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Found 319 results
  1. Event
    until
    Bringing together a community of human factors in patient safety advocates across Ireland and abroad, the annual Human Factors in Patient Safety Conference will offer the opportunity to gain valuable knowledge and insights from human factors experts. The conference will include contributions from: Martin Bromiley OBE, Founder of Clinical Human Factors Group UK – Listening Down to Develop your Safety Behaviours Mr Peter Duffy, Consultant Urologist – Whistle in the Wind: a Personal Exploration of the Consequences of Whistleblowing in Healthcare Professor Eva Doherty (Chair), Director of Human Factors in Patient Safety – The Irish Context, panel discussion Healthcare professionals can register for the event here. For more information, please email mschumanfactors@rcsi.ie.
  2. Community Post
    Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS an attractive place to work again, providing the NHS Constitution for England is at the heart of changes and is kept up to date. In my experience, having worked in healthcare for the private sector and the NHS, and lived and worked in other countries, we need to open our eyes. At present it could be argued that we have the worst of both worlds in England. A partially privatised health system and a fully privatised social care system. All strung together by poor commissioning and artificial and toxic barriers, such as the need for continuing care assessments. In my view a change, for example to a German-style system, could improve patient safety through empowering the great managers and leaders we have in the NHS. These key people are held back by the current hierarchical crony-ridden system, and we are at risk of losing them. In England we have a system which all too often punishes those who speak out for patients and hides failings behind a web of denial, obfuscation and secrecy, and in doing this fails to learn. Vast swathes of unnecessary bureaucracy and duplication could be eliminated, gaps more easily identified, and greater focus given to deeply involving patients in the delivery of their own care. This is a contentious subject as people have such reverence for the NHS. I respect the values of the NHS and want to keep them; to do this effectively we need much more open discussion on how it is organised and funded. What are people's views?
  3. Community Post
    The West Suffolk Independent Review published yesterday indicates that safety concerns were ignored and the hunt for an anonymous whistleblower was "flawed" and "ill-judged". https://www.england.nhs.uk/east-of-england/wp-content/uploads/sites/47/2021/12/west-suffolk-review-081221.pdf This Review was commissioned following widely reported events arising from an anonymous letter that was sent in October 2018 to the relative of a patient who had died at the West Suffolk NHS Foundation Trust (the Trust). The 225 page report contains important learning and highlights the need for an open culture in the NHS and an end to a culture of avoidance, denial and victimisation of those who speak out for patient safety. This report highlights the need for cultural change and raises several key points: The importance of real and empowered clinical leadership. The importance of NHS leaders being self-questioning, open to criticism and to listen to staff. The importance of leaders understand the value of dissent and disagreement. Where concerns and criticisms appear or do turn out to be misguided, the need for NHS leaders to avoid jumping to any conclusion that the individual raising them is simply making trouble.
  4. Community Post
    It's #SpeakUpMonth in the #NHS so why isn't the National Guardian Office using the word whistleblowing? After all it was the Francis Review into whistleblowing that led to the recommendation for Speak Up Guardians. I believe that if we don't talk about it openly and use the word 'WHISTLEBLOWING' we will be unable to learn and change. Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. So many genuine healthcare whistleblowers seem to be excluded from contributing to the debate, and yes not all those who claim to be whistleblowers are genuine. The more we move away for labelling and stereotyping, and look at what's happening from all angles, the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and with a genuine desire to learn and change.
  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
    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.
  7. 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.
  8. 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."
  9. 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.
  10. 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.
  11. Content Article
    The case of Lucy Letby, who was convicted of the murder of seven babies and attempted murder of another six in August 2023, has shocked both the public and the healthcare community. In this BMJ editorial, independent investigator Bill Kirkup and James Titcombe, Chief Executive of Patient Safety Watch, outline how the failure to listen to healthcare professionals raising concerns in the case may have contributed to further deaths. They highlight that when doctors at the Countess of Chester Hospital had concerns that they were seeing more deaths than expected, managers failed to take seriously their instinct that there might be a specific underlying cause. The doctors were even pressured into apologising to Letby. They argue that in spite of efforts by the NHS to create a culture where it is safe for staff to speak up about concerns, whistleblowers are still often ostracised and threatened when they highlight patient safety concerns. The article calls for health organisations to adopt the voluntary charter around candour currently being signed by police services and other bodies, pending the implementation of the proposed Public Authorities (Accountability) Bill, which would place a much-needed enduring duty of candour on NHS staff and organisations.
  12. 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.
  13. Content Article
    In this letter, Rob Behrens, the Parliamentary and Health Service Ombudsman, calls on the Secretary of State for Health and Social Care, Steve Barclay MP, to prioritise improving patient safety in the wake of the Lucy Letby trial.
  14. 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.
  15. Content Article
    We now know that Lucy Letby is a murderer, responsible for the deaths of seven babies and the attempted murders of six more. But as unimaginable as her crimes were, this verdict raises as many questions as it answers. Letby was not working in a vacuum. Could the killings at the Countess of Chester Hospital NHS Foundation Trust have been stopped sooner? Did organisational failures cost the lives of babies who could have been protected? The timeline gives us a clue, writes Minh Alexander, a retired consultant psychiatrist and NHS whistleblower, in this Guardian opinion piece. In June 2016, Letby’s hospital trust commissioned a review of neonatal care by the Royal College of Paediatrics and Child Health after “concerns about increasing neonatal mortality”, which oddly did not feature a case-note review. This prevented detailed examination of the deaths, which should have been the prime objective. The college reported “extremely positive relationships” among staff but “remote” relationships with executives. Astonishingly, the college’s report seemingly did not explicitly acknowledge a possibility of deliberate harm. Nevertheless, the college raised concern that not all deaths were followed by postmortem investigations – as they should have been, according to guidelines – and that where postmortems did take place, they did not include systematic blood tests and toxicology. It noted concerns from obstetrics staff about four unexpected deaths. In the coming days, there will be many questions. Why did it take so long for the hospital to refer matters to the police? Were doctors pressured not to persist with their concerns about Letby? How many trust board members knew there was a possibility of deliberate harm but failed to act?
  16. Content Article
    Babies would have survived if hospital executives had acted earlier on concerns about the nurse Lucy Letby, a senior doctor who raised the alarm has said. In an exclusive Guardian interview, Dr Stephen Brearey accused the Countess of Chester hospital trust of being “negligent” and failing to properly address concerns he and other doctors raised about Letby as she carried out her killings. Brearey was the first to alert a hospital executive to the fact that Letby was present at unusual deaths and collapses of babies in June 2015. The paediatrician and his consultant colleagues raised concerns multiple times over months before Letby, then 26, was finally removed from the neonatal unit in July 2016. The police were contacted almost a year later, in May 2017. Speaking publicly for the first time, Brearey told the Guardian that executives should have contacted the police in February 2016 when he escalated concerns about Letby and asked for an urgent meeting.
  17. Content Article
    NHS England commissioned a limited scope independent review into patient safety concerns and governance processes related to the North East Ambulance Service. Chaired by Dame Marianne Griffiths DBE, the review considered the facts surrounding a number of individual cases, reviewed the processes surrounding coronial investigations and reviewed the seven previous investigations and reviews undertaken by the ambulance service to determine if they were sufficient to fully understand and resolve issues.
  18. Content Article
    Are whistleblower reward programmes a charter for malicious complaints, as some claim, or are they a genuine incentive providing a safety net against retaliation? How successful are these programmes in recovering fraud and other proceeds of crime and serious organised crime? This paper aims to answer these questions—it was produced by WhistleblowersUK in collaboration with US lawyers who contributed to the development and improvement of US reward programmes. It aims to address questions about the legislation around US reward programmes, dispel some of the myths and look at some of the objections attributed to British attitudes about rewarding whistleblowers.
  19. Content Article
    An article from Roger Kline on the failure of many NHS organisations to create a climate where it is safe for staff to speak up. Roger reflects on the recent report published by the National Guardian’s office which summarises the results from the NHS staff survey completed by over 600,000 staff and highlights the story of a senior manager who tried to speak up and the consequences that followed. Further reading: Still not safe to speak up: NHS Staff Survey Results 2022 (Patient Safety Learning blog)
  20. Content Article
    An NHS consultant who was sacked after whistleblowing says it was because he raised concerns that “normal birth” ideology was putting the lives of women and babies at risk. Martyn Pitman, a respected obstetrician and gynaecologist, became a whistleblower to prevent “avoidable disasters” in NHS maternity care, but it cost him his career. Pitman lost his job last month after more than 20 years as a consultant at Royal Hampshire County Hospital in Winchester. His bosses cited an “irretrievable breakdown in his relationship with management”. His dismissal caused outrage from hundreds of former patients and doctors’ leaders, who say it highlights an NHS culture of “punishing those who dare to speak out”.
  21. Content Article
    Background to the independent review by Lewisham and Greenwich into Dr Chris Day's whistleblowing case.
  22. News Article
    Nearly 150 doctors have been disciplined for sexual misconduct in the last five years, as surgeons call for action on the “systemic” and “cultural” problem of sexual assault within healthcare, The Independent can reveal. Doctors campaigning for the UK’s healthcare services to address widespread problems with sexual harassment and assault in medicine have warned that people do not feel safe to come forward with allegations amid deep-seated “hierarchies” within healthcare. The Royal College of Surgeons’ Women in Surgery chair has said the issues are “widespread” across the health services and improvements to protecting whistleblowers needed to be made nationally. Last year, surgeons Becky Fisher and Simon Fleming wrote an academic paper exposing the problem of sexual assault, harassment and rape in surgery and surgical training. In interviews with The Independent, both have warned the “institutional” problem goes beyond surgery and across all of the healthcare services. Mr Fleming said the figures from the GMC were the “the very tip of the iceberg” in terms of actual levels of sexual assault within healthcare. Talking about the role of the GMC, Mr Fleming said he’d been told “by more than one person” that when they’ve reached out to the GMC over sexual assault or misconduct they were “failed” by the regulator and were “either not helped, abandoned or told to deal with it locally”. Read full story Source: The Independent, 15 February 2022
  23. News Article
    The leadership of a prominent cancer trust acted in a ‘defensive and dismissive’ manner when serious concerns were raised about bullying behaviours and multiple failings in the handling of a major research contract, an external review has found. As previously revealed by HSJ, NHS England commissioned the review into events at The Christie Foundation Trust after whistleblowers raised numerous concerns over a research project with pharmaceutical giant Roche, and about the way they were treated as a result of speaking out. The NHSE review, which was led by Angela Schofield, chair of Harrogate and District FT, was published earlier today within trust board papers. It described the trust’s research division as “ineffective” and said it had “allowed inappropriate behaviours to continue without challenge”. The review added: “It may… be thought to be surprising that NHSE/I found it necessary to commission an external rapid review to look into concerns which had been raised by colleagues within the research and innovation division." “The root cause of this seems to be an apparent failure by those people in leadership positions who were aware of the concerns that had been raised, in the circumstances covered by the review, to listen to and take notice of a number of people who have some serious issues about the way they are treated and wish to contribute to an improvement in the culture." It also summarised the experiences of 20 current and former staff members who said they suffered “detriment as a result of raising concerns”, although it did not make a clear judgement on whether their claims were justified. They said: “An experience of bullying, harassment and racial prejudice was described along with lack of respect at work… Patronising behaviour, humiliation and verbal aggression by managers and clinicians in public and private spaces contributed to the perception that working environments were emotionally unsafe.” Read full story (paywalled) Source: HSJ, 27 January 2022
  24. News Article
    One of the NHS’ most high-profile mental health trusts has ‘multiple’ corporate governance problems and ‘deep-seated’ cultural issues, according to an external review. Tavistock and Portman NHS Foundation Trust, which provides mental health, educational and training services in London, commissioned an external firm to look into its leadership amid a period of intense public scrutiny in the latter half of 2021. Among cultural issues identified at the trust, which reviewers described as “deep seated”, was a reluctance of staff to speak up about concerns. Assessors said a recent employment tribunal, which ruled the trust’s treatment of a whistleblower had damaged her professional reputation and “prevented her from proper work on safeguarding”, had impacted the ability of staff to raise concerns. They urged leaders to review their Freedom to Speak Up and whistleblowing procedures. And while reviewers commended board members for commissioning an external review of race equality, they said it had “yielded an outpouring of emotion” which suggested many staff from minority ethnic groups do not feel consistently supported, respected or valued. Read full story Source: HSJ, 25 January 2022
  25. News Article
    The chair of West Suffolk hospital trust has resigned over a whistleblowing scandal exposed by the Guardian, as fresh questions are asked over why the trust continues to pay at least £270,000 a year to its former chief executive. Sheila Childerhouse was criticised by an independent NHS report for her failure to question senior executives who had hounded Dr Patricia Mills after Mills had raised concerns about a colleague seen injecting himself with drugs while on duty. Childerhouse has announced that she will step down in January after consultants at the Bury St Edmunds hospital told her last week that her position was “untenable”. The NHS report, by Christine Outram, found that Childerhouse failed to take up Mills’ concerns when she was sent a “confidential” email in 2018 expressing alarm that the self-injecting doctor was being allowed to continue to treat patients. Read full story Source: The Guardian, 23 December 2021
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