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In 2015 the Government introduced a Freedom to Speak Up Guardian and a system of Local Speak Up Guardians in response to the recommendations made by Sir Robert Frances following the scandal at Mid Staffordshire. From the outset, this system has attracted significant criticism and the APPG has heard from whistleblowers who have been failed by local guardians sharing their experiences that included the disclosure of their identity to hospital management and boards – resulting in retaliation. The APPG has also heard from Local Guardians who were not supported and themselves the target of retaliation after supporting whistleblowers. Local Guardians in East Kent were described as, “dishonest” and that the Guardian system had failed in every case that had been investigated throughout the UK. Further evidence was provided of a tick box approach to the Duty of Candour introduced by the former Secretary of State for Health. The APPG was told that both the Guardian and Duty of Candour systems are beyond resurrection and that across the NHS there is no ownership of problems. All attempts to encourage speaking up have been hindered by a failure to introduce an effective and safe whistleblowing regime across the NHS, resulting in the NHS being unsafe for whistleblowers, making it unsafe for patients. The APPG were told that, in over 50 years of investigation experience, little has changed, and that “these issues are not new, nor are they confined to a small number of rogue hospitals”. That league table results are inaccurate because of a flawed regulatory system with no ownership of the problems and where the regulators are “caught up in the fraud”. The APPG was provided with a series of examples of what were described as “deep seated problems” relating to teamwork and culture, which resulted in the failure to join up clinical and ethical responsibilities. These responsibilities were described as being on separate tracks and a failure by the regulatory regime to identify or report on the impact of this has significant consequences for patients, whistleblowers and the future of the NHS, as demonstrated by the case of the Bristol Children’s Heart scandal brought to light by Dr Steve Bolsin 30 years ago. Dr Bolsin was shunned for exposing the failures that resulted in the death of so many babies because funding the unit was more of a priority that the lives of the babies (he has since made a successful career in Australia). In every case, a failure to listen to whistleblowers, followed by attempts to discredit the whistleblowers, and a deliberate cover up has proved in many cases fatal for patients. What has been proved time and time again is that The Public Interest Disclosure Act (PIDA) has made little or no difference to this failure to protect patients or whistleblowers or to learn and improve our NHS. Evidence provided to the APPG is of a lack of system-wide action and an absence of commitment to speaking up beyond excellent PR. It is unclear who, if anyone, is responsible for the monitoring and reporting on recommendations contained in investigation reports. In addition, there is no coherent process for triggering high-level independent reviews of major patient safety failings. This causes confusion, suffering and leads to missed opportunities. Mary Robinson MP, chair of the APPG for Whistleblowing, said: “We have a duty to support and protect whistleblowers because without them we cannot prevent more deaths like those in East Kent. My APPG is committed to making whistleblowing safe and will continue to press the Government to introduce the Whistleblowing Bill which will incentivise and normalise speaking up. I encourage everyone to write to their MPs and ask them to join the APPG and support the Whistleblowing Bill.” The Right Hon. Baroness Susan Kramer, said: “Doing nothing is not an option that we can afford. It’s time to put an end to ‘tick box culture’ and turning a blind eye to whistleblowers. Whistleblowing law must be meaningful, easily understandable and enforceable. The Whistleblowing Bill will do this and in doing so will save lives and protect our NHS.” Wendy Morden MP, member of the APPG for Whistleblowing, said: “I hear about problems when I am at the hairdresser because people are too afraid to speak up in their place of work. The Office of the Whistleblower will be the catalyst for meaningful change.” Dr Bill Kirkup, author of Reading the Signals Report, said: “I support the proposals set out in the Whistleblowing Bill because the NHS urgently needs an effective early warning system.”

Coroner's concerns Whilst at King’s College Hospital, Martha was not referred to the paediatric intensivists promptly. If she had been referred promptly and had been appropriately treated, the likelihood is that she would have survived her injuries. The bedside paediatric early warning score (BPEWS) system at King’s is currently still paper based, unlike the adult system. It was put to the coroner very forcefully by medical staff that, until the PEWS system moves to an electronic base as part of electronic recording of the paediatric records as a whole, monitoring and care of children may be sub optimal, with a higher risk of this sort of situation recurring. The King’s serious incident investigation identified that Martha’s care fell down between the paediatric hepatologists and the paediatric intensivists. Evidence suggests that it is the intention of King’s to improve the formal relationship between the hepatology and the paediatric intensive care departments, and to ensure that there is pro-active paediatric intensive care outreach. However, the intended programme has stalled, partly because of the pandemic. It seems that there needs to be an impetus for this to be re-started and to gain sufficient momentum to operate smoothly in the future. Response from King's College Hospital Further reading Sharing her story in the Guardian, Merope, Martha's mother, gives a heart breaking account of how Martha was allowed to die: ‘We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death (Guardian article)

At the start of last summer, Merope Mills' 13-year-old daughter Martha was busy with life. She’d meet her friends in the park, make silly videos on her phone and play “kiss, marry, kill”. Her days were filled with books and memorising song lyrics. She’d wonder aloud if she might become an author, an engineer or a film director. Her future was brimming with promise, crowded with plans. By the end of the summer she was dead, after shocking mistakes were made at one of the UK’s leading hospitals. "Her preventable death is an example of what a hospital official described to us, in a barbarous phrase, as a 'poor outcome'. I will spend decades asking: why was my child the one to suffer such an unlikely fate?", writes Merope. Further reading Prevention of Future Deaths Report: Martha Mills

The article includes an example of how cronyism plays out in the healthcare workplace and asks some important questions about how workplace cultures exclude people who don't fit in with an ethos which puts reputation over transparency and learning and create an environment where an approach akin to a 'code of omertà ' exists to silence dissent. It discusses the impact on individuals and the sense of isolation and hypervigilance that can result from cultures of fear. It includes commentary for Michael Bang Petersen Professor of Political Science at Aarhus University and Blaine Landis on why cronyism comes naturally. It also considers the question of how close regulators are to those they are regulating. "This piece is important because it gets to some of the root causes as to why many people leave organisations & why retention of staff can be a major problem. This is an issue that is particularly relevant in healthcare, including the NHS in the UK. Cronyism in the workplace is a worldwide cultural and societal problem and in #healthcare it's a #patientsafety issue." - Steve Turner

In this report the CQC have seen much good and outstanding care, in particular around: responsiveness staff interactions with patients effective treatment leadership and engagement with staff and patients. However, there were a number of areas where services needed to make substantial improvements: governance clinical audit safety culture.

Courage is one of the nursing 6Cs "Courage enables us to do the right thing for the people we care for, to speak up when we have concerns. It means we have the personal strength and vision to innovate and to embrace new ways of working." (NHS England, 2015). But... Why should we need courage to come to work? Why do we need to find this strength to do our job? Why do patients have to rely on us to have courage to keep them safe? Being able to speak up, to innovate and implement new ideas should be a way of normality. We should not have to feel threatened, inadequate or ‘the pest’. I would like to share my experience the other shift. A story of ‘courage’ and advocating for patient safety within a clinical setting. Working in Black escalation is hard. Working on an acute surgical ward we have elective patients that are booked in weeks in advance, often we have to cancel cases to make sure the flow of patients keeps moving through the hospital. It’s a constant raft of bed meetings and handovers to various managers about who can go home, who is medically fit to move off, why can they go home today, why are they not ready... Much of the day is consumed by this. It feels like a conveyor belt, laden with sick patients – some will go home but some will slip off the edge. I feel like we are trying to keep everyone moving in the right direction and not to lose anyone down the cracks in the process. So, what happened that shift that made me apprehensive about raising concerns about a patient and their care? It was 4:30pm. A patient arrives from the emergency department (ED), his NEWS Score was 5. This is a high score and this score has increased since his admission to ED, so this patient was deteriorating. He was in his late 60s, ordinarily a fit man. A stoic man, who doesn’t like to cause a fuss. He is lying in bed, he has intravenous fluids running. He is pale, he has mottling over his tummy and has a pain score of 8/10. His family is by his bedside compliant and submissive with current plans of care. He had been admitted to our ward with a perforated duodenum (a hole in the bowel). It is written in the notes, which is barely legible, that this man is for conservative management. This means that there will be no surgical intervention and he will be treated with medicines only while the hole ‘self-repairs’. In my experience as a nurse in this area, these types of perforations do not heal themselves. What do I do? Firstly, I assess the patient. I perform an ABCDE assessment. I look at his observations and his fluid chart, his blood results. I take some further blood, along with a venous blood gas. Collecting numerical data on sick patients is a way of communicating to doctors. As nurses, we see subtle changes to our patient; they may become more confused, more clammy, pale, agitated or ‘just different’. This type of information is difficult to articulate and quantify. So, finding a common language within the multidisciplinary team is vital to ensure your concerns are taken seriously. After I take the blood, the patients family ask me if I am concerned. I ask them why they have asked this question, as this is not something that relatives usually ask… unless they have concerns too. The relatives are concerned about the decision not to operate at this point. They see that their loved one is unwell and can see he is getting worse since admission. They feel that they have not been listened to. I call the surgeon to come and reassess, he is about to go home – but kindly comes up before he goes. "…but, we are just the peasants…" This was the response from the family when I asked them what their concerns were. They felt that their opinion was not credible. This made me feel so sad. Even relatives and carers feel unempowered to speak up. This offers little hope for the patient lying in bed. The patient’s wife claims that she is worried sick, she knows that he is getting worse. She feels she is watching him deteriorate in front of her eyes. She wants someone to listen to her and act on her concerns. The next set of observations show that his NEWS is now 7. He has deteriorated further, despite the patient looking the same. At this point the surgeon is in the room. He is also assessing the patient. "...In my view, I think you are a little better Sir." The patient’s wife looks at me. I look at her. We both know that this is not the case. What are my options? I agree with the surgeon. Regurgitate what he has explained to the patient back to her and agree with ‘watching and waiting’. This is not advocating for the patient or the family and, on my part, negligent. Losing the trust of a family is a complete failure in care. I disagree with the surgeon, risking his response to be defensive. By being confrontational, I risk him not engaging with anything I say – especially in front of the patient and relatives. Once the surgeon is out of the room, I place a medical emergency call. This is within our escalation policy. However, this may damage the relationship we have with our surgeons by going ’above their head’. We have to work together on a daily basis. We need to trust them, and they need to trust us. I didn’t do any of the above, which is a breach of the Trust's escalation policy. This is a ‘work as imagined’ (policy) and ‘work as done’ is how it actually works. I am aware of what I should be doing but choose to escalate my concerns with the parent team. If I was to place a medical emergency call out now – the surgeon is left with feelings of disempowerment, failure and mistrust. Like I say, we have to work as a team. If the patient was deteriorating quickly, and we were unable to get any help and he was not receiving the treatment then of course a medical emergency call would be placed. I decided not to agree or disagree. I stated facts. Facts that could not be ignored. "Patient [X] NEWS score has increased from 5 to 7, his blood pressure has dropped by 30 mmHg, his heart rate is 130 bpm, he has been oliguric but now in the last hour, anuric despite having 4 litres of fluid. His venous lactate remains high. He is deteriorating." There was a pause. The surgeon looked at me and agreed. We both then made the plan that he would call his consultant and I would get intensive care involved. The patient went to theatre within the next hour or so. He is recovering well. There are many themes at play here. Cognitive bias from the surgeon, fear from the surgeon to call his consultant out of hours, fear from asking for help. 'Imposter syndrome' from the nurse – I can’t disagree with a surgeon – "I’m just a nurse". Hierarchy has a place in healthcare but, when looking after sick patients, hierarchy is a huge barrier to escalating that patient to receive the right care in a timely fashion. Courage was displayed by the nurse (myself) in speaking up to the surgeon. The surgeon showed courage in listening to the nurse and asking for help to his consultant. We should not need courage to keep our patient safe.

This guide is designed to help people experiencing bullying and harassment at work. It covers: What is bullying? Examples of bullying What is harassment? What to do next The legal position Mediation and counselling Employer responsibilities Best practice for employers Students: being bullied whilst on placement Cyber bullying Sickness and work-related stress Been accused of bullying and/or harassment? Witnessed bullying? Further information

ELFT's Quality Improvement website provides many resources, as well as their QI projects, events and training.

This blog highlights solutions to the problem of poor culture of speaking up and bullying within healthcare. Dr Blair Bigham and Dr Amitha Kalaichandran propose three solutions to enable a culture without fear. Measure culture within the organisation. Hire talented leaders. Embrace diversity and inclusion and reject hierarchy.