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Found 217 results
  1. Content Article
    We asked the Patient Safety Group (PSG) of The Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top 10 priorities for patient safety in surgery. This resource is for surgeons, anaesthetists and other healthcare professionals who work in surgery and contains links to useful tools and further reading. See also: Safety in surgery series Top 10 tips for surgical safety: ‘Think Safety, think SEIPS’ Top 10 patient safety tips for surgical trainees 1. Foster a culture of safety through design Establish a psychologically safe environment, through design, where staff feel empowered to speak up without fear of blame. Promote a Just Culture, balancing personal accountability with systems-based learning from adverse events and near misses. Actively encourage multidisciplinary teamwork and peer support, with support from senior leadership, to enhance safety and well-being. Other useful RCSEd resources: Anti bullying and undermining campaign Sexual misconduct in surgery - Lets remove it campaign Addressing conflict in surgical teams workshop 2. Implement team-based quality and safety reviews Use team-based quality reviews (TBQRs) and structured case analysis to learn from everyday work, incidents and near misses. Translate findings into sustainable improvement initiatives that enhance both patient outcomes and staff experience. Foster a culture of collective learning, ensuring safety insights lead to actionable change. Other useful RCSEd resources: Making sense of mistakes workshop 3. Apply Human Factors principles and systems thinking principles in surgical and clinical practice Design resilient systems that mitigate work and cognitive overload and enhance performance reliability. Use TBQR principles to support this. Standardise workflows, optimise usability of IT systems and medical devices, and integrate cognitive aids (e.g. WHO Safe Surgery Checklists, prompts). Ensure governance processes support safe, efficient and user-friendly surgical environments. Other useful RCSEd resources: Systems safety on surgical ward rounds Improving the working environment for safe surgical care Improving safety out of hours 4. Enhance communication & handover processes Implement structured communication tools such as SBAR (Situation, Background, Assessment, Recommendation) to improve clarity and effective decision-making. Optimise handover processes with digital tools, checklists and standardised documentation. Reinforce closed-loop communication, ensuring critical information is confirmed and acted upon. Other useful RCSEd resources: Consultation Skills that matter for Surgeon (COSMOS) 5. Strengthen leadership & accountability in patient safety Senior leaders must visibly support safety initiatives and proactively engage frontline staff in decision-making. Embed structured mechanisms for raising concerns, including TBQR, safety huddles and escalation pathways. Ensure staff have access to training, resources and protected time for safety and quality improvement work. 6. Minimise medication errors in surgery Implement electronic prescribing and technology assisted medication administration to mitigate errors. Enforce double-check procedures for high-risk medications and standardised drug labelling. Improve intra and peri-operative medication safety with clear labelling, colour-coded syringes and real-time verification. 7. Improve early recognition & response to deterioration Appropriate regular training of teams on processes and pathways supported by good design of staff rota ensuring adequate staffing levels. Implement early warning scores and establish rapid response pathways for deteriorating patients. Standardise post-operative surveillance strategies, ensuring timely escalation and intervention. Other useful RCSEd resources: Recognition and prevention of deterioration and injury (RAPID) course for training in recognising critically ill patients 8. Engage patients & families as safety partners Encourage shared decision-making to align treatment plans with patient expectations and values. Provide clear communication on risks, benefits and post-operative care, using tools like patient safety checklists and focus on informed consent processes. Actively involve patients and families in safety and quality initiatives and hospital discharge planning. Other useful RCSEd resources: Patient/carer/families resources and information Informed consent courses (ICoNS) 9. Standardise, simplify & optimise surgical processes Reduce unnecessary complexity in clinical workflows, making processes intuitive, efficient and reliable. Co-design standard operating procedures, policies and pathways with frontline teams to minimise variation. Implement automation and digital solutions where feasible to streamline repetitive tasks. Other useful RCSEd resources: NOTSS (Non Operative Technical Skills for Surgery) courses for surgeons DenTS courses for dentists 10. Promote continuous learning & simulation-based training Conduct regular simulation training for critical scenarios (e.g. sepsis, airway emergencies, human factors). Use insights from TBQR and incident reviews to target training needs and refine clinical practice. Ensure ongoing professional development by providing staff with time, resources, incentives and institutional support for learning. Other useful RCSEd resources: Education pages Edinburgh Surgery OnLine MSc in Patient Safety and Clinical Human Factors
  2. Content Article
    A Brighton GP surgery is under threat despite providing excellent services and strong links to the local community. This decision flies in the face of the proven 'social value' being delivered and potentially puts patients at risk. The reasons are presented in this excellent article which exposes the continued 'race to the bottom' due to an apparently unnecessary tendering exercise, a decision made behind closed doors and a failure to consult. Quote from Polly Toynbee's article in the Guardian: "Here’s the puzzle. Andrew Lansley’s calamitous system that opened the NHS to “any willing provider” to compete for contracts was supposedly swept away in 2022, replaced with ICBs that strove for cooperation across all NHS and social services in England. Yet some ICBs still apply the old competitive impulse to NHS services, even though they now have an obligation to ensure that tenders help to reduce inequalities."
  3. Content Article
    Leadership Futures recently published a report 'Harnessing technology for human progress: Advancing into Industry 5.0', which is driven by a bold ambition: to transform organisations worldwide through technological advancements. In this blog, Caroline Beardall looks at the implications of this for healthcare and suggests five actions that organisation's should take to ensure we achieve the benefits from technology while keeping patient safety at the forefront of an evolving landscape. The recent Leadership Futures report 'Harnessing technology for human progress: Advancing into Industry 5.0' provides a valuable framework for integrating technology with human-centered leadership, which is highly applicable to advancing patient safety in health and care. Its vision of Industry 5.0 as a collaborative human-AI partnership offers a route to reduce errors, enhance clinician capacity and improve patient outcomes. However, realising these benefits requires caution—ethical and inclusive implementation strategies that address the complexities and risks unique to health and care settings. It throws up three fundamental challenges: How can healthcare leaders ensure AI tools are safe to use and that clinical staff can trust them? Who should be responsible if an AI system makes a mistake that affects a patient? How can healthcare organisations use technology to work better without losing the importance of human interaction and the skills needed for high levels of patient satisfaction and safety? In order to answer these questions, and deepen the discussion on harnessing technology responsibly to safeguard and improve patient care, there are some actions we can take to build on the report and begin to gain evidence and experience specific to healthcare. As the landscape of healthcare shifts and evolves, we should consider applying the following five actions (with examples of how to do this) so we can achieve the maximum benefits from technology for patient safety. 1. Foster collective, collaborative leadership across boundaries Leaders should actively promote cooperation and shared responsibility across organisational and professional boundaries, focusing on the overall patient journey rather than siloed departmental goals. This aligns with the report’s emphasis on human-machine collaboration and the need for integrative leadership cultures that support safe, seamless care delivery. By working collectively, leaders can ensure technology is implemented with broad input and oversight, reducing risks and enhancing patient safety. Implement interdisciplinary collaboration practices: Organise regular team meetings involving diverse healthcare professionals to discuss patient care holistically, ensuring all voices contribute to decision making. Create shared goals and aligned metrics: Develop common objectives focused on patient safety and quality that unify departments and reduce siloed working. Lead by example: Demonstrate collaborative behaviours and openness to input, encouraging a culture of trust and teamwork. 2. Embed ethical, human-centred use of technology Leaders must champion ethical principles in technology adoption, ensuring AI and digital tools augment rather than replace human judgment and empathy. This includes rigorous validation of new technologies, transparency in AI decision-making, and ongoing monitoring to prevent harm or bias. Prioritising patient experience and human values in technology deployment safeguards safety and trust. Prioritise transparency and clinician involvement: Engage frontline staff early in AI and technology design and deployment to ensure tools meet clinical needs and ethical standards. Establish continuous monitoring and feedback loops: Use data and user feedback to identify and mitigate risks or biases in technology that could impact patient safety. Promote ethical leadership training: Equip leaders with skills to balance innovation with patient experience and accountability. 3. Develop and support workforce readiness and engagement Preparing staff to work effectively alongside new technologies is vital. Leaders should invest in training that builds digital literacy, critical thinking and resilience, while also fostering a positive work climate where staff feel valued and supported. Engaged and confident clinicians are better able to use technology safely and maintain high standards of care. Invest in targeted training and digital upskilling: Provide contextual, in-app guidance and interactive training to help staff adopt new technologies confidently and efficiently. Foster a culture of psychological safety and empowerment: Encourage open discussion, honest feedback and staff involvement in decision making to build trust and resilience. Practice empathetic leadership: Focus on emotional and professional needs of staff to reduce burnout and improve engagement. 4. Set clear, aligned objectives focused on quality and safety Leadership should establish clear, challenging and aligned goals at every level that prioritise patient safety and quality improvement over mere efficiency or target-driven metrics. This clarity helps reduce staff stress and confusion, enabling teams to focus on delivering compassionate, safe care supported by technology. Communicate clear expectations and priorities: Use consistent, transparent communication to align teams around patient safety goals and reduce ambiguity. Implement continuous feedback and learning systems: Regularly review performance data and patient feedback to refine objectives and improve care quality. Balance efficiency with human factors: Ensure operational goals do not compromise critical human skills or patient-centred care. 5. Champion diversity, inclusion and accountability in leadership Inclusive leadership practices that promote equality and diversity are essential to fostering innovation and ethical decision-making in healthcare technology adoption. Leaders must also clarify accountability frameworks for technology-related decisions and errors, ensuring responsibility is shared and transparent to maintain patient safety. Promote inclusive leadership practices: Value diverse perspectives and foster equity to enhance innovation and ethical decision-making Clarify accountability frameworks: Define roles and responsibilities clearly, especially concerning technology-related decisions and errors, to maintain trust and safety Model human-centred leadership traits: Practice self-awareness, compassion and mindfulness to create cultures of excellence, trust, and caring. By integrating these strategies, human-centric leaders can effectively translate the insights from the Leadership Futures report into practical actions that improve patient safety, staff satisfaction and overall health system resilience. This approach embraces complexity and change as opportunities, not obstacles, which then enables sustainable progress in better health and care delivery. Further reading Amelia N. 6 Effective Leadership Strategies for Healthcare in 2025. Edstellar, 31 December 2024. West M, et al. Leadership in Healthcare: a Summary of the Evidence Base. Kings Fund; Faculty of Medical Leadership and Management; Center for Creative Leadership, 2015. LeClerc L, Kennedy K, Campis S. Human-Centered Leadership in Health Care: An Idea That's Time Has Come. Nursing Administration Quarterly 2020; 44(2):p 117-26.
  4. Content Article
    Learn how to spot the red flags for harmful cultures in healthcare. The Patient Experience Library's Responding to Challenge report reveals the patterns of behaviour that crop up time and again in healthcare disasters. It explains what poor cultures look like - in teamwork, compliance, accountability, organisational learning and more. It can support staff training and organisational learning - helping people to get a better idea of what "culture" actually means in healthcare, and how it can go wrong. Use the Red Flag Tracker to find real-life examples of warning signals, drawn from ten years of official inquiries in UK health and care settings. The tracker will be useful for people charged with the task of "reading the signals" of harm - complaints managers, patient experience staff, Freedom to Speak Up Guardians and local Healthwatch staff, as well as service managers and Trust Board members.
  5. Content Article
    Families bereaved by state-related deaths and those affected by miscarriages of justice have issued a clear warning to Government following reports that the forthcoming Bill will fail to contain the key elements of Hillsborough Law. A new report published by INQUEST brings together the powerful voices of bereaved families, victims and survivors of some of the worst failings of public services and the legal system in the UK. This includes those affected by the Hillsborough disaster, Grenfell Tower fire, Post Office Horizon scandal, infected blood scandal and many others. These participants are united in their concerns about the Government’s plans for a Hillsborough Law, which was included in the 2024 King’s Speech. The testimony featured in this report reflects the emotional and financial toll of families forced to spend years, and in some cases decades, fighting for the truth despite cover-ups, denials and outright lies told by public and private organisations. The report also shows how the injustice experienced by the bereaved and survivors following the Hillsborough disaster is still a painful reality today. It is therefore critical, families told INQUEST, that a Hillsborough Law ensures a statutory duty of candour backed up by effective provisions to ensure compliance, and robust sanctions to ensure accountability. This would bring to an end the culture of denial and cover-ups following state failings which currently prevail. Another key demand of families is for the law to provide for public funding for their legal representation following state failures to ensure equality of arms with public bodies. Under the current system, families are often left without public funding and forced to crowd fund to cover their legal costs, whilst state bodies have legions of lawyers. Families see Hillsborough Law as a potential watershed moment, one that could redress the power of the state, fulfil the legacy project that Hillsborough families and survivors have fought for, and prevent future deaths and harm. However, the report makes clear that families and victims fear the Government will change or amend the 2017 Bill and, as such, are demanding that Hillsborough Law be “all or nothing”. Those involved in this report hope the Government heed their voices and resist attempts to dilute the bill, stressing that any compromise would undermine its vital purpose.
  6. News Article
    The Department of Health and Social Care is launching a delivery unit that promises to tackle some of the NHS’s most pressing problems. The secretary of state's delivery unit will sit within DHSC and act as a mechanism through which the health secretary can hold NHS England and other relevant organisations to account for delivering on the government’s priorities, according to a job advert for the unit’s director. It will “bring a laser-like focus on delivering the reform needed to drive improvement generally across health and care and specifically on the three things that surveys show matter most to the public”, the ad says – namely elective waiting times; urgent and emergency care waiting times and performance; and GP access. The department is offering £125,000 a year for a director to lead the unit’s “small, multidisciplinary team”, who will be tasked with “tracking and challenging” delivery of the health secretary’s priorities, including manifesto commitments. The unit will work to “raise the profile of delivery” throughout the department and will “operate in lockstep with departmental strategy functions”, according to the candidate pack for the role. It will “share responsibility for ensuring that the delivery issues of the day are tackled in ways that do not defer problems for the long term and do not make implementation of the long-term strategy emerging from the 10-year plan more difficult”. Read full story Source: Civil Service World, 7 March 2025
  7. Content Article
    The regulation of NHS managers must drive real change by addressing root causes, prioritising patient safety, and ensuring accountability without repeating past failures, writes Roger Kline in this HSJ article. Principles a code might adopt should include: Make safety the prime litmus test for all initiatives and “stop the line” (from board to ward and community setting) when it is not. Make speaking truth to power a precondition of effective leadership. Prioritise the duty of care all staff owe. Expect and support managers (and staff) to always behave respectfully to each other (and to patients) and to relentlessly seek to create a culture of psychological safety, civility and inclusion, not least by leaders and managers modelling the behaviours they should expect of all staff; Cease performative measures to tackle toxic cultures. Employer legal proceedings involving staff who have raised concerns should also be regarded as a “never event” and all costs disclosed. Employers must review at pace (with independent support) all cases of staff who have left or been dismissed after raising concerns with a view to helping them gain NHS employment; Appointment and appraisal decisions. Openness and transparency. Duty of candour. Specifically regarding as a breach of the Code “never events”.
  8. Content Article
    This article, co-authored by IHI President Emeritus and Senior Fellow Don Berwick, highlights how healthcare in the US is failing patients and presents a vision of a system that better supports the nation’s needs. 
  9. News Article
    The author of a major report into quality and governance in the NHS has stressed the responsibility of local boards – and hinted at a rebalancing from regulators to providers. Penny Dash – who on Monday was confirmed as the new chair of NHS England – told a patient safety conference that accountability and responsibility for delivery were much clearer in many other industries. “It is not like this in other industries,” she said. “They have very clear lines of accountability and responsibility, particularly through boards. It is usually much clearer who is responsible for delivering and who is responsible for regulating. That does not just stop at the board but throughout the organisation. It’s very clear what people’s jobs are.” Dr Dash completed a review of the Care Quality Commission last year, and a second review covering wider quality and safety oversight is expected within the next three weeks. Dr Dash told the HSJ podcast last month that her review would emphasise the role of boards, and that quality should encompass productivity and efficiency as well as safety and effectiveness, messages she also addressed at the Patient Safety Forum conference, organised by Public Policy Projects with Patient Safety Learning. She said: “We know that well-managed services lead to more efficient use of resources – that in itself is a big quality opportunity. We can actually do things for less that frees up money for more care.” Read full story (paywalled) Source: HSJ, 4 March 2025
  10. Content Article
    “Safe to Speak: Psychological Safety and Accountability for a Blame-Free Culture” is a groundbreaking guide for healthcare leaders, managers and professionals who want to create a culture where safety, accountability, and open communication thrive. In this transformative book, Perbinder Grewal explores the critical balance between psychological safety and accountability, offering practical strategies to eliminate fear, encourage speaking up, and foster a culture of learning rather than blame. In healthcare, where mistakes can have life-or-death consequences, creating an environment where staff feel safe to report concerns is essential to improving patient safety and team performance. “Safe to Speak” provides a comprehensive roadmap for building a blame-free culture where everyone—from front-line staff to leadership—takes responsibility for safety without fear of retribution. Inside this book, you will discover: Why psychological safety is the foundation for better patient care and how to implement it in your team. How to balance accountability with compassion and ensure mistakes are seen as opportunities for learning, not punishment. Actionable strategies and tools to create and sustain a culture of safety, from courageous conversations to effective feedback loops. Real-world case studies and practical exercises to help you apply these concepts in your own healthcare environment. Step-by-step guidance on overcoming resistance to change and measuring progress in psychological safety.
  11. Content Article
    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
  12. News Article
    Families of children operated on by a disgraced surgeon have labelled independent reports into their care as a "whitewash" and a "final insult". Yaser Jabbar, a former surgeon at London's Great Ormond Street Hospital (GOSH), carried out procedures including leg lengthening and straightening. He also operated on children with complicated disorders. But some cases linked to him resulted in harm, including life-long injuries and amputation. Mr Jabbar left the hospital in 2023 after a report by the Royal College of Surgeons (RCS) found some of the surgery had been "inappropriate" and "incorrect". Following the RCS report, GOSH said each of Mr Jabbar's 723 patients would receive an independent report to conclude what level of harm they had suffered. The reviews, which are being carried out by specialist surgeons who did not work at GOSH, are based on patient notes provided by the hospital. Families have started receiving reports about the care their children received. BBC News has now spoken to four families - and had indirect contact with 12 more - who say the reports do not reflect their children's experiences and often raise more questions than they answer. Many of the reports were concluded without any interviews or interaction with the family or patient, they say. Parents describe the reports as part of a "culture of cover-up", telling the BBC that GOSH has "failed their children", leaving them physically and mentally damaged. Read full story Source: BBC News, 6 December 2024
  13. Content Article
    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]
  14. News Article
    A major consultation on introducing professional regulation of NHS managers and leaders proposes applying the measures to NHS England board members. One of the questions in the Department of Health and Social Care’s consultation on regulating NHS managers, published this afternoon, asks participants whether “appropriate board members at arms-length bodies (for example, NHS England)” should face a system of regulation. However, the consultation does not ask participants whether NHSE employees should be included in plans for an individual statutory duty of candour, which could see managers face legal penalties for failing to report safety concerns. Instead, it only asks if managers at Care Quality Commission-regulated organisations should face tougher legal accountability, and at which level this should be considered. The consultation, set to run for 12 weeks, will consider the type of regulatory system that would be deemed appropriate, which managers should be in scope, what kind of body should be responsible for its regulation, and what types of standards managers should be required to demonstrate. Read full story (paywalled) Source: HSJ, 27 November 2024
  15. Content Article
    A consultation seeking your views on options for regulating NHS managers, and on the possibility of introducing a professional duty of candour for NHS managers. This consultation is now closed to submissions. It is vital that we take further action to strengthen the accountability of NHS managers, with the overarching aim of ensuring patient safety. The government’s manifesto committed to introducing professional standards for, and regulating NHS managers. The consultation will seek partners’ views on the type of regulation that may be most appropriate for leaders and managers, such as: which managers should be in scope for a future regulatory system what kind of body should exercise such a regulatory function consideration of the types of standards that managers should be required to demonstrate as part of a future system of regulation. The consultation will also seek views on matters relating to candour, including first on the possibility of delivering a professional duty of candour for NHS managers and leaders. It will also seek views on making managers accountable for responding to concerns about the provision of healthcare patient safety.
  16. News Article
    UK doctors are having suicidal thoughts because disciplinary proceedings against them by their NHS employer take so long to resolve, research has found. Medics who have been accused of misconduct say the current system of investigating allegations is “brutal” and “humiliating” to go through and can feel “like a witch-hunt”. Three out of four doctors who had faced proceedings said the length of time it took to conclude them damaged their mental health and led to them suffering anxiety, stress and depression. Almost nine out of 10 (88%) said they were left feeling angry and frustrated by the disciplinary process. Four out of five were left feeling as if they were “guilty until proven innocent”, with some complaining that they were treated “like a criminal”. Half of the doctors who recounted their experience as part of the MPS’s study said they had been accused of wrongdoing after raising concerns about patient safety where they worked. That prompted concern that misconduct charges are used as part of a “culture of fear” in the NHS. Read full story Source: The Guardian, 6 November 2024
  17. Content Article
    The organisation Medical Protection are calling on NHS Trusts across England to correctly follow national guidelines, to ensure doctors are treated fairly during disciplinary proceedings. Failure to conduct disciplinary processes swiftly and fairly can also perpetuate a culture of fear amongst doctors in the NHS. This also works against improving patient safety. Openness and learning in the NHS relies on doctors having confidence in senior management and their commitment to due process, which further underlines why it is so important to get this right. A recent survey of a group of Medical Protection members who have experienced a disciplinary during the past seven years found: 53% said that the disciplinary investigation against them lasted over 1 year - 22% said the process was over 2 years. 80% said the disciplinary investigation had a detrimental impact on their mental health. 44% said that they experienced suicidal thoughts during the investigation. 72% said it affected their personal lives. 75% said the length of the investigation affected their mental health. 81% said feeling 'guilty until proven innocent' affected their mental health. 85% said the malicious nature of the allegation significantly impacted their mental health. 18% either chose to retire early or had no choice but to retire early. 24% either left the Trust, or had no choice but to leave the Trust. 13% considered leaving the medical profession due to their experience. The report identifies four themes for ensuring a ‘good’ disciplinary process. Within each of these themes, specific areas are identified where changes should be made. Theme 1: Efficient Proportionate - Trusts must consider whether a matter may be dealt with in a less formal manner before proceeding to an MHPS investigation. Any move to exclude the doctor from their duties must also be proportionate to the nature of the investigation. Timely - When a doctor is put through a disciplinary process, it should begin and conclude in a timely manner. Theme 2: Fair Fair treatment for all parties The doctor and their representatives should receive fair treatment during proceedings, with due process followed and all necessary disclosures made. NHS staff involved in carrying out the disciplinary processes should also receive adequate, specialised training; Trusts should not be relying on competence or experience. Dedicated time should be ring-fenced for those involved in an investigation to ensure that MHPS deadlines can be met. Free from bias and discrimination Steps must be taken to ensure discrimination and bias are not factors that can initiate a disciplinary investigation. Information about the importance of defence organisation and union membership should be highlighted at each induction to maximise the chances of a doctor being able to access appropriate support during an investigation. Theme 3: Compassionate Considerate - The wellbeing of the doctor subject to investigation should be considered at all times, and active steps taken to offer support and mentorship. Well communicated - The disciplinary process should be communicated clearly and in plain language at the outset, and frequent communication should continue throughout, so doctors are aware of the status of the investigation and any delays. Theme 4: Accountable Accountability of employers - When a Trust or another employer is found to have behaved in a seriously wrong way during proceedings, a clear method needs to be established to hold them to account. Scrutiny - Senior managers and Trust Boards should have greater knowledge and scrutiny of disciplinary processes. Standardised reporting and data collection, such as the inclusion of disciplinary processes in governance audits, should be rolled out.
  18. 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?
  19. 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. 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.
  20. 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.
  21. Content Article
    In this anonymous blog, a patient shares their experience of orthodontic treatment which they undertook to reduce overcrowding of their teeth. However, instead of solving the problem, the treatment caused multiple, complex dental issues that have resulted in severe pain and a high financial cost. The patient talks about how their orthodontist has been unwilling to take any responsibility for the issues caused, threatening legal action if the patient pursues any claims against them. They also discuss the reluctance of other orthodontists to get involved in trying to treat the issues they now face, and call for regulators and governments to look into the issue of negligent orthodontic treatment. I underwent an orthodontic treatment that unfortunately turned into a complete nightmare. My motivation for pursuing this treatment was to address overcrowding in my teeth so as to reduce the risk of decay due to overlapping. An orthodontist assured me that it would be a straightforward treatment and that it would last approximately two years. As a result I decided to move forward with the treatment, which consisted of fixed braces. Throughout the treatment, I diligently attended all scheduled appointments, trusting in the orthodontist's expertise. The orthodontist did not raise any concerns regarding the progress even though after 2.5 years, it became evident that the treatment was far from completion, and my teeth appeared worse than when I started the treatment. I started to get concerned about the treatment but the orthodontist assured me that the treatment would be finalised within a few months. As the treatment progressed, I was chipping my upper front teeth with the brackets on my lower front teeth and the orthodontist added posterior bite stoppers to my molars. I was getting concerned about my bite (occlusion) and was asking the orthodontist about this and about the stoppers. However, despite expressing my concerns to the orthodontist multiple times, I was dismissed as a perfectionist, and my worries were brushed aside. The orthodontist insisted that any potential remaining imperfections in my bite would be resolved through selective grinding after removing the braces and bite stoppers. After enduring four years of treatment, the braces and bite stoppers were finally removed. To my surprise, I realised that I was only biting on some of my front teeth and that I had no contact in my back teeth. I immediately raised this issue with the orthodontist, but was advised to wait for my bite to settle naturally. I also voiced concerns about the visibility of the rough surface of my teeth, but once again, I was told that it would resolve on its own. However, my bite felt extremely uncomfortable with every passing second and this discomfort did not subside—I couldn't chew properly and I soon realised that it was not a matter of simply adjusting to a new bite. As a result, I sought a second opinion from another dental specialist. In the meantime, after a few weeks of biting on my front teeth, I also started to experience pain in two of my front teeth which continued to increase to the point that I was literally crying in pain. The dental specialist suggested removing the high spot on my front teeth as this could lead to damage, but they advised me to go back to the original orthodontist who did the treatment as they did not want to intervene in the matter. Upon trying to do so, the original orthodontist declined to address the issue or to even see me and advised me to communicate only through a lawyer. Despite numerous attempts to find resolution through additional dental appointments, I continued to suffer from pain and discomfort in my front teeth due to the unresolved high spot, since all the biting forces were being placed on just two front teeth. Eventually, another orthodontist and several other dentists tried to reduce this high spot by shaving from my front teeth, which slightly reduced the extreme pain. However, my front two teeth had already endured significant trauma from bearing the brunt of the bite pressure for an extended period and as a consequence, I continue to experience persistent pain in my front teeth to this day. The original orthodontist and the clinic refused to provide my treatment notes and records, and instead presented a report that shifted blame for the unfavourable outcome onto me. Eventually, through legal channels, I acquired my treatment notes and records. The orthodontist provided photos of my post treatment clay models that depicted contact points on my back teeth which I did not possess. This discrepancy was subsequently corroborated by another orthodontist, revealing that the original orthodontist had manipulated the clay models' contact points to create a false impression that I was biting on all my teeth. Furthermore, after shaving to reduce the high spot on my front two teeth as explained above, a thorough occlusion checkup and several 3D scans confirmed that I was left with only two pairs of contact in my teeth and that I had a bilateral posterior open bite. The majority of the dental specialists I visited in the same country refused to treat me with another orthodontic treatment, and advised me to go back to be treated by the previous orthodontist. Eventually, I had to travel to a different country to assess if my issue could be truly fixed and to assess if any damage had been done to my teeth. Unfortunately, things turned out to be worse than anticipated since further examinations and scans by specialists abroad revealed that I had severe root resorption especially in my upper front tooth, permanent enamel damage on all teeth caused during incorrect bracket removal, and bone loss due to incorrect the orthodontic movements and techniques that had been used. Some teeth were also improperly positioned in the bone, including some teeth with roots pointing outwards. I also got confirmation that the original orthodontist managed both my vertical and horizontal dimensions incorrectly through bad use of bite stoppers which pushed my molars into my gums (intrusion) and bad anchorage management respectively. It is very concerning that the orthodontist was so negligent and/or incompetent that even after I repeatedly expressed my concerns during the treatment, they still failed to identify and address several mistakes that were being made. Unfortunately, this had a cascading effect on my dental health, leading to root resorption, bone loss, incorrect tooth torque and several other effects. Furthermore, the fact that the same orthodontist has shown a complete lack of accountability and refused to take any responsibility, gaslit me and assured me to wait for my bite and roughness (the latter turned out to be permanent enamel damage) to settle is also very alarming behaviour. The selective grinding that I was advised about during the treatment also turned out not to be a solution for the extent of malocclusion I was left with. Moreover, the fact that I was left to bite solely on my front teeth for months once the braces and bite stoppers were removed led to more trauma and damage to the affected teeth. The experience of enduring trauma and its aftermath becomes even more distressing when victims find themselves subjected to gaslighting not only from their initial orthodontists, but also by other dental specialists within the same country. Such instances involve attempting to conceal the severity of the issues faced by the patients so as to avoid entanglement in legal matters, rather than prioritising the best interests of the patient, as outlined in their professional oath. Moreover, seeking an orthodontist willing to provide expert testimony in legal proceedings poses an additional challenge to the victims. All of this further exacerbates the already challenging journey of those enduring such a trauma, adding another layer of complexity to the ordeal. The impact of this ordeal has extended far beyond my dental health, affecting various aspects of my life, including my physical wellbeing, my career and my personal relationships. My ability to chew food and enjoy a normal diet has been severely compromised and I cannot even enjoy a pizza, amongst several other foods. I have already had a year and a half of my life literally taken away from me. The extensive time and effort I spent researching orthodontic solutions, seeking someone that could help me, and advocating for my own health has also only added to the distress caused by the initial treatment. In an attempt to regain some functionality, I now find myself facing the prospect of undergoing another one to two years of orthodontic treatment with the added concern of potential tooth damage or loss due to the damage that has already been done by the previous treatment. Unfortunately, orthodontists still cannot guarantee that contact will be achieved since a posterior open bite should ideally be fixed with braces, however, I have to resort to Invisalign treatment as it seems to be the only viable option considering the trauma and root resorption that prohibits me from using traditional braces on my front teeth due to the forces. The process is far from straightforward, and the cost involved to "fix" all the issues that had been created by the original orthodontist runs into tens of thousands of euros. What should have been a 1.5-2 year treatment has now become a prolonged and distressing 7-8 year nightmare. The original orthodontist turned down requests to settle the damages and has even raised the threat of legal action against me should I choose to pursue further claims regarding the damages I have suffered. Patients place their trust and well-being in the hands of medical experts, and negligent treatment can lead to significant physical and emotional distress. I felt compelled to share my story, hoping to raise awareness about the importance of compassionate and responsible care within the dental field. I would like to seek acknowledgment of the seriousness of this matter and urge authorities to consider the potential consequences of such negligence and/or incompetence and this situation calls for measures to prevent similar distressing and traumatic incidents in the future.
  22. Content Article
    Two years after his 13-year-old child died needlessly in hospital, Paul Laity reflects on life without her. Martha Mills died of septic shock due to a series of serious failures in her care after she injured her pancreas in a cycling accident. Her father Paul talks about the ongoing pain of grief, and the additional burden of knowing that Martha's death was preventable, caused by the complacency of her doctors and a culture in the hospital that meant consultants were reluctant to ask expert advice from paediatric ICU. "Martha’s avoidable death was unusual in that the prime causes weren’t overwork or a lack of resources, but complacency, overconfidence and the culture on the ward. What upsets me most was that the consultants – a different one most days – took a punt that she was going to be OK over the weekend. No one assumed responsibility; they hoped for the best rather than playing safe. Was everything done for Martha that could have been done? Emphatically not. It’s very hard to live with this knowledge. But just as hard is the recognition that I, too, didn’t do enough." Further reading ‘We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death (The Guardian, 3 September 2022) Prevention of Future Deaths Report: Martha Mills (28 February 2022)
  23. Content Article
    In this blog post, Charlotte Augst looks at the impact of the Lucy Letby conviction on views of patient safety and accountability. The case has brought debates about patient safety into the mainstream media and public consciousness, and rather than focus simply on one extreme case, she believes it is important to look into common patterns in the NHS that lead to harm. She highlights that while such an awful case—where a healthcare professional caused deliberate harm to the most vulnerable patients—is shocking, it is also rare. She outlines a need to focus on the systemic issues that are resulting in repeated harm to patients, particularly in maternity services. Patients continue to be harmed because of rifts between management and clinical staff, the inability of the healthcare and regulatory system to really listen to patients, systemic discrimination and cognitive bias. Charlotte argues that while we may find ourselves focusing on the character of a nurse who committed such heinous crimes, we need to pay equal attention to the normalised behaviours and attitudes that harm patients and take place every day throughout the NHS.
  24. Content Article
    In June 2022, General Sir Gordon Messenger and Dame Linda Pollard published their final report on the review of leadership and management in the health and social care sector, as commissioned by the Secretary of State for Health and Social Care in October 2021. This briefing by NHS Providers summarises the key areas covered by the report, grouping recommendations under the following headings: Training  Development Equality, diversity and inclusion  Challenged trusts, regulation and oversight
  25. Content Article
    Delays in the handover of patient care from ambulance crews to emergency departments (EDs) are causing harm to patients. A patient’s health may deteriorate while they are waiting to be seen by ED staff, or they may be harmed because they are not able to access timely and appropriate treatment. This national investigation sought to examine the systems that are in place to manage the flow of patients through and out of hospitals and consider the interactions between the health and social care systems (the ‘whole system’). This report brings together the findings from the investigation’s three interim reports and provides an update since they were published. You can view the interim reports on the hub: Interim report 1 (16 June 2022) Interim report 2 (3 November 2022) Interim report 3 (27 February 2023) The investigation provided further evidence of well recognised issues that contribute to patient harm. These were documented in three interim reports published on HSIB’s website. This is a summary of the findings from these reports: The movement of patients into, through and out of hospitals has a direct impact on ambulances queuing at emergency departments and creates patient safety risks and issues throughout the healthcare system (see interim report 1). Patient safety is managed differently across the healthcare system and does not consider the ‘air gap’ (see interim report 2) between health and social care. There is not a patient safety accountability framework which identifies individuals accountable and responsible for patient safety (see interim report 2). Poor staff wellbeing due to stress, moral injury, incivility and burnout (see interim report 3). Additional national investigation findings The reference investigation highlighted several challenges that reflect those found across other acute trusts in England. These national challenges include: Acute trusts not being able to accept new patients because their hospital is full despite a significant number of patients being medically fit for discharge. This means patients in hospital who no longer need to be there but are unable to be safely discharged to the right place of care. Ambulance crews caring for patients in the back of their ambulances for over 12 hours. When hospitals are unable to accept new patients, this has a direct impact on flow on other hospitals who will see these patients in addition to their own. Planned procedures may be delayed and/or cancelled due to the number of emergency procedures. Previous initiatives to improve patient flow have focussed on performance targets in EDs, such as the 4-hour standard, rather than changes to the whole system to facilitate patient flow. A key contributor to the problems with patient flow into, through and out of hospitals is not being able to discharge patients who no longer require hospital care. Seven-day a week services are expected to include daily reviews however this is not happening across all healthcare providers. The criteria to reside tool (a tool that helps clinicians determine appropriate discharge pathways) expects that patients on general wards should be reviewed twice daily to determine suitability for discharge (or need for care in hospital). This has not been consistently implemented across healthcare settings in England. Safety recommendations Department of Health and Social Care (DHSC) HSIB recommends that the Department of Health and Social Care leads an immediate strategic national response to address patient safety issues across health and social care arising from flow through and out of hospitals to the right place of care. HSIB recommends that the Department of Health and Social Care conduct an integrated review of the health and social care system to identify risks to patient safety spanning the system arising from challenges in constraints, demand, capacity and flow of patients in and out of hospital and implement any changes as necessary. In interim report 2 a safety observation was made, following the collection of further evidence this has now been escalated to a safety recommendation: HSIB recommends that the Department of Health and Social Care develops and implements a patient safety accountability framework that spans the health and social care system. This is to help address the lack of accountability relating to patient safety risks spanning health and social care. NHS England HSIB recommends that NHS England includes staff health and wellbeing as a critical component of patient safety in the NHS Patient Safety Strategy. Safety observations HSIB has made two safety observations to date as a result of this ongoing investigation. It may be beneficial for there to be a whole-system patient safety accountability and responsibility framework that spans health and social care. It may be beneficial for NHS organisations to provide time and safe spaces for staff to engage in reflective practice and talk about the emotional impact of their work, with support from people with expertise in staff wellbeing.
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