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News Article
Gang culture at neurosurgery department, doctor alleges
Patient Safety Learning posted a news article in News
A "gang culture" existed at an NHS neurosurgery department, a doctor has claimed at his employment tribunal. Neurosurgeon Mansoor Foroughi is one of two surgeons who alleges patients were put at risk at University Hospitals Sussex, where police are investigating 105 cases of alleged medical negligence. Four whistleblowers at the trust previously told BBC Newsnight that patients had died unnecessarily while others were "effectively maimed". They also complained of a "Mafia-like" management culture. Mansoor Foroughi alleges one colleague was approved to perform complex spinal surgery without adequate training. He claims a second surgeon undertook procedures that led to a "disproportionate" level of deaths. Mr Foroughi says a third surgeon undertook private work whilst on call to the NHS, which if true would be a breach of the NHS Code of Conduct. Universities Hospitals Sussex dismissed Mr Foroughi following a disciplinary hearing which upheld three allegations against him. He alleges the trust punished him because he raised these safety concerns. The trust said it would "vigorously contest" his claims. Read full story Source: BBC News, 11 April 2024 -
Content Article
In this report, Patient Safety Learning analyses the results of questions in the NHS Staff Survey 2023 specifically relating to reporting, speaking up and acting on patient safety concerns. It raises questions as to why there has been so little progress despite policy intention in this area. It concludes by setting out the need to improve the implementation, monitoring and evaluation of work seeking to create a safety culture across the NHS. This article contains a summary of the report, which can be read in full here or from downloading the attachment below.- Posted
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Content Article
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Richard von Abendorff, an outgoing member of the Advisory Panel of the Healthcare Safety Investigation Branch (HSIB), has written an open letter to incoming Directors on what the new Health Services Safety Investigations Body (HSSIB) needs to address urgently and openly to become an exemplary investigatory safety learning service and, more vitally, how it must not contribute to compounded harm to patients and families. The full letter is attached at the end of this page.- Posted
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News Article
NHS watchdog to review patient safety at Glasgow A&E department
Patient Safety Learning posted a news article in News
Patient safety in the Accident & Emergency unit at the Queen Elizabeth University Hospital in Glasgow will be reviewed by an NHS watchdog. Healthcare Improvement Scotland (HIS) was first contacted by 29 A&E doctors in May 2023 warning that safety was being "seriously compromised". HIS last month apologised for not fully investigating their concerns. The review will consider leadership and operational issues and how they may have impacted on safety and care. In the letter to HIS, the 29 consultants highlighted treatment delays, "inadequate" staffing levels and patients being left unassessed in unsuitable waiting areas. They claimed this resulted in "preventable patient harm and sub-standard levels of basic patient care". The doctors also said critical events had occurred including potentially avoidable deaths. The consultants said repeated efforts to raise the issues with health board bosses "failed to elicit any significant response". Read full story Source: BBC News, 4 April 2024 -
Content ArticleLetter Patient Safety Commissioner, Henrietta Hughes, wrote to Amanda Pritchard, NHS England, on the implementation of Martha's Rule.
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EventJoin Emergency Services Times to delve deep into fostering a culture of that encourages speaking up in emergency services, shedding light on effective strategies and leaving outdated approaches behind. Reports into culture may grab headlines but underneath, it is about behaviour and creating a working environment and channels that allow staff to have a voice, speak up and report without fear of reprisal. Through the lens of Crimestoppers and the National Guardian's Office, we look at what works and how to move on from approaches that simply don't serve the needs of those working within the emergency services sector. Register
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Content ArticleIn this episode, we hear from Sue Allison who blew the whistle on a Senior Radiologist within her department who repeatedly failed to diagnose women who had breast cancer at NHS Morecambe Bay Trust. She explains her battle to overturn her NDA at employment tribunal and the ‘insidious bullying’ that followed after blowing the whistle on concerns about patient safety. She is joined by Samantha Prosser an experienced employment law litigator from BDBF LLP who has specialist experience in advising private and NHS consultants from leading hospitals on private and NHS whistleblowing and discrimination claims.
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News Article
Doctors' A&E safety warnings snubbed by watchdog
Patient Safety Learning posted a news article in News
An NHS watchdog has apologised to 29 doctors at Scotland's biggest hospital for not fully investigating their concerns about patient safety. A&E consultants at Glasgow's Queen Elizabeth University Hospital wrote to Healthcare Improvement Scotland (HIS) to warn patient safety was being "seriously compromised". They offered 18 months' worth of evidence of overcrowding and staff shortages to back their claims. But HIS did not ask for this evidence. The watchdog also did not meet any of the 29 doctors - which is almost every consultant in the hospital's emergency department - to discuss the concerns after it received the letter last year. Instead, it carried out an investigation where it only spoke to senior executives at NHS Greater Glasgow and Clyde before then closing down the probe. HIS has now issued a "sincere and unreserved apology" to the consultants and upheld two complaints about the way it handled their whistleblowing letter about patient safety. One consultant who signed the letter told BBC Scotland: "We'd exhausted all our options and thought HIS was a credible organisation. "We offered to share evidence of patient harm. We were shocked that they ignored this and didn't engage with us as the consultant group raising concerns." Another consultant added they were "shocked at their negligence." Read full story Source: BBC News, 25 March 2024 -
News Article
Concerns over ‘Government’s failure’ to act on patient safety recommendations
Patient Safety Learning posted a news article in News
The Government has failed to implement a number of recommendations from significant inquiries into major patient safety issues, years after they were agreed to, according to an independent panel. The report, commissioned by the Health and Social Committee in the wake of the Lucy Letby case, voiced concerns about “delays to take real action”. As part of its investigation, the panel selected recommendations from independent public inquiries and reviews that have been accepted by government since 2010. Nine or more years have passed since these recommendations were accepted by the government of the day These covered three broad policy areas – maternity safety and leadership, training of staff in health and social care, and culture of safety and whistleblowing – and were used to evaluate progress. The panel gave the Government a rating of “requires improvement” across the policy areas. One of the recommendations was rated good. The report said that “despite good performance in some areas” the rating “partly reflects the length of time it has taken for the Government to make progress on fully implementing four of the recommendations which were accepted nine years ago, or longer”. “Progress is imminent in several areas, which is reassuring, but we remain concerned about the time it has taken for real action to be taken,” it added. Read full story Source: The Independent, 22 March 2024 Read Patient Safety Learning's response to the report: Response to Select Committee report: Evaluation of the Government’s progress on meeting patient safety recommendations -
Content Article
The Health and Social Care Select Committee’s Independent Expert Panel produces reports which assess progress the Government has made against their own commitments in different areas of health and care policy. On the 22 March 2024 they published a new report evaluating the implementation of accepted recommendations made by inquiries and reviews into patient safety. This blog sets out Patient Safety Learning’s response to its findings. -
Content ArticleNHS Boards are required under the National Whistleblowing Standards (the Standards) to publish annual whistleblowing reports setting out performance in handling whistleblowing concerns.
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News Article
Letby inquiry: NHS staff want their voices heard
Patient Safety Learning posted a news article in News
A group representing hundreds of clinicians has applied to contribute to the Lucy Letby inquiry, to challenge NHS culture around whistleblowing. Their experiences of raising concerns should inform the inquiry, they say. Letby murdered seven babies and attempted to murder another six while working at the Countess of Chester NHS trust between June 2015 and June 2016. The public inquiry is examining how the nurse was able to murder and how the hospital handled concerns about her. "The evidence of this group relating to how whistleblowers are treated, not just at one trust but across the UK, is of huge significance," Rachel di Clemente, of Hudgell Solicitors, acting for the clinicians, said. The group, NHS Whistleblowers, comprising healthcare professionals across the UK, including current and former doctors, midwives and nurses, has written to Lady Justice Thirlwall's inquiry, asking for them to be formally included as core participants. The inquiry has stated it will consider NHS culture. And the group says "a culture detrimental to patient safety" is evident across the health service. "NHS staff who have bravely spoken up about patient-safety concerns or unethical practices deserve to have their voices heard," Dr Matt Kneale, who co-chairs Doctors' Association UK, which is part of the group, said. Read full story Source: BBC News, 21 March 2024 -
Content ArticleThese principles underpin how NHS services must approach concerns that are raised by staff, students and volunteers about health services.
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Content ArticleIn 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. Concluding with optimism that new legislation going through Parliament offers a way forward from which everyone will benefit.
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News ArticleA group of doctors offered a controversial medical technique which allegedly put kidney patients' health at risk. At least 20 patients at Queen Alexandra Hospital (QA) in Portsmouth have been using the procedure, which is not recommended in UK guidelines. A consultant was wrongly sacked from the hospital in 2018 after objecting to the practice. The hospital trust said the safety and care of its patients was its priority. Jasna Macanovic, who worked at the QA for 17 years, had raised concerns about the way the trust was allowing some staff to deliver the dialysis technique - known as buttonholing. "I don't think they're fit to practise medicine," Dr Macanovic told the BBC. When Dr Macanovic examined the records of 15 patients using the buttonholing technique at the QA, she found infection rates four times higher than they experienced using the standard technique. Read full story Source: BBC News, 15 March 2024
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Content ArticleIn this Guardian interview, Rob Behrens, the outgoing NHS Ombudsman for England, says that too much unsafe care is still happening in the health service and that a culture of cover up makes it hard for bereaved families to find out the truth about their loved one's death. He describes the NHS as a complex institution run by mostly excellent, committed staff that is beset by cultural issues and a focus on limiting reputational damage at the expense of transparency and fair treatment of staff who speak up.
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News Article
Nurse reveals sexual harassment and whistleblowing ‘nightmare’
Patient Safety Learning posted a news article in News
A nurse has warned that she has been “crushed and silenced” over a battle with the NHS and the nursing regulator to investigate claims that she was sexually harassed by a colleague at work. Michelle Russell told Nursing Times of the “eight-year nightmare” she has endured since coming forward about her experiences and that she said had recently led her nursing career to come to an end. “Knowing what’s happened to me is not going to make it easier for anybody else to speak out" She has argued that “speaking up is not encouraged” in the NHS and that her case would discourage other nurses from coming forward about sexual harassment. Ms Russell said: “Anybody who has been around me would be able to see the emotional impact of all of this on me. “I’ve lost my job for highlighting a public safety concern.” The national guardian for the NHS told Nursing Times sexual harassment was a “patient safety issue” and warned that staff continued to face difficulties when speaking out. It comes as the latest NHS Staff Survey this month revealed that almost 4% of nurses and midwives had been the target of unwanted sexual behaviour in the workplace by another member of staff in the last 12 months. Read full story Source: Nursing Times, 15 March 2024 -
Content ArticleThe NHS will always need whistleblowers as healthcare is complex, rapidly changing and dangerous. However, whistleblowers continue to be treated very poorly by the health service, as this Private Eye special report highlights. The report looks in detail at several whistleblowing cases and how attempts to cover up mistakes and wrongdoing have resulted in patient deaths and devastated the careers and personal lives of staff who speak up for patient safety.
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News Article
Trust ordered to make second £400k-plus payment to a whistleblower
Patient Safety Learning posted a news article in News
A trust which last year was ordered to pay a whistleblowing nurse nearly £500,000 must now give a surgeon £430,000 to compensate him for the racial discrimination and harassment he faced after raising patient safety concerns. Tribunal judges previously upheld complaints made by Manuf Kassem against North Tees and Hartlepool Foundation Trust and have published a remedy judgment this week setting out the levels of damages the NHS organisation must pay. The judgment comes just over a year after a former senior nurse at the trust was awarded £472,600 for unfair dismissal after she warned high workloads had led to a patient’s death. Mr Kassem raised 25 concerns regarding patients’ care during a grievance meeting in August 2017. He alleged patients had “suffered complications, negligence, delayed treatment and avoidable deaths”. A trust review concluded appropriate processes were followed in the 25 cases. However, the tribunal ruled Mr Kassem was subjected to detriment after making the protected disclosure. According to the judgment, Mr Kassem was subsequently removed from the on-call emergency rota and his identity as a whistleblower was revealed by clinical director Anil Agarwal. In September 2018, he was the subject of a disciplinary investigation following several allegations against him made by colleagues and others, which concerned “unsafe working practices,” “excessive working hours,” and “potential fraudulent activity.” The investigation lasted 17 months and none of the allegations against Mr Kassem were upheld or progressed to a disciplinary hearing. Read full story (paywalled) Source: HSJ, 15 March 2024 -
News ArticleStaff whistleblowers have raised concerns over patient safety at one of Northern Ireland's biggest health trusts. Information received by UTV under Freedom of Information shows that most of the worries from health workers at the Belfast Health Trust relate to the Royal Victoria Hospital. Belfast Health Trust said any concerns raised by staff are investigated. The Royal College of Nursing NI was due to hold a webinar with members on Tuesday evening to discuss concerns members have about safety of patients being treated on corridors. The RCN's Rita Devlin said that the number of concerns raised with health trusts through the whistleblowing policy is only the tip of the iceberg. The concerns included unsafe staffing levels, bed shortages, boarding of patients, ED overcrowding, alleged drug dealing on a hospital site, staff sleeping on night duty, lack of mental health beds and the quality of staff training. The Belfast Trust said all staff are encouraged to make management aware of issues giving them concern through the whistleblowing process. The Trust added: "Any concern we receive is subject to a fair and proportionate process of investigation. "Whistleblowing investigations are of a fact finding nature and all relevant learning is shared as appropriate and taken forward by the Trust." Read full story Source: ITVX. 12 March 2024
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Content Article
NHS Staff Survey National Results 2023 (7 March 2024)
Patient Safety Learning posted an article in Culture
The NHS Staff survey is one of the largest workforce surveys in the world and is carried out every year to improve staff experiences across the NHS. It asks staff in England about their experiences of working for their respective NHS organisations. Of the 1.4 million NHS employees in England, 707,604 staff responded to the survey in 2023. -
Content ArticleMartha's rule stipulates the right of patients and their families to escalate care as a way to improve safety while in hospital. This article analyses the possible impact of the proposed policy through the lens of a behaviour change framework and explores new opportunities presented by the implementation of Martha's rule.
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News Article
Surgeon claims Bath's RUH 'covered up' patient blinding
Patient Safety Learning posted a news article in News
A surgeon sacked by a hospital after raising safety concerns has accused the trust of a cover-up after a patient was partially blinded during an operation. Juanita Graham, 41, lost the sight in her left eye during an operation at Bath's Royal United Hospital (RUH) in 2019. She is now suing the trust. Serryth Colbert said he was put down as the lead author on an investigation into the incident, but said he "did not write a word" of it. Mr Colbert has described the hospital investigation into Mrs Graham's operation as "deeply flawed". The surgeon, who specialises in the head, neck, face and jaw, has made several serious allegations about patient safety at the RUH, and believes these claims led to him being regarded as a troublemaker and dismissed in October 2023. Mrs Graham, from Trowbridge, said she was still traumatised by the operation on her eye. "I remember coming round, seeing the time and felt like a gush and I couldn't see," she said. "The next time I remember waking up again, I thought it was my partner but it was a surgeon and he was crying. I said 'what's gone wrong?'". After the operation, a Root Cause Analyses (RCA) report produced by the trust said the hospital was not to blame, although it did say the risks could have been explained more clearly to Mrs Graham. Mr Colbert, whose name was added as the lead investigator, said his only involvement in the report was when he was called on the phone by a nurse, who he said did the RCA, to explain what the operation involved. The 48-year-old surgeon said: "I have been put down here to my amazement as the lead author on this. "That is not correct. I did not write a word of this. "The conclusion is the root cause of the complication was down to a bit of paperwork which could have been performed a bit better. "The root cause was not down to paperwork. It was all covered up... that was indefensible." Read full story Source: BBC News, 29 February 2024 -
News ArticleWhistleblower Dr Chris Day has won the right to appeal when a a Deputy High Court Judge Andrew Burns of the Employment Appeal Tribunal granted permission to appeal the November 2022 decision of the London South Employment Tribunal on six out of ten grounds at a hearing in London. The saga which has now being going on for almost ten years began when Dr Day raised patient safety issues in intensive care unit at Woolwich Hospital in London. The Judge said today this was of the “utmost seriousness” and were linked to two avoidable deaths but their status as reasonable beliefs were contested by the NHS for 4 years using public money. In a series of twists and turns at various tribunals investigating his claims Dr Day has been vilified by the trust not only in court but in a press release sent out by the trust and correspondence with four neighbouring trust chief executives and the head of NHS England, Dr Amanda Pritchard and local MPs. This specific hearing followed a judgement in favour of the trust by employment judge Anne Martin at a hearing which revealed that David Cocke, a director of communications at the trust, who was due to be a witness but never turned up, destroyed 90,000 emails overnight during the hearing. A huge amount of evidence and correspondence that should have been released to Dr Day was suddenly discovered. The new evidence showed that the trust’s chief executive, Ben Travis, had misled the tribunal when he said that a board meeting which discussed Dr Day’s case did not exist and that he had not informed any other chief executive about the case other than the documents that were eventually disclosed to the court. Read full story Source: Westminster Confidential, 26 February 2024
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Content Article
This month marks two years of the hub's Patient Safety Spotlight interview series. Patient Safety Learning's Content and Engagement Manager Lotty Tizzard reflects on the value of sharing personal insights and identifies the key patient safety themes that interviewees have highlighted over the past two years.
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