for business. Whistleblowers are the most effective first line of defence against crime, corruption and cover up. Whistleblowing Awareness Week (WBAW) is an opportunity for MPs to understand how proposed legislation is key to driving a culture where speaking up is valued, and where people who try to silence whistleblowers or suppress evidence of wrongdoing face the full force of the law. WBAW will dispel the stigma and suspicion that overshadow whistleblowers. It will also set out how the Whistleblowing Bill developed by WhistleblowersUK for the APPG for Whistleblowing will transform the way that whistleblowers and whistleblowing are treated. See the events going on for WBAW
  24. News Article
    Bereaved families are having to report maternity blunders because watchdogs and hospitals are unable to spot failings, an expert has warned. Bill Kirkup said avoidable deaths were "a badge of shame" but would continue without urgent change. Eight years on from his report into the Morecambe Bay maternity scandal, he said the failure of officials to act had needlessly cost more lives. "I am very disappointed – and surprised – that we're still where we are", he said. "That's a terrible badge of shame for the health service that it takes families to come and tell us what's wrong. "Yet just about every tragedy that I've ever been involved with investigating has come to light when there's a group of families who say 'You've got a problem here'. "People are lying, they're not being open and they're concealing what's happening. "If we can't bring this change, I'm not confident that there won't be another East Kent, Morecambe Bay or Nottingham, somewhere else." Read full story Source: Mail Online, 10 March 2023
  25. News Article
    A review into the culture at Birmingham's biggest hospitals trust amid allegations of bullying and undue pressure on staff has found 'substantial issues' of concern, a brief report has revealed. A short briefing for councillors by NHS Birmingham and Solihull chief executive David Melborne offers the first insight into the findings of Professor Mike Bewick and his review team who were tasked with investigating damning allegations made by current and former staff at University Hospitals Birmingham. More than 50 medics, including some with decades of experience, came forward to criticise a 'toxic' working culture at the trust, many sharing their experiences with MP Preet Kaur Gill (Birmingham Edgbaston). Among the most serious claims that emerged were that whistleblowers concerned about patient safety were silenced with threats of disciplinary action. In a written report to Birmingham and Solihull councils' joint health overview and scrutiny committee, meeting Monday, Mr Melborne says the rapid review into the Newsnight allegations and subsequent complaints has found 'no fundamental safety issues at the Trust'. However, he goes on: "That said, there are substantial issues around culture, behaviour, leadership and governance that will need to be addressed". Read full story Source: Birmingham Live, 10 March 2023
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