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Showing results for tags 'Organisational culture'.
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News Article
Child deaths 'not properly investigated' at top hospital
Patient Safety Learning posted a news article in News
Great Ormond Street Hospital (GOSH) failed to properly investigate child deaths, suggests evidence uncovered by the BBC. The source of one fatal infection was never examined and in another case GOSH concealed internal doubts over care. Amid claims GOSH put reputation above patient care, former Health Secretary Jeremy Hunt urged it to consider a possible "profound cultural problem". Responding, the central London hospital said it rejected all suggestions that it treated any child's death lightly. BBC Radio 4's File on 4 programme has spoken to several families whose children were treated at the world-famous hospital. All said that while care at one point had been excellent, when things went wrong GOSH appeared to have little interest in fully understanding what had happened. The concerns over how Great Ormond Street is run are shared by staff. A staff survey, published last month, made grim reading for management. On two aspects, including whether there is a safety culture, it received the lowest score of all trusts in its category, while on three other questions, including how bad bullying and harassment were, and how good the quality of care was, its own staff rated it as among the worst. "If we want the NHS to offer the highest quality care in the world, then we have to change a blame culture and sometimes a bullying culture, for a learning and an improvement culture," the former Health Secretary Jeremy Hunt told File on 4. "That staff survey would indicate they don't have that culture at Great Ormond Street." Read full story Source: BBC News, 17 March 2020 Read Joanne Hughes' response to this news in her blog shared on the hub.- Posted
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News ArticleThe mother of a student, who took his own life, said today she felt 'sick to her stomach' after an NHS communications manager labelled a media report on her son's suicide a 'malarkey'. Pippa Travis-Williams, whose son Henry was found dead days after leaving a mental health unit run by the Norfolk and Suffolk Foundation Trust (NSFT) in 2016, said an email sent by NSFT communications manager Mark Prentice to his boss was 'disgusting'. It comes weeks after Mr Prentice gloated in another email to his boss that the NSFT had 'got away (again)' with media coverage of the death of a dementia patient. In an email to his boss, explaining why NSFT chief executive, Jonathan Warren, was going on BBC Look East, Mr Prentice said the NSFT might look 'uncaring' if Mr Warren did not appear and then described the coverage of Mr Curtis-Williams' suicide as a 'malarkey'. Read full story Source: Ipswich Star, 10 March 2020
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News Article
Northern Devon Healthcare NHS Trust: 20 deaths or serious harm cases in maternity
Patient Safety Learning posted a news article in News
At least 20 maternity deaths or serious harm cases have been linked to a Devon hospital since 2008, according to NHS reports obtained by the BBC. A 2017 review which was never released raised "serious questions" about maternity care at North Devon District Hospital. The BBC spent two years trying to obtain the report and won access to it at a tribunal earlier this year. Northern Devon Healthcare NHS Trust (NDHT) said the unit was "completely different" after recommended reforms. A 2013 review by the Royal College of Obstetricians and Gynaecologists (RCOG) investigated 11 serious clinical incidents at the unit, dating back as far as 2008. The report identified failings in the working relationships at the unit, finding some midwives were working autonomously and some senior doctors failed to give guidance to junior colleagues. Despite the identified problems with "morale", the subsequent investigation by RCOG in 2017 expressed concerns with the "decision-making and clinical competency" of senior doctors and their co-operation with midwives. An independent review into midwifery in October 2017 noted "poor communication" between medical staff on the ward for more than a decade. The report identified a "lack of trust and respect" between staff and "anxiety" among senior midwives at the quality of care. Read full story Source: BBC News, 16 March 2020 -
Community PostI am interested in what colleagues here think about the proposed patient safety specialist role? https://improvement.nhs.uk/resources/introducing-patient-safety-specialists/ https://www.independent.co.uk/news/health/nhs-patient-safety-hospitals-mistakes-harm-a9259486.html Can this development make a difference? Or will it lead to safety becoming one person's responsibility and / or more of the same as these responsibilities will be added to list of duties of already busy staff? Can these specialist be a driver for culture change including embedding a just culture and a focus on safety-II and human factors? What support do trusts and specialists need for this to happen? Some interesting thoughts on this here: https://twitter.com/TerryFairbanks/status/1210357924104736768
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Content Article
Patient Safety Specialist: Consultation submission
Patient Safety Learning posted an article in NHS Improvement
The NHS Patient Safety Strategy, published in June 2019, sets out three strategic aims around Insight, Involvement and Improvement which will enable it to achieve its safety vision. It defines the Involvement aim as ‘equipping patients, staff and partners with the skills and opportunities to improve patient safety throughout the whole system’. A key action associated with this is a proposal to create Patient Safety Specialists within each NHS organisation in England. The strategy explains that ‘giving everyone in the NHS a foundation level understanding of patient safety is critical, but we also need experts to lead on safety in their own organisations’.NHS England and NHS Improvement have published draft Patient Safety Specialist requirements for public consultation. Patient Safety Learning welcome any increase in patient safety capacity and expertise in the NHS and have provided specific feedback on the draft requirements for this role. In our response we identify several areas where we believe these can be improved, including the following points: Patient Safety Specialists having a clear and direct reporting line to a named executive director on the Board with an assigned patient safety role and to a non-executive director with a similar role. Ensuring that the requirements identify key relationships for the role holders not identified in the draft document: Medical Examiners, Coroners, Healthcare Safety Investigation Branch, Governors, Non-Executive Board Members, HR Directors and NHS Resolution. Including a requirement that Patient Safety Specialists should demonstrate that they have the right skills and experience to work with patients, families and their carers on patient safety issues. They should also show that they can support their organisation to engage effectively in co-production with these groups. The need to strengthen the requirements for the individuals holding these roles to have knowledge and experience of: Investigations, Complaints, Just Culture, Systems Thinking and Human Factors. Giving consideration to how Patient Safety Specialists will engage with frontline staff, who are notable by their lack of reference in the draft requirements. -
News Article
NHS to pay £870,000 to whistleblower doctor who spoke out on patient safety
Patient Safety Learning posted a news article in News
A London NHS trust has been ordered to pay a leading heart doctor more than £870,000 after he was sacked for whistleblowing about safety concerns following a patient’s death. Dr Kevin Beatt, one of the UK’s most respected consultant cardiologists, was fired from Croydon Health Services in 2012 after reporting staff shortages, inadequate equipment and workplace bullying at the trust. The tribunal heard Dr Beatt’s dismissal “had a devastating effect on his career and his wellbeing”. He told the Evening Standard: “I was forced into a position where I lost my career for trying to highlight dangerous practices in the NHS. It has taken seven years to get to this point, which is just appalling. It has been a huge ordeal and I have the greatest sympathy for any whistleblower who has to go through something like this.” Read full story Source: Evening Standard, 11 March 2020 -
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News Article
NHS nurse sacked after warning increased workload on staff led to patient's death
Patient Safety Learning posted a news article in News
A senior NHS nurse was fired after warning the increased workload on her pressured staff had contributed to a patient’s death. Linda Fairhall, 60, had an unblemished record of almost 40 years’ service when she turned whistleblower at North Tees and Hartlepool NHS trust. In 2015 she raised concerns over a new requirement for district nurses to monitor patients’ prescriptions. She said it meant a sudden increase of around 1,000 extra visits a month for her hard-pressed team of 50 nurses with no extra resources. Over the next 10 months she reported 13 matters, alleging the health or safety of patients and staff was being or was likely to be put at risk. After a patient died in 2016 she claimed it may have been prevented if her concerns had been addressed. She told the trust’s care group director Julie Parks she wished to start the formal whistle-blowing procedure. Soon after she was suspended over allegations of potential gross misconduct relating to her leadership, and then sacked. Dr Henrietta Hughes, the UK’s national NHS guardian, said: “Workers who speak up should be thanked for doing so and the organisation should demonstrate they are taking action to address the issues raised.” North Tees and Hartlepool NHS Trust said it will appeal the decision. Read full story Source: The Mirror, 2 March 2020 -
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The lifecycle of the whistleblower (8 February 2020)
Patient Safety Learning posted an article in Whistle blowing
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Learning from excellence: Entrance interview questionnaire
Claire Cox posted an article in Motivating staff
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News Article
‘Shameful’ data reveals NHS treatment of minority ethnic staff
Patient Safety Learning posted a news article in News
Five years after launching a plan to improve treatment of black and minority ethnic staff, NHS England data shows their experiences have got worse. Almost a third of black and minority ethnic staff in the health service have been bullied, harassed or abused by their own colleagues in the past year, according to “shameful” new data. Minority ethnic staff in the NHS have reported a worsening experience as employees across four key areas, in a blow to bosses at NHS England, five years after they launched a drive to improve race equality. Critics warned the experiences reported by BME staff raised questions over whether the health service was “institutionally racist” as experts criticised the NHS “tick box” approach and “showy but pointless interventions”. Read full story Source: The Independent, 18 February 2020 -
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News Article
Senior nurse who tried to whistleblow unfairly dismissed, tribunal rules
Patient Safety Learning posted a news article in News
A trust unfairly dismissed a senior nurse after she tried to invoke its formal whistleblowing policy, an employment tribunal has ruled. North Tees and Hartlepool Foundation Trust had suspended Linda Fairhall for 18 months without a “meaningful or adequate” explanation prior to her dismissal, the judgment said. Ms Fairhall, who led a team of 50 district nurses in Hartlepool, reported on the trust’s risk register that a “change in policy” by the local authority had directly led to increased workloads for her staff. The change meant staff had to monitor patients who had been prescribed medication “so as to ensure the correct medicines were being taken at the correct time”, the judgment said. She reported numerous concerns to senior management between December 2015 and October 2016, amounting to 13 protected disclosures according to the tribunal, ranging from work-related stress, sickness, absenteeism and a need to retrain healthcare assistants. A patient’s death triggered a meeting involving her and senior managers, which she said could have been prevented had her earlier concerns “been properly addressed”. Ms Fairhall told care group director Julie Parks she wanted to initiate the formal whistleblowing policy on 21 October 2016, before going on annual leave a few days later. When she returned, she was told she had been suspended for 10 days. The judgment, handed down at Teesside Justice Hearing Centre and published last week, added: “No reasonable employer, in all the circumstances of this case, would have conducted the investigation in this manner.” The judgment said the tribunal believed the principal reason for her dismissal was because she had made protected disclosures. It upheld her claim that her dismissal was automatically unfair. Read full story (paywalled) Source: HSJ, 17 February 2020 -
News Article
Harrowing stories of burned out NHS doctors bullied and broken
Patient Safety Learning posted a news article in News
Dedicated to caring for the sick and vulnerable, junior doctors should expect to be supported and valued as they carry out their vital work. However, hundreds have revealed they are subjected to bullying and harassment at overstretched hospitals that have been plunged into a staffing crisis by a decade of savage health cuts. A Mirror investigation uncovered harrowing stories of young medics being denied drinking water during gruelling shifts, working for 15 hours on their feet non-stop and of uncaring managers tearing into them for breaking down in tears over the deaths of patients. One was even accused of “stealing” surgical scrubs she took to wear after suffering a miscarriage at work. The distraught woman finished her shift wearing blood-soaked trousers, instead of going home to rest. Doctors are now quitting in their droves, leaving those left struggling to cope with a growing workload. The Mirror investigation reveals the reality of working for an NHS which has been subject to a record funding squeeze and is 8,000 medics short. Health chiefs vowed to investigate the Mirror’s evidence from 602 testimonials submitted to the lobbying group Doctors Association UK. Chairman Dr Rinesh Parmar said: “These heartbreaking stories from across the country show the extent of bullying and harassment that frontline doctors face whilst working to care for patients". Read full story Source: The Mirror, 12 February 2020 -
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Learning from Excellence
Claire Cox posted an article in Implementation of improvements
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Content ArticleThis powerpoint presentation from the Birmingham Women and Children's Hospital NHS Foundation Trust explains the data backing up this fantastic initiative.
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My thoughts on the Paterson Inquiry: a blog from a scrub theatre nurse
Anonymous posted an article in By health and care staff
"There must be multidisciplinary teams working in all private hospitals – it’s standard in the NHS but almost non-existent in the private sector. And the Care Quality Commission must be provided with the same performance data, in the same format from the private sector as it demands of the NHS in order to create a clear and consistent picture of patient safety across the board.” [Linda Miliband, a lawyer at Thompsons representing 650 of Paterson's victims]. It makes me shudder to think that until now, there are surgeons who think they are above the law and the staff are just there to do their bidding and cover up their failings! In the Paterson case, we question why it took so long. If women are having a skin sparing mastectomy for breast cancer, why would they worry about their cleavage? Were they convinced that this was important by this rogue surgeon? Did the scrub practitioners and surgical assistants not query this? No organisation is perfect – it can always be improved. We are told to be proactive, yet when we are employers are reactive. At the end of the day, it's not about earning higher wages than our colleagues in the NHS hospitals, it is about patient advocacy, compassion, integrity and patient safety, and also being able to sleep peacefully at night with a clear conscience. Moving forward, we must hope and pray that swift changes are made by our government to the private sector, so patients do not suffer unduly and their safety once again compromised. I look back at the incident I experienced in theatre where a surgeon dropped an instrument, washed it under a tap and reused it without sterilising it. I keep wondering whether the anaesthetist applied Duty Of Candour and explained to the patient why he was giving her another 'big' dose of antibiotics the following morning due to dropping the instrument and not sterlising it. Did the surgeon inform the patient? I don't know. I was not part of the investigation. All I heard was that the surgeon was happily back to work and my shifts were blocked! As a follow up, I received a P45 in the post three months later with no explanation or email/ phone call. I've still heard nothing to this day. I know of three colleagues who also received P45 in the post after making a safety complaint. What is it about speaking up that employers do not like? As scrub practitioners we need to focus on doing the right thing and if we are always thinking that every patient is a member of our own family, we will do it correctly. My mother told me before I left my country to start nursing in the UK: "God gave you a tongue, always use it to ask questions and stand up for yourself and others!" In the future, I will ask these questions at my next interview: "Are staff allowed to Speak Up and report safety incidents?" "Are the reports followed up and lessons shared without victimising the person who reported it?" I may not get the job, but at least I can cast a small stone to create a few ripples. I will never stop Speaking Up for patient safety. I do not want to work in an environment where patient safety is compromised. What about you? What will you do? We all need to take action NOW.- Posted
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News ArticleOne in three trainee doctors in Australia have experienced or witnessed bullying, harassment or discrimination in the past 12 months, but just a third have reported it. That's according to a national survey of almost 10,000 trainee doctors released today by the Australian Health Practitioner Regulation Agency (AHPRA). The results of the survey, co-developed by the Medical Board of Australia (MBA), send a "loud message" about bullying and harassment to those in the medical profession, said MBA chair Anne Tonkin. "It is incumbent on all of us to heed it," Dr Tonkin said. "We must do this if we are serious about improving the culture of medicine." "Bullying, harassment and discrimination are not good for patient safety, constructive learning or the culture of medicine," Dr Tonkin continued. "We must all redouble our efforts to strengthen professional behaviour and deal effectively with unacceptable behaviour." Read full story Source: ABC News, 10 February 2020
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News ArticleA whistleblower raised the alarm over patient safety at West Suffolk Hospital because of concerns about the behaviour of a doctor who had been seen injecting himself with drugs, the Guardian has revealed. The incident had already prompted internal complaints from senior staff at West Suffolk hospital, but the whistleblower decided to take matters a step further when the same doctor was later involved in a potentially botched operation. The whistleblower then wrote to relatives of a dead patient and urged them to ask questions about the conduct of the doctor and his background. When they did this, the hospital launched a widely criticised “witch-hunt” in an attempt to find out the identity of the leaker. The doctor’s drug use, which the trust has never acknowledged until now, helps explain why it demanded fingerprint and handwriting samples from staff – tactics which the NHS regulator roundly condemned in a hard-hitting report last week. Read full story Source: Guardian, 5 February 2020
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News Article
Paterson scandal: Is the NHS learning from mistakes?
Patient Safety Learning posted a news article in News
Shipman, Mid Staffordshire, Morecambe Bay, and now Ian Paterson, the breast surgeon that performed botched and unnecessary operations on hundreds of women. The list of NHS-related scandals has got longer. It's tempting to say the health service has not learned lessons even after a string of revelations and reviews. But is that fair? asks BBC Health Editor Hugh Pym. The inquiry, chaired by Bishop Graham James, makes clear there were failings at every level of a dysfunctional health system when it came to patient safety. The public and private health systems did not compare notes about suspicious behaviour by a consultant. Staff working with Paterson thought that his surgical methods were unusual but, perhaps cowed by being ignored after raising concerns, kept their heads down. Add to that the power and status of a surgeon in the medical world and, in the words of the report, Paterson was "hiding in plain sight". So could it happen again? James says it's clearly impossible to eliminate the activities of determined criminals in any profession. He acknowledges that some improvements have been made on policing. But he says that a decade on from the Paterson scandal, he is not convinced that medical regulators, with a combined budget of half a billion pounds a year, are doing enough collectively or collaboratively to make the system safe for patients. The review chair notes tellingly that while regulators spoke of major improvements which should identify another Paterson, some doctors and nurses had told the inquiry that it was "entirely possible that something similar could happen now". Read full story Source: BBC News, 4 February 2020 -
Content ArticleNHS Improvement are asking NHS organisations to identify, by June 2020, at least one person from their existing employees as their patient safety specialist. Training for these specialists will be based on the national patient safety syllabus being developed with Health Education England. Working with representatives from a few NHS trusts, patient safety partners (patient and public voice representatives) and clinical commissioning groups, NHS Improvement have drafted the requirements for a patient safety specialist to help organisations identify the most appropriate person(s) for the role. You can download the draft requirements here. NHS Improvement are inviting comments and feedback on this through their survey which can be accesed via the link at the bottom of this page. Consultation closes 12 March 2020.
