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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. Content Article
    In this article for Health Services Insight, NHS consultant David Oliver examines why most comments on articles in the Health Services Journal (HSJ) are posted anonymously. He highlights that this tendency towards anonymity from commenters who are clearly in influential, senior NHS posts, indicates that the culture in the NHS management community, from NHS England down, is one that makes most people fearful of saying anything in their own name in case of reprisal. He also points out that a culture where people are afraid to make comments and criticisms in their own name is in conflict with the Nolan Principles of 'selflessness', 'integrity', 'objectivity', 'accountability', 'openness', 'honesty' and 'leadership' that senior NHS managers and officials are supposed to be guided by.
  12. Content Article
    In the wake of the conviction of Lucy Letby, a neonatal nurse who has been found guilty of the murder of seven babies and attempted murder of six babies, the focus of the nation is on the multiple tragedies that the families have faced, the healthcare staff who tried to blow the whistle, and safety issues in hospitals. NHS England has responded to the conviction by stating that trusts should look at whistleblowing policies, that those unfit to hold directorships should not be appointed, and with that well worn phrase “lessons will be learned.” But will they? In this BMJ opinion piece Alison Leary, professor of Healthcare and Workforce Modelling at London South Bank University, looks at why the NHS has failed to learn lessons from patient safety tragedies spanning the last fifty years. She highlights that unlike other safety critical industries, healthcare is still wedded to concepts that effectively deny the complexity of work and the social structures that surround work. This includes a failure to see the value in retaining experienced staff and a hierarchical approach to the value of work. She also outlines that more focus should be placed on management listening, rather than on staff having to find the courage to speak up when they have concerns: "When workers are listened to and constructive dissent is encouraged and normalised, along with the reporting of incidents, there is little need for whistleblowing. A workforce that must resort to whistleblowing is a symptom of poor safety culture."
  13. Content Article
    This is an oral statement given to the House of Commons by the Secretary of State for Health and Social Care, Steve Barclay MP, to update on the Lucy Letby statutory inquiry.
  14. Content Article
    In this interview for Times Radio, Sir Robert Francis KC, who led the 2010 inquiry into failures in care at Mid Staffordshire NHS Foundation Trust, discusses the benefits and disadvantages of statutory and non-statutory inquiries. In light of Lucy Letby's conviction for the murder of seven babies under her care while she worked as a NICU nurse, he also talks about how poor organisational culture can lead to staff covering up patient safety concerns.
  15. News Article
    NHS clinicians who were sacked after blowing the whistle about avoidable patient deaths say they fear lessons from the Lucy Letby murder trial have not been learned and the case will make no difference to their own claims for unfair dismissal. They say hospital bosses are still more concerned about reputation than patient safety, despite what emerged in the Letby case about the tragic consequences of ignoring consultants who first raised suspicions about her killing babies. Mansoor Foroughi is appealing against his dismissal by University Hospital Sussex NHS trust in December 2021 after raising concerns about patient deaths. Mansoor Foroughi, a consultant neurosurgeon, was sacked by University Hospital Sussex NHS trust (UHST) in December 2021 for allegedly acting in bad faith when he raised the alarm about 19 deaths and 23 cases of serious patient harm that he said had been covered up in the previous six years. Those deaths and at least 20 others are now being investigated by Sussex police after allegations of medical negligence. Foroughi, whose appeal against his dismissal is due to be held in the coming months, told the Guardian: “I don’t think mine or anyone’s chances of success has increased [after Letby], and only a change in the law will do that.” Read full story Source: The Guardian, 1 September 2023
  16. Content Article
    Dr Chris Day has for the last ten years pursued a legal battle against Greenwich and Lewisham NHS Trust (GWT), claiming his whistleblowing action about unsafe staffing while working in ICU was used against him by the Trust and Health Education England. Following a 2022 employment tribunal involving Dr Day and GWT, consultancy firm KPMG was commissioned by the Trust to conduct an independent review of the Trust's governance and media strategy. In this LinkedIn blog, Dr Chris Day outlines the context of a Byline Times article that questions the independence of this review, due to director of corporate affairs at the Trust, Kate Anderson, being a former employee of KPMG.
  17. News Article
    An integrated care board chair is keeping her job despite complaints being upheld against her in a previous role, it has emerged. Danielle Oum left her position as Birmingham and Solihull Mental Health Foundation Trust chair last October. It later emerged that an independent investigation carried out the month before her departure, the results of which were leaked to HSJ, had upheld several complaints against her and found she did not always act with “honesty, truthfulness and clarity”. She was appointed to the ICB position in October 2021, four months before the complaints were made against her by an individual at the trust. But NHS England now says it has reviewed the matter and concluded that it “continue[s] to offer Danielle our full support in her role as chair of Coventry and Warwickshire ICB”. Following the independent investigation, which upheld 16 complaints against Ms Oum in total, NHSE carried out its own review of the issues. NHSE said its review involved a “rigorous fact-finding process” and it was grateful to those who raised “freedom to speak up” concerns. It said in a statement: “A thorough review has taken place at regional and national level, and the committee responsible for adjudicating these issues has delivered what we believe is a fair decision." Read full story (paywalled) Source: HSJ, 31 August 2023
  18. 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
  19. 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
  20. 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
  21. 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
  22. 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
  23. 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
  24. 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
  25. 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
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