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In December 2022 Dylan Cope, a 9-year-old boy, died of sepsis after being discharged from hospital. A coroner found the boy's death “would have been avoided if he had not been erroneously discharged”, and said what happened "amounts to a gross failure of basic care”. In this blog, Dylan’s mum Corinne Cope draws on her lived experience to explain what accountability means to bereaved families and harmed patients.  For me, as a bereaved mother, accountability isn’t a theoretical concept - it’s deeply personal. And for harmed patient’s/bereaved families, it’s not what is said - it’s what changes, and whether anyone can see it. I think many people are working incredibly hard within investigations. But from a family perspective, the outcomes don’t always reflect that effort, particularly when learning isn’t visible, or when the process feels defensive or incomplete And we need to be clear about what accountability is, and what it isn’t. To any reasonable person, accountability isn’t blame or punishment. Ownership, explanation and demonstrable change What accountability means to harmed patient’s/bereaved families When harmed patients and bereaved families talk about accountability, we are not asking for the impossible. We’re asking for: a full, honest explanation of what happened and why clear ownership of actions, omissions, and decisions - and their consequences genuine reflection and sincere, timely apologies for both individual and organisational failures organisational responsibility for system failures, with prompt correction and visible evidence that meaningful, timely learning and reflection has taken place And that final point matters most. Because accountability is not what is said - it’s the change that matters. Where the system is failing From a family perspective, accountability often feels delayed, filtered, or out of view. Learning is described…but not always demonstrated. Apologies are offered…but often without ownership. And too often, the harmed/bereaved find themselves driving the process. In my own experience, after Dylan’s death, I didn’t just seek answers; I found myself proposing a sepsis awareness campaign. I also found myself working to improve how investigations are carried out; encouraging organisations to respond differently to preventable harm or death, and to say: “We do not always get things right, we are truly heartbroken that this tragedy happened under our watch; and here is what we are doing to improve.” Something practical. Something needed. But that learning wasn’t led by the organisation…much of it was driven by me. And that is a huge part of the problem from my perspective. Harmed patients and bereaved families should not have to investigate, push, or drive safety improvements in response to harm or death. When they do, it doesn’t feel like accountability, it can feel like a continuation of the harm. And when similar failures happen again, with little visible change, that becomes very difficult to reconcile. Apology and honesty I also want to say something about apology, followed by a lived example. A sincere, timely apology is not a legal risk - it is a professional and human responsibility. Too often, what families receive is not an apology for what went wrong, but a general expression of sympathy…“I’m sorry for your loss.” Condolences are not the same as acknowledging failures in care. While well-intentioned, they do not meet the expectations of candour, and for many families, they fail to acknowledge responsibility or the reality of what went wrong. Individual errors can and do occur alongside wider system failures and both must be explored with equal rigour, because understanding one without the other limits learning and risks repeating the same harm. A just culture doesn’t exclude holding individuals to account where there is evidence of serious or gross negligence. From a harmed/bereaved perspective, there is a concern that in practice, ‘no blame’ can sometimes become ‘no accountability’. Honesty and reflection matter very deeply. But in my experience, those elements can sometimes be delayed or filtered out. And I wonder whether apology is sometimes still viewed through the lens of blame rather than responsibility. And that raises an important question… Is the system, at times, protecting itself at the expense of truth and learning? Humanity filtered I want to give a brief example. There was suboptimal treatment identified in Dylan’s hospital readmission. A healthcare professional involved in Dylan’s care wrote in an early statement draft that they “wished” they had stayed with him. I only saw that years later. That single sentence - an honest expression of reflection - meant a great deal. But it was removed from the final version. In my experience, the very things that support accountability - reflection, honesty, humanity - were either delayed or filtered. And when investigations feel defensive, opaque, or incomplete, the impact is not neutral…it causes secondary harm. It erodes trust. And it drives families to seek answers elsewhere. Final thoughts Accountability requires action. Because learning without visible ownership…can feel hollow. And accountability without learning achieves very little. And crucially: families should not have to drive that change themselves. If nothing visibly changes, and families are left to fight for answers or without a timely and sincere apology, then from a family perspective, it isn’t accountability. It’s just process, that is deeply insulting and guaranteed to compound harm. Related content Investigating harm with humanity - practical guidance for NHS investigators, clinical teams and legal representatives (by Corinne Cope) Destructive investigations: our experience of the investigation into our son's death Seeking better sepsis awareness in Wales (a film by Corinne and Laurence Cope) Dylan's Story (Welsh Ambulance Services University NHS Trust)

Martin Fletcher, hub topic lead for professionalisation and regulation, has been part of transformational change in professional regulation through his tenure as Chief Executive of the Australian Health Practitioner Regulation Agency (Ahpra). In a new blog for the hub, Martin asks: How do we better connect the work of professional regulation with a systems focus on improving patient safety? And how do we navigate this interface in a health and societal context which is rapidly changing? Zubin Austin writes eloquently about the challenges of the ‘chaotic tumult’ of the many wicked problems that face professional regulators and, indeed, our health system more widely.[1] These form both the context and scaffolding for our work in years to come. The rise of entrepreneurial and profit-driven models of care, telehealth, unregulated medicines for sale online, the role of social media and AI-driven therapeutics are disruptors which have introduced new risk profiles. Traditional regulatory frameworks and approaches to patient safety must adapt. These shifts demand new thinking around safety, accountability, transparency and equity. Traditionally, professional regulation has more narrowly focused on the conduct, competence and performance of individual health practitioners, with an emphasis on public protection. However, we know that the safety of patients is shaped by a wider range of inter-related factors, including clinical governance, team dynamics, design of systems and processes, technology and organisational safety culture. There can be no healthcare without a health workforce. And an ethical, safety-conscious, competent and accountable health workforce is critical for a safe, high quality healthcare system. I have previously written for Patient Safety Learning on the need to more closely link the work of service, product and system regulators, and patient safety improvement bodies. Shared goals, role clarity, information flows and aligned actions are critical. When we operate in silos, we risk missing the bigger picture. Without coordinated action across agencies, patients remain vulnerable. The rapidly growing cosmetic practices sector illustrates these challenges vividly. In both Australia and the UK, reviews have shown that regulating practitioners alone isn’t enough.[2] [3] Products, procedures, facilities, social media, information asymmetry, service licensing arrangements and weak professional ethics all contribute to the potential risk of harm to patients. More widely, there are significant opportunities to better use and share data and intelligence to both anticipate and understand risks of patient harm. The legalisation of medicinal cannabis in Australia powerfully illustrates this need. Incident reports, notifications and complaints are often lag indicators—we need to get ahead of emerging risks of harm to patients, especially in the face of the many healthcare disruptors we face. I hope the hub community is a vehicle for sharing ideas, strategies and real-world examples of how to build foundations and bridges between professional regulation and patient safety improvements more widely. New thinking and approaches are needed. And despite many differences in the way that health systems are organised and funded across the world, there are many common challenges. References Austin Z, Haji A. Regulation of wicked problems: opportunities, responsibilities, and threats. J Med Regulation. 2023;109(3):6–11. doi:10.30770/2572-1852-109.3.6. Brown A, Duggan A, Kirkland A, McCausland R. Independent review of the regulation of medical practitioners who perform cosmetic surgery: Final report. Melbourne: Australian Health Practitioner Regulation Agency; August 2022. UK Parliament. The regulation of non-surgical cosmetic procedures in England. House of Commons Library, 10 September 2025. Further blogs on the hub from Martin Professional regulation and patient safety systems: parallel planets or partners in improvement?

When repeated harm occurs in healthcare, public debate often centres on identifying an individual responsible. Although accountability is essential, patient safety may be better served by asking another question first: Were there earlier signals that something was going wrong? This blog reflects the perspective of Aditi Desai, a surgeon with nearly three decades of clinical experience and an interest in patient safety systems, surgical quality monitoring and organisational learning. Recent high‑profile cases, such as the case of surgeon Yasser Jabbar at Great Ormond Street Hospital,[1] have prompted difficult reflection across the profession about how systems detect repeated patient harm. These situations understandably lead to questions about individual responsibility, but they also highlight the importance of recognising warning signals earlier. After nearly three decades in surgical practice, I have seen how outcomes can fluctuate. A surgeon may perform many procedures safely, then experience several complications in close succession. Some of this represents natural variation. But sometimes patterns emerge that should prompt earlier concern. Modern healthcare systems collect large amounts of clinical data, yet we rarely use it systematically to detect deteriorating performance early.[2] Risk‑adjusted monitoring of outcomes over time, combined with supportive mentoring and fair accountability, could help organisations intervene sooner, protecting both patients and clinicians. Improving patient safety requires moving beyond a simple choice between blaming individuals or fixing systems. Safer care depends on recognising both the human realities of clinical practice and the need for strong organisational oversight. Recognising the early warning signs of unsafe surgical practice Having practised surgery for more than 28 years, I have learned that clinical outcomes are rarely perfectly predictable. A surgeon may perform a hundred operations without complication. Then, within a short period, several adverse outcomes may occur—like unexpected bleeding, infection or an unintended injury during surgery. When this happens, patients suffer first and most. For clinicians, complications also carry a heavy emotional weight. Many doctors recognise the sleepless nights and intense self‑reflection that follow when a patient is harmed. In recent years, public discussions around cases of repeated patient harm have raised difficult questions about how healthcare systems detect unsafe practice. The case of Yasser Jabbar at Great Ormond Street Hospital, widely reported in the UK, has prompted reflection not only about accountability but also about whether earlier signals of unsafe care might have been detectable. The instinctive response is often to ask: “Who is the rogue clinician?” But from a patient safety perspective, an equally important question may be: “Where was the signal that care was becoming unsafe?” Distinguishing variation from unsafe care All clinical practice carries risk. Even highly skilled surgeons experience complications. Medicine is complex, and outcomes vary according to patient condition, procedural difficulty and chance. The real challenge is distinguishing between: Expected complication rates and natural variation, and Patterns that may indicate deteriorating performance or unsafe practice. This distinction is rarely straightforward. It requires careful interpretation of clinical outcomes and trends over time. The human side of surgical practice Medicine often expects clinicians to perform at a consistently high level throughout long careers. Yet surgeons, like everyone else, experience illness, fatigue, personal stress and periods of reduced resilience. Most clinicians continue working through these pressures because the culture of medicine places great value on strength, reliability and professionalism. Recognising this human reality does not diminish professional responsibility. Instead, it highlights the importance of systems that can identify when a clinician may be struggling and offer support or review before patient harm accumulates. The missing safety infrastructure Healthcare organisations collect vast amounts of data about procedures and outcomes. Yet in many systems, we still lack robust mechanisms that can: Risk‑adjust outcomes for patient complexity. Monitor outcome trends over time. Identify negative outliers early. Trigger timely peer review or mentoring. Such systems are not primarily about punishment. Their purpose is to protect patients while supporting clinicians to maintain safe practice. Moving beyond 'individual versus system' Patient safety discussions often frame harm as either the fault of an individual clinician or the result of system failure. In reality, safety depends on both. Strong systems should be able to detect emerging risks early, while still ensuring fair accountability when unsafe practice becomes clear. This approach aligns with the principles of a just culture, where organisations seek to understand and respond to risks rather than relying solely on retrospective blame.[3] A role for data, mentorship and oversight In other high‑performance fields, such as aviation and elite sport, continuous monitoring and coaching are routine. Medicine has traditionally been slower to adopt this approach. Yet supportive oversight and mentoring could help clinicians identify and address problems earlier in their careers or during periods of difficulty. Clinicians may benefit from ongoing coaching and feedback, not only during training but throughout their professional lives.[4] Surgeon and writer Atul Gawande, the WHO checklist pioneer, highlighted this idea in his TED Talk “Want to get great at something? Get a coach”, where he describes how even experienced surgeons can improve performance and safety through structured coaching and peer observation.[5] Looking forward Cases where repeated harm occurs inevitably raise questions about accountability. Where clear incompetence or unsafe practice exists, fair accountability is essential. But patient safety improves most when healthcare systems are able to recognise warning signs early, before serious harm accumulates. By combining risk‑adjusted data, supportive oversight and a culture of learning, healthcare organisations can better protect patients while supporting clinicians to maintain safe practice. Ultimately, safer care depends not only on responding to failure, but on building systems capable of recognising risk sooner. References Triggle N. Great Ormond Street doctor who botched surgery harmed nearly 100 children. BBC News, 29 January 2026. Royal College of Surgeons of England. Surgical outcomes data and transparency. Outcomes FAQ. NHS England. Being fair tool: supporting staff following a patient safety incident. 9 May 2025. Pradarelli JC, Yule S, Panda N, et al. Optimising the implementation of surgical coaching through feedback from practicing surgeons. JAMA Surgery, 2021; 56;(1): 42-49. doi:10.1001/jamasurg.2020.4581. Gawande A. Want to get great at something? Get a coach. TED Talk, April 2017.

When Stuart Ball previously wrote for the hub, he described how his wife Rachel’s death was not the result of one single missed appointment or one incorrect clinical decision. It was the result of fragmentation—significant red flags recorded across time and across specialties, but never structurally reviewed together. Since then, Rachel’s case has been raised through a Parliamentary Question, Stuart has received written replies and there has been renewed discussion around the NHS 10 Year Health Plan. The Plan sets out a long-term ambition to move from reacting to illness towards predicting and preventing it. It speaks about digital integration, genomics and a single patient record. In this follow up blog, Stuart explains why this direction of travel is welcome, but how ambition and infrastructure are not the same as accountability. Stuart asks for an accountable model, with clear ownership, for cumulative hereditary risk review across time and specialties. "Rachel’s Rule: Protecting Today, For Tomorrow" In recent Parliamentary correspondence, it has been confirmed that hereditary cancer services are delivered through the Genomic Medicine Service, with referral based primarily on clinical and family history criteria, and with clinicians expected to maintain appropriate knowledge. The 10 Year Health Plan has been cited as the framework for longer term genomic expansion and reform. These responses clarify direction and capability. However, they do not clearly describe a mandated, accountable model for cumulative hereditary risk review across time and specialties. Rachel’s case was not a technology failure Rachel did not lack access to doctors. She did not lack access to records. She did not lack access to treatment. What she lacked was a defined point where someone was responsible for stepping back and asking: Does this pattern mean something more? She was diagnosed with ovarian cancer at a young age. Later, she developed a second primary ovarian cancer, and years later breast cancer. She had multiple liver hamartomas and ongoing clinical indicators recorded across different specialties. Each event was documented. None were structurally joined. There was no named owner for cumulative hereditary risk recognition. There was no mandated checkpoint requiring a review of the whole picture. And after diagnosis, there was no single, coordinated surveillance plan owned by one accountable role. This was not about individual clinicians failing. It was about system design. The 10 Year Plan: capability versus structure The NHS 10 Year Health Plan outlines important ambitions: Expansion of genomic capability. Better data integration. Personalised risk information. Digital coordination through shared records. These are enabling tools. But tools do not automatically create safety standards. A record is not a review. A risk score is not accountability. Current public responses confirm that hereditary cancer services operate through the Genomic Medicine Service, with referral based on clinical and family history criteria, and with clinicians responsible for maintaining knowledge. That describes capability and professional expectation. It does not clearly describe: A mandated longitudinal hereditary risk review checkpoint. A named accountable owner when cumulative red flags emerge. An automatic re-review trigger after second primary cancers. A defined operational standard for coordinated post-diagnosis surveillance. Without those elements, expanded genomics may still sit within a structurally fragmented system. The gap before diagnosis In Rachel’s case, hereditary risk was not recognised early enough. Importantly, she did not have a strong family history. Her risk lay in the pattern of events over time. If risk recognition depends heavily on family history or opportunistic identification, patients without obvious family clustering remain vulnerable. A structured, repeatable review process—triggered by defined criteria such as early cancer, second primaries, unusual pathology, or cross-specialty indicators—introduces a simple but powerful safeguard: Someone must pause. Someone must review the whole picture. Someone must document a decision. Ownership reduces diffusion of responsibility. The gap after diagnosis Diagnosis does not end the safety question. In many cases, it increases the need for coordination. In cancer, the consequences of missed hereditary risk often unfold over years. Surveillance can become fragmented across hospitals, clinics and appointment systems. Imaging may focus on one organ or site without stepping back to ask whether a broader, coordinated plan is required. Rachel received treatment and follow-up. At the time, we believed the cancer had been dealt with. Six years later, it returned and she died. Earlier recognition does not guarantee different outcomes in every case. But delay reduces available options. Fragmented surveillance compounds risk. That is why Rachel’s Pathway calls for: One named owner for surveillance coordination. One written, shared plan across services. Defined re-review points when new pathology emerges. Clarity about what surveillance is intended to detect, and what it is not. This is not about demanding universal scanning. It is about preventing predictable fragmentation. Why interim standards matter The 10 Year Plan is long term. Delivery will be phased. Large reforms are subject to operational pressures and parliamentary cycles. Meanwhile, patients continue to present. In safety critical systems, known vulnerabilities are usually mitigated while reform is being built—not left exposed until infrastructure is complete. An interim standard does not compete with the 10-Year Plan. It complements it. It introduces structural accountability now, while contributing to durable long-term design. The central question This ultimately comes down to one question: Who owns cumulative hereditary risk recognition and coordinated surveillance when patterns emerge across time and across specialties? If the answer is “all clinicians,” responsibility risks being diluted. If the answer is “no one specifically,” then the vulnerability remains. Clear ownership is not a technological issue. It is a patient safety issue. Rachel’s Rule is not a rejection of genomic ambition. It is a call to translate ambition into accountable structure: One owner. One review. One coordinated plan. That is how patterns stop being missed. That is how fragmentation is reduced. And that is how long-term ambition becomes real patient safety. Further information about the full proposals for Rachel’s Rule and Rachel’s Pathway can be found at rachelsrule.org. If you would like to support the campaign, please consider signing and sharing the petition at change.org/RachelsRule. Further reading on the hub: How one woman’s missed referrals exposed a systemic gap in hereditary cancer care: Why I'm campaigning for Rachel's Rule 10 Year Health Plan for England: fit for the future Rachel's Rule: Signs in plain sight by Stuart Ball Top picks: Rare diseases

Over the past 15 years, Martin Fletcher has been part of transformational change in professional regulation through his tenure as Chief Executive of the Australian Health Practitioner Regulation Agency (Ahpra). In this blog for the hub, Martin shares Australia's regulatory journey and reflects on the UK's more gradual path to reforming their legislative frameworks. He highlights both countries' shared common goals and the challenges faced along the way. He ends the blog with three priorities for future action: integrating professional regulation into system safety, better use of data to anticipate risk and embedding equity and cultural safety. Effective regulation is a cornerstone of safe, quality healthcare, regardless of the health profession or practice context. We all know that healthcare is changing rapidly and regulation of health professionals must evolve with it.[1] This means that adaptability and the ability to pivot are essential competencies for any professional regulator.[2] Establishing the Australian Health Practitioner Regulation Agency Over the past fifteen years, I have been part of transformational change in professional regulation through my tenure as Chief Executive of the Australian Health Practitioner Regulation Agency (Ahpra). In 2010, Australia launched the National Registration and Accreditation Scheme, consolidating 85 separate registration boards and 65 pieces of legislation into a single national regulatory scheme.[3] The goals were clear: to create national consistency, support workforce mobility, raise standards for public protection and promote greater integration between professional groups delivering health and care.[4] Through this reform, Ahpra was established to administer these national regulatory arrangements in partnership with 15 National Boards, which now cover over 930,000 health practitioners across 16 professions. The UK's path to reform Transformational change in professional regulation is rare and the UK has taken a more gradual path to reform. Over a number of years, UK regulators have called for action to modernise their legislative frameworks. In response, the UK government’s consultation on Regulating Healthcare Professionals, Protecting the Public underscored the need for faster, more flexible regulation that supports innovation while safeguarding safety.[5] Yet, legislative change has been much slower, sometimes taking years to come to fruition, and, unlike Australia, the UK continues to deliver professional regulation through 10 independent regulatory bodies with differing legislative frameworks. Regulatory work is highly situational and dependent on numerous stakeholders, at times with competing views of public interest.[6] And in both Australia and the UK, there is ongoing debate about the timeliness, responsiveness and proportionality of regulatory responses to fitness to practice concerns and the issues to consider in assessing the suitability of someone to be a registered health practitioner.[7] Common goals Despite differences in the pace of change and the structure of professional regulatory arrangements, both countries share common goals: protecting patients, supporting the professionalism and ethical conduct of practitioners, responding to public expectations, and ensuring regulation keeps pace with the changing health care landscape and responds to workforce needs. The Covid-19 pandemic exposed both the strengths and limitations of our regulatory systems. In both countries, regulators responded quickly—fast-tracking registration pathways, adjusting accreditation requirements and convening stakeholders to support a surge workforce. This demonstrated that regulation can be agile when safety is at stake. The crisis reinforced the importance of collaborative regulation—where professional oversight is part of a broader safety ecosystem. Connecting professional regulation with system-wide efforts Nonetheless, one of our shared challenges is better connecting professional regulation with system-wide efforts to improve patient safety. Traditionally, professional regulation has focused on the conduct, competence and performance of individual health practitioners. As I saw from my tenure as Chief Executive of the NHS National Patient Safety Agency, patient safety is shaped by a range of factors, including clinical governance, team dynamics, design of systems and processes, technology and organisational safety culture. The rapidly growing cosmetic practices sector illustrates these challenges vividly. In both Australia and the UK, reviews have shown that regulating practitioners alone isn’t enough.[8][9] Products, procedures, facilities, social media, information asymmetry and weak professional ethics all contribute to risk of harm to patients. Without coordinated action across agencies, patients remain vulnerable. More widely, the rise of entrepreneurial models of care, telehealth, unregulated medicines for sale online, social media and AI-driven diagnostics has introduced new risk profiles to which traditional regulatory frameworks and approaches to patient safety must adapt. These shifts demand new thinking around safety, accountability, transparency and equity. A way forward Let me suggest three priorities for future action: Integrate professional regulation into system safety: We must work more closely with service, product and system regulators, and improvement bodies. Shared goals and aligned actions are critical. When regulators operate in silos, we risk missing the bigger picture. At the same time, patient safety system advocates must give due recognition to the critical role of ethical, safety-conscious, competent and accountable health professionals at the frontline of care. Better use of data to anticipate risk: Ahpra and UK regulators hold vast datasets. By investing in analytics and research, we can shift from reactive to proactive regulation. Notifications and complaints are often lag indicators—we need to get ahead of emerging risks of harm, especially in the face of the many healthcare disruptors we face. Embed equity and cultural safety: Regulation must reflect the many communities we serve. That means listening to lived experience and addressing systemic barriers. In the Australian context, this has meant facing the ugly reality of racism in the healthcare system for Aboriginal and Torres Strait Islander Peoples. The naming of racism in the National Law, which underpins the regulatory arrangements in Australia, has been a powerful catalyst for action.[10] Undoubtedly, the UK faces similar challenges in addressing racism in a multicultural society.[11] Regulation is more than rules—it’s about trust, transparency and care. As Australia marks 15 years of national regulation and the UK continues its reform journey, it is essential to place patient safety at the heart of everything we do and close the gap between professional oversight and system-wide efforts to improve safety. References Professional Standards Authority for Health and Social Care. Reviewing right-touch regulation: discussion paper. London: PSA; March 2025. Institute of Regulation. Rapporteur report: annual conference of the Institute of Regulation 2025. London: Institute of Regulation; 2025. Australian Health Practitioner Regulation Agency. Annual Report 2009-10. Melbourne: Ahpra; 2010. Fletcher M. Reflections on 15 years of National Health Practitioner Regulation in Australia. Australian Health Review 2025; 49, AH25131. https://doi.org/10.1071/AH25131 Regulating healthcare professionals, protecting the public: consultation response - executive summary - GOV.UK Austin Z. Regulation of wicked problems: opportunities, responsibilities, and threats. J Med Regul. 2023;109(3):6–11. doi:10.30770/2572-1852-109.3.6 National Health Practitioner Ombudsman and Privacy Commissioner. Investigation into delay and procedural safeguards for practitioners who are subject to immediate action. Melbourne: NHPPC; June 2024. Brown A, Duggan A, Kirkland A, McCausland R. Independent review of the regulation of medical practitioners who perform cosmetic surgery: Final report. Melbourne: Australian Health Practitioner Regulation Agency; August 2022. The regulation of non-surgical cosmetic procedures in England - House of Commons Library Australian Health Practitioner Regulation Agency. Joint statement: Aboriginal and Torres Strait Islander health and cultural safety at heart of National Law changes Melbourne: AHPRA; October. Accessed 15 June 2025. Royal College of Nursing. RCN reports 55% rise in members facing racist abuse. 27 October 2025.

The forthcoming Public Office (Accountability) Bill 2025, known informally as ‘Hillsborough Law’, presents a landmark shift in public sector accountability. The Bill introduces a new ‘duty of candour’ on public sector officials and a legal duty to assist in inquests and public inquiries, backed by criminal sanctions. Joanna Lloyd, Carlton Sadler and Priyesh Patel are experts in advising organisations engaged in inquests and public inquiries. Join us as we explore what these reforms mean in practice for healthcare providers and local authorities, and the likely impact of expanding legal aid for bereaved families to all inquests where a public authority is an interested person. Register

In this interview series, NHS whistleblower Peter Duffy and Patient Safety Learning’s Chief Executive Helen Hughes explore how the healthcare system responds when its staff raise concerns about patient safety. In each episode, Helen and Peter interview someone who has spoken up about patient safety issues in healthcare organisations, or who works to help staff raise concerns where they see unsafe care. In this interview, Peter and Helen speak to Helené Donnelly OBE, who spoke up about unsafe care she witnessed while working as a nurse at Mid Staffordshire NHS Foundation Trust. Helené contributed as a witness to the inquiry led by Sir Robert Francis KC into failings at the trust and was also an advisor in the Freedom to Speak up Review in 2015, where she called for the creation of Freedom to Speak Up Guardians in the NHS. Helené explains why she decided to raise concerns about the quality of nursing care at Stafford Hospital A&E and describes the bullying and threats she received from other staff as a result. She discusses with Peter and Helen the barriers that still prevent staff speaking up today and what can be done to create a more open and responsive culture in teams and organisations. Helené highlights the need to reform how human resources departments respond to staff raising concerns and the vital role of embedding speaking up and organisational culture in the curriculum of all healthcare professional training courses. Subscribe to our YouTube podcast to keep up to date with the latest episodes. View a transcript of this interview Read a blog from Peter and Helen about the interview series

In this interview, David Osborn, chartered occupational safety and health practitioner and member of the Covid-19 Airborne Transmission Alliance (CATA), speaks to Lotty Tizzard, Digital Content Manager at Patient Safety Learning, about how CATA was established during the pandemic to advocate for adequate respiratory protection for NHS employees.  David explains how CATA advocated for the government and heath service to recognise that Covid-19 is passed on by aerosol transmission (through microscopic particles in the air). He also outlines why surgical masks do not adequately protect people against catching airborne viruses and describes how inadequate respiratory protective equipment (RPE) contributed to thousands of NHS staff catching Covid-19 at work. As a result, many healthcare workers died and a large number still live with the ongoing symptoms of Long Covid. David describes CATA's involvement as a Core Participant in the Covid-19 Inquiry and outlines what he hopes will be done to ensure the UK is better prepared for future pandemics. Patient Safety Learning is also a member of CATA. Clarification David wishes to clarify a point raised in the interview: "When talking about the “IPC Cell” I said that they 'didn’t produce minutes'. In fact, notes or minutes were taken at all IPC Cell meetings. The point I was making is that they were not published ('produced' in the sense of being released into the public domain), when the minutes of most other groups such as SAGE and NERVTAG were published. The few IPC Cell minutes that have trickled into the public domain have mostly been as a result of Freedom of Information requests by a colleague and a few that I have managed to obtain myself. In some cases, public authorities have taken around 18 months to disclose documents, and it has required the intervention of the Information Commissioner's Office. I anticipate that more minutes will be disclosed for public scrutiny as time goes on." You can read more about CATA and the Covid-19 Inquiry in David's blogs and presentations on the hub: Respiratory protective equipment: An unequal solution for healthcare workers? A blog by David Osborn Healthcare workers with Long Covid: Group litigation – a blog from David Osborn Covid-19 : A risk assessment too far? A blog by David Osborn CATA and the UK Covid-19 Public Inquiry: Presentation from David Osborn Join the conversation Were you working in health and social care during the pandemic? We'd like to hear about your experience of health and safety at work. Were you provided with adequate PPE to carry out your job safely? Did you catch Covid-19 while at work? You can join the conversation by commenting below (you'll need to sign up first) or get in touch with us directly by emailing [email protected]

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. Hi Derek, thank you for speaking to me today. Firstly, can you describe the attitude of managers and senior clinicians at the Trust towards your family after Harry’s death? Leaders and staff at EKHUFT were closed off to us from the beginning. At every step, it very much felt like they were saying, “There’s nothing to see here.” Looking back, I realised very soon after Harry’s birth that we needed to start documenting what was happening because the Trust was not being honest. When I arrived at the hospital, we asked a nurse for the name of the doctor who had overseen my daughter-in-law Sarah’s care, and who my son Tom had expressed concerns about. The nurse told us, “You can’t have that information, it’s confidential.” At that point I started photographing Sarah’s notes as I wanted to make sure we had a record. Once the Trust’s internal investigation into Harry’s death started, they told us they couldn’t talk to us while it was ongoing. When we said that we wanted to contribute, we were totally shut out. It was upsetting that the investigation was used as a reason to avoid engaging with us, but we allowed them to get on with it for four months until they released the root cause analysis report into Harry’s death. We were offered a meeting at the Trust in March 2018, so we requested to see the report beforehand. After initially saying they would just show us the report at the meeting, they eventually agreed to send us a hard copy by post, saying they couldn’t send it by email. When we finally got to read it, the report was full of errors and just didn’t add up. At the meeting, it became clear that we knew more about their report than the consultants in the room did. They were totally in denial that Harry’s death could have been avoided and were told that there was no way it needed to be referred to the Coroner. I couldn’t put my finger on exactly what was going on, but I just knew something was wrong with the way Harry’s death was being treated. I began to suspect that what happened to us had happened to many, many families before us—the Trust had avoided taking responsibility and failed to make referrals to the Coroner for years, saying that baby deaths were ‘expected’. Their argument that Harry’s death was expected was that they didn’t have to factor in anything that happened more than 24 hours before they withdrew life support. Later we found that, on their internal notes, Harry’s death was described as an unexpected outcome. It is undoubted that there had been a cover up in the maternity department for many years and I don’t think anyone would deny that now. To quote the Kirkup report, “This pattern of behaviour by the Trust, clearly evident in this case, recurred in many others that we examined. It included denying that anything had gone amiss, minimising adverse features, finding reasons to treat deaths and other catastrophic outcomes as expected, and omitting key details in accounts given to families as well as to official bodies. Although we did not find evidence that there was a conscious conspiracy, the effect of these behaviours was to cover up the truth.” When it came to Harry’s inquest, the Trust didn’t expect or want it to happen and were obstructive throughout the process. When the Coroner suggested that it should be an Article 2 inquest, the Trust disputed it, arguing that it didn’t even come close to the criteria, which was obviously untrue. If the hospital had been upfront with us about what had happened in Harry’s case right at the beginning, we would have been able to forgive the staff and move on. But they didn’t do that. Instead, it felt like a battle from day one and I had to force myself into areas they did not want me to look. At times, I have been painted by Trust staff as a trouble maker. The Trust’s Chief Executive had to apologise to me after writing to our local MP Sir Roger Gale that I was trying to “undermine the reputation of the entire hospital.” This was in response to a letter Roger wrote to the Trust when I raised concerns that they were rating their maternity department 10/10. When NHS Resolution finally investigated, they found that the Trust was actually only scoring 6/10, and the Trust had to repay the large rebate the maternity department had been awarded for their self-audited high score. How were you able to keep pushing for answers in the face of the Trust’s attitude to your family? As Harry’s grandfather, I was one step removed from the situation. That enabled me to stand back and look at what was going on, to ask questions and raise issues that newly bereaved parents would struggle to raise. I call it ‘the grandparent effect’, and it made a huge difference in this case. I was able to be an advocate for Harry’s parents Sarah and Tom, who were obviously severely affected by losing their baby. I looked into the various reviews and audits the maternity unit had been through, and kept uncovering more evidence. The Trust was lacking in so many areas—I dug and dug and with every layer of the onion I took off, I found more rot beneath. I feel it’s so important to share what we’ve been through and what we managed to achieve by not backing down. Once the inquest was over, I learned how to set a website up and published Harry’s Story. I wanted to collect all the information and evidence we had gathered in one, accessible place. I’m still working with EKHUFT now, trying to help them make improvements and deliver Bill Kirkup’s Reading the Signals report, but there’s still such a long way to go. How easy was it to find out which organisations you could refer your concerns about Harry's care to? The Trust left us to our own devices, so I took any route I could to try and find out the truth about what happened to Harry. I went to many organisations such as AvMA and kept being told, “Yes, we hear of these things happening, have you tried X organisation?” We were being sent from pillar to post, but kept trying to find out how we could take it further. I happened to have a relative working for an unrelated department of the Care Quality Commission (CQC) and she recommended that I make a report to the CQC. It was an uphill struggle to be heard by them and I initially found that they really didn’t want to engage with me. They eventually, after 10 months, got back to me saying there was nothing for them to investigate, and at that point I replied by copying in Professor Ted Baker, then Chief Inspector at the CQC. At that point, things started to change! Although the CQC eventually started to engage with us, I’m struck by how we were expected to go to them. We were invited to a meeting in London—we paid our own train fares and Tom had to take a day off work, which is difficult as a teacher. Were there individuals who engaged with you and your family well? What was it about their response that was positive? The individuals who engaged well with us were honest and listened to what we had to say. The Director of Maternity for Healthcare Safety Investigation Branch (HSIB), Sandy Lewis, was so helpful. She would call me with regular updates and communicate how much Harry’s case mattered to her. I could sense her commitment to seeing change. HSIB in general were exceptionally helpful, but there were hurdles to overcome there too. Harry was born in November 2017, but HSIB only had the remit to investigate cases from April 2018. I spoke with various individuals at the organisation including the medical director, who was keen to take on Harry’s case as he recognised its seriousness. They eventually found a way to take it on, by carrying out a learning investigation rather than a maternity investigation. The coroner’s officer was also fantastic—she listened and was so encouraging. I was constantly emailing new evidence over and in every email I would apologise for the extra reading, but she was so affirming and would say, “Send me whatever you want, I’ll make sure the Coroner sees everything.” The Coroner was also very respectful and told me what a difference I was making; after Harry’s inquest, he said to me, “You’ve done a good thing. Without you this wouldn’t have come before me Mr Richford.” I get very emotional thinking about it even now. You and your family suffered a terrible loss. How did the responses of the Trust following Harry's death affect your family further? We’ve discussed this as a family before. The loss of Harry was on one level, but the denial and the way we were treated by the Trust was almost worse—I would say it added at least 50% to the trauma. The approach taken by the Trust was to deny, delay and defend, and the damage that has caused us as a bereaved family is immense. Have you seen any positive change in how bereaved families are treated by the system? One positive move is that I was recently involved in the panel to appoint the new Chief Midwife for England. It was a privilege to be part of the process, and it felt like being told, “You are welcome at this table.” So maybe we are making a difference, but progress is far too slow. For patients and families, the cost of engaging is far more than it should be, both emotionally and financially, as I mentioned earlier. It’s only because I run my own business that I was able to do what I did. I spent hours and hours investigating Harry’s death. We need the NHS to actively help make it easier for people to engage, and to overcome barriers such as financial cost and working hours. During our first meeting with the CQC, I realised that we had access to information that they didn’t—for example, they weren’t aware of a Royal College of Gynaecologists (RCOG) report about EKHUFT that was referenced in the Trust’s board papers. I had done the legwork to draw all the evidence together, which none of the statutory organisations had done. Eventually the CQC agreed to prosecute the Trust for unsafe care and treatment. The prosecution was successful, and the evidence we had collected contributed significantly to that. Lots of families whose babies have died due to harm in or after labour get in touch with me, and their experiences tell me that bereaved families are still being treated with suspicion and a lack of care. I recently discovered that some of the families who took part in the EKHUFT Kirkup investigation—and whose cases featured in the final report—are having to go through a whole new investigation process to claim compensation through NHS Resolution. That means reopening case notes and revisiting yet again the harrowing events that led to the deaths of their babies. The level of trauma this will cause for parents who had hoped the inquiry would bring the justice they need is huge. It is yet another example of how the system is not designed to support victims of harm, and how it fails to place compassion and dignity for patients and their families at the centre of pathways and processes. What do we still need to see change in how organisations respond to families when a loved one dies due to avoidable harm? We need people like me (but not me!) at the top of the NHS—‘real-life’ people who can represent the patient perspective at local board level and right up to the top of the NHS. Most of the people who are currently in leadership have only ever worked for the NHS or have worked there for years, and they don't know any other way of working. There’s an extent to which NHS leaders are institutionalised—they accept the foibles of the system as normal. In the face of serious patient safety concerns many seem to simply say, “No, that’s not what goes on here.” We need leaders who are upfront and honest and will say, “We made a mighty mistake and we’re sorry. We’ll do something about it.” We also need to see trust leaders being held to account. During our experience, we heard the phrase, “the Trust has done this,” a lot, with no individuals taking ownership of actions and decisions. Ultimately, people in leadership were responsible for so many of the lies we were told, but they never had to answer for that. In any other business, people would be held to account, but I am concerned that NHS leaders are allowed to do whatever they want. If this doesn’t change then very little else will. You can read more about the investigations into Harry’s death and Derek’s work to improve the safety of maternity care on the Harry’s Story website.