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Content Article
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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 -
Content ArticleWhen big problems in the NHS are highlighted by comparing it to other organisations, the service often reacts in a hostile and dismissive manner. But these complaints usually completely miss the point of the comparison. Recently Diane Coyle suggested the NHS could learn from the way a Formula 1 racing team operates, but it was met with unwarranted hostile reaction by some commentators. In this HSJ article, Steve Black explores how resistance to outside comparisons hides deep flaws in NHS systems, priorities, and data use.
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Content ArticleWorkplace incivility and bullying have persisted in healthcare in the USA since increasing during the Covid-19 pandemic. As the healthcare landscape continues to evolve, so do the challenges teams face, according to Brian Reed, vice president and chief human resources officer for Indianapolis-based Indiana University Health’s east region. This article in Becker's Hospital Review outlines seven strategies to reduce workplace incivility among healthcare teams:
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Content ArticleThis webinar sponsored by the AHRQ-led National Action Alliance for Patient and Workforce Safety, highlights the importance of safety culture and teamwork in healthcare settings. This webinar, held 15 April 2025, was the third in a three-part series on safety culture in healthcare. Speakers from AHRQ, Duke Center for the Advancement of Well-being Science and Westat discussed how strategies such as conflict resolution and leader engagement are essential for improving healthcare worker well-being and patient outcomes. Panelists answered audience questions on how to get physicians to participate in the patient safety culture surveys and recommended ways to encourage a teamwork climate. Access the recording and presenter materials from this event.
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Content ArticlePatient safety is a fundamental aspect of any healthcare system. Edmund Bailey and Mohammed Dungarwalla explore the development of patient safety both generally and in relation to dentistry over the past ten years. Other aspects of healthcare and various concepts are explained and described, including human factors, Safety I and Safety II, patient safety culture, managing patient safety incidents and the second victim concept, perfectionism and punishment myths, and hierarchy, along with wellbeing and support for practitioners. They bring together ten years of experience in patient safety related to dentistry and discuss this in the context of wider developments in patient safety, with reference to reports and policies that have influenced this field. The paper also includes helpful resources and suggestions to allow readers to discover more about patient safety in dentistry, and to examine the safety culture in their own organisations. They conclude by contemplating on what the next decade might bring.
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News ArticleA coroner has warned of a "culture of cover-up" at a care home where neglect contributed to the death of a disabled 12-year-old girl. Raihana Awolaja, who required 24-hour one-to-one care, died of cardiac arrest in 2023 after her breathing tube became clogged while she was left alone at Tadworth Court in Surrey, a residential care facility operated by The Children’s Trust. Now a senior coroner looking into her death, Professor Fiona Wilcox, has written to the Trust's chief executive, warning there could be further deaths at the home if improvements aren't made. Prof Wilcox raised several serious concerns about the home, including that severely disabled children may not be receiving the level of care needed to keep them safe and more staff training was required. She also warned there "may be culture of cover up at Tadworth Children’s Trust". She added: "They carried out a flawed investigation after this incident, pushing blame onto an innocent individual and thereby avoiding highlighting systemic failures and learning and thus risking lessons that should be learned are lost that could prevent future deaths." Read full story Source: ITV News, 21 May 2025
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Content Article
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The Royal College of Surgeons of Edinburgh (RCSEd) have drawn up their top 10 tips for surgical safety using the SEIPS (Safety Engineering Initiative for Patient Safety) model. Click on image to enlarge or download from the attachment below: See also: Safety in surgery series Top 10 priorities for patient safety in surgery Top 10 patient safety tips for surgical trainees- Posted
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EventPromoting Psychological Safety Masterclass is the ideal session for purpose-driven leaders who want to create safe, enriching spaces for employees. Develop your leadership skills to enhance employee and stakeholder wellbeing, and instill a sense of inclusivity and belonging within your community. Join this informative masterclass to explore psychological safety in the workplace. Reflect upon a range of evidence-based strategies and audits, to support workplace wellbeing. This masterclass/session will enable you to: Understand the concept of psychological safety Reflect upon different leadership styles and how this impacts psychological safety Develop evidence-based strategies for workplace wellbeing Explore psychological safety from a diversity, equity and inclusion perspective Engage in reflective discussion on how to embed psychological safety into workplaces Register hub members receive a 20% discount. Email [email protected] for discount code.
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Content ArticleThe NHS workforce is under considerable operational pressure at every level from the combined effects of record demand and shortages of capital and resource. In addition, seismic shifts are on the horizon, including the abolition of NHS England (NHSE), the expected recommendations from the second Penny Dash report on patient safety, and the upcoming 10 year health plan. The level of change the NHS is facing, as a safety critical sector, makes culture a strategic priority. To achieve the ambition behind these changes, we need an engaged, motivated workforce and a supportive, enabling environment, writes Isabelle Brown and Laura Turner. Getting the “how” right of any reform that might be introduced by the 10 year health plan is just as important as the “what” and the ”why.”
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Content ArticlePatient safety culture (PSC) is crucial for reducing medical errors and improving patient outcomes globally. This study aims to identify key improvement targets in China’s PSC to promote a safer healthcare environment. It found that while teamwork is a notable strength, there is room to enhance the nonpunitive response to errors. Improving feedback and communication practices can further bolster openness and collaboration within teams, leading to an overall healthier work environment.
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News Article
Trust in row with BMA over senior doctor
Patient Safety Learning posted a news article in News
A hospital trust is involved in a row with the British Medical Association amid concerns over a ’bullying culture’, it has emerged. HSJ has learned of tensions at Doncaster and Bassetlaw Teaching Hospitals Foundation Trust, including an ongoing dispute over a senior medic who has been off work for an extended period. Meanwhile, in recent weeks, the union Unison has launched a survey of the trust’s staff about behaviour, and begun offering staff “don’t bully me” badges, according to flyers claiming there is a “bullying culture”. The union’s organiser Sarah Brummitt said its survey had been launched in response to local reports of bullying concerns. She said: “The survey is open to all staff, and will hopefully give us a better understanding of what issues they are facing, if any.” It follows several concerns raised over the past year about leadership and culture at the trust. The trust says it is “committed to fostering a respectful and inclusive working environment.” Read full story (paywalled) Source: HSJ, 15 May 2025 -
Content ArticleThe way in which healthcare organisations are expected to respond after patient safety events in England changed significantly in August 2022 when the new Patient Safety Incident Response Framework (PSIRF) was introduced. What has actually happened is that the new processes built around the use of the Learning Response Tools in general and for After Action Review (AAR) in particular, are very varied. In this article, Judy Walker looks at the the variation in executing AARs and why this risks jeopardising the very essence of the AAR. *This article was first published in The After Action Review Newsletter May 2025 written by Judy Walker Associates Ltd. The way in which healthcare organisations are expected to respond after patient safety events in England changed significantly in August 2022 when the new Patient Safety Incident Response Framework (PSIRF) was introduced. What has actually happened is that the new processes built around the use of the Learning Response Tools in general and for After Action Review in particular, are very varied This is not surprising and is not concerning, as the PSIRF is purposefully designed to empower healthcare providers to implement in the framework in the way that suits their context best. However, I am concerned that the variation is also being manifested in the approach taken within the execution of the AAR itself, which risks jeopardising the very essence of the AAR. One of the risks is to the quality of the engagement and accountability with those who are attending the AARs. It was an excellent article published by Psychological Safety, on the Spectra of Participation which explores these concepts that gave me the idea for a framework for describing what I have observed that is a concern. Participation doesn’t guarantee engagement Looking at the IAP2 and other frameworks, the article explores the idea that participation doesn’t always guarantee engagement. The quality of engagement is a direct result of the goal of the process and the amount of psychological safety present. This analysis got me thinking about creating a scale of participation to bring to life the variety seen in AARs and is designed to help those leading AARs to be clear on the what their goals are. This table below sets out the five levels of participation that I’ve developed. Involve, Facilitate and Empower are all possible and healthy uses of the After Action Review approach. Organisational requirements will impact on how the AAR approach is deployed in each context and the full “Empower” approach where AAR participants are given full scope to act on the learning and their own recommendations, may not be appropriate for AARs taking place within a PSIRF governed process. However, it is a legitimate and valuable approach in project teams and other contexts. The continuum When you look at the continuum, you can see there is a shift from left to right of the AAR Conductor having knowledge of the event to needing to have very little. The Inform position is one where the AAR Conductor already has knowledge and is inviting participants to contribute to enrich the knowledge already held. This is not genuine engagement and along with the Consult approach, can be experienced as a tokenistic application of the AAR. The Facilitate and Empower positions, are those where the AAR Conductor needs have little knowledge prior to the AAR since the work is centred around the participants’ contributions and responses the AAR questions alone. This ensures meaningful engagement with the participants and requires skill in creating the psychological safety for honest conversations and asking the searching questions. The Empower position is different in that the aim is not to hand back the responsibility for action and reporting to the AAR Conductor, but to enable the participants to be ready to take the learning forward. Examples of the types of questions asked along the continuum Inform – “Did you have enough staff on duty?”, “ Was the NatSSIPS process followed?” Consult – “How did the patient respond?”, “Why weren’t the police called?” Involve – “What else was happening on the ward at the time?”, “What might prevent this happening again?” Facilitate – “Communication between agencies has been mentioned a few times: what might improve communication between agencies in future?” “Which of these ideas would make most impact?” Empower – “What do you want to do with this learning?” What support do you need to put this into action?” In summary As an AAR Conductor, you have to operate within your organisations’ context but it is vital to build trust in the AAR process. You will do this by ensuring your actions match your stated intentions and you are transparent about the level of participation you’re aiming for. Getting this right isn’t just about the integrity and standardisation of the AAR approach, it is also about maximising the potential for improvements in patient safety. Those AARs where Involving, Facilitating and Empowering are the goal, increase the level of accountability for change owned by the participants. We know from the research that when staff are fully engaged in the AARs they attend, their behaviour changes and patients are safer as a result.
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Content Article
Patient safety articles by Professor Braithwaite
Patient Safety Learning posted an article in Research papers
Professor Jeffrey Braithwaite is Founding Director of the Australian Institute of Health Innovation, Director of the Centre for Healthcare Resilience and Implementation Science and Professor of Health Systems Research at Macquarie University. Professor Jeffrey Braithwaite is a leading health services and systems researcher with an international reputation for his work investigating and contributing to systems improvement. He has particular expertise in the culture and structure of acute settings, leadership, management and change in health sector organisations, quality and safety in healthcare, accreditation and surveying processes in the international context and the restructuring of health services. Professor Braithwaite is well known for bringing management and leadership concepts and evidence into the clinical arena and he has published extensively, with over 788 refereed contributions (including 15 edited books, 95 book chapters, 506 articles and 65 refereed conference papers; and 320 peer-reviewed abstracts and posters; and 231 other publications, e.g., international research reports). Links to some of Professor Brainthwaite's work can be found below. Patient safety articles by Professor Braithwaite Implementation Science and Translational Health Research Articles by Professor Braithwaite Resilient healthcare series Professor Jeffrey Braithwaite on patient safety and health systems improvement -
Content ArticleEnsuring Patient Safety in healthcare is essential and requires efficient methods to reduce risks and improve the quality of care. Although incident reporting tools are commonly used to identify possible and actual care failures, their efficacy differs among various environments. The aim of this study was to evaluate the effectiveness of incident reporting tools in enhancing patient safety.
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Content Article
In this blog, Siân Slade shares how, through her research interest into the difficulties of navigating the healthcare system in Australia, she created a policy and advocacy project: #NavigatingHealth. The aims of the project are to streamline the silos and address the fragmentation of healthcare by bringing together all those who are developing solutions to enable patients and carers to better navigate healthcare journeys. Background About 10 years ago, I listened to a friend’s experience navigating cancer and puzzled over the challenges encountered. These made me question my prior assumption of 'patient-centricity' across healthcare. In 2015, the Organisation for Economic Co-operation and Development (OECD) released a report highlighting the complexities of the Australian healthcare system. This led me to realise that while we do have patient-centred care, it is often provider dependent, not system-wide, and relies on the patient (or carer) to navigate the system; a time when individuals are at their most vulnerable. Given 'the standard you accept is the standard you walk past”, I decided to do 'my bit' to address this. I enrolled in a Master of Public Health, researching healthcare navigation in Australia. I found there was a fragmented approach to try and address an already fragmented problem. This led me to embark on a PhD as well as develop a policy and advocacy platform: #NavigatingHealth. Setting up a national network and community of practice My focus has always been on a practical approach that solves problems for individuals but also seeks to understand how to scale these at a systems level to sustain change in the long-term. If this was a known problem, why was nothing being done to address it? Surely this was something government were addressing... or there must be an app? I spoke to lots of people—patients, carers, speakers at conferences, those who had written books of their healthcare experience and, yes, those developing apps. Everyone agreed it was a problem, but nothing was addressing the totality of the problem. The problem was not just in navigating healthcare, but also the challenges navigating related systems, such as those for people with disabilities, or for aged care, as well as social services and education. #NavigatingHealth started life as two, 60-minute webinars held in mid and late September 2021, supported by the Australian Disease Management Association. The inaugural webinar speakers provided vignettes across a life journey—from childhood through to getting older—based on their own lived-experiences as patients, carers or professionals (not-for-profit, health services and government). The positive reception of the webinars led to setting up a bimonthly national network and community of practice in Australia that ran until the end of 2024. The meetings were deliberately not recorded to build a safe space for people to share ideas, build tacit (word of mouth) knowledge and a like-minded solutions focused community. Summaries of all the events and speakers are available on the #NavigatingHealth project page. In health, information and projects evolve. Building an online community was low-cost and accessible to everyone. The success of the Australian approach led to a series of global webinars using the same format of expertise provision from individuals in research, policy, and advocacy and health services. The first global webinar was held in 2022 attracting over 20 countries. Connecting and collaborating The 'glocal' community continues to grow. Projects are constantly evolving, elevating and expanding as well as exiting often impacted by funding constraints. In the spirit of a complex adaptive learning health system, core to our success is the community knowledge built through relationships, trust, like-values and non-linear interactions. Taking an approach that is resourceful versus one requiring constant resourcing (we use accessible tools such as LinkedIn and more recently Bluesky) to provide an effective, free platform to keep individuals in touch with one another. Our dedicated #NavigatingHealth project page on the Nossal Institute for Global Health website at the University of Melbourne acts as a central hub for events and resources. The genesis during the pandemic and expansion virtually through Teams and Zoom, as well as in-person post-pandemic, has enabled different ways to expand the national community, the global network and we welcome all-comers. The project is voluntary and our success is based on linking people, developing relationships, sharing expertise, maintaining momentum and the opportunity we all have to impact into #NavigatingHealth. The annual forums, 2024 #NavigatingHealth Simplifying Complexity and 2025 #NavigatingHealth Enabling Patients, System-Wide, focused on bringing together colleagues nationally in Australia. The in-person workshops created the opportunity to build community, share ideas, leverage learnings and also provide educational content. These collaborations have allowed development of materials for curriculum and teaching, and an evolving conversation about the importance of systems-thinking. We developed a short global project collecting stories from individuals who are happy to be involved. Our video, NavigatingHealth - why this matters, provides a glimpse of our approach. Looking forward The Future of Health Report published in 2018 highlights that our health systems, locally and globally, will change from 'one size fits all' to one that is personalised. The challenge is how? Future of Health Report, CSIRO 2018. The 'secret sauce' is that by working collaboratively we can all be part of evolving and effecting systems change. The work is underpinned by equity and a focus on enabling early access to care, addressing barriers, such as financial or cultural constraints, and helping to make visible information asymmetries and power imbalances to ensure effective collaboration and co-production. Building on the success of our past forums, planning for 2026 is underway. Block out 1 April 2026 in your calendar for the inaugural #NavigatingHealth Day! Our collective expertise is our power—let’s do this! Want to know more? Please get in touch with Siân at [email protected] or via LinkedIn. Further reading on the hub: The challenges of navigating the healthcare system How the Patients Association helpline can help you navigate your care Lost in the system? NHS referrals -
Content Article
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We asked the Patient Safety Group (PSG) of The Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top 10 patient safety tips for surgical trainees. See also: Safety in surgery series Top 10 tips for surgical safety: ‘Think Safety, think SEIPS’ Top 10 priorities for patient safety in surgery Listen to the patient and what matters to them; share decisions with them. Encourage the patient to be in control of their care; they only have to consider their own care and will not be lost to follow up. Trust your instincts; always speak up if you think something is not right. Never be afraid to ask for help if you need it. Look after yourself and your team; there can be no patient safety without team safety. Foster good team working; recognise and respect the value of all team members; take account of everyone’s strengths and weaknesses. Take responsibility for the safety of your patients; patient safety is everyone’s responsibility, not just that of the quality improvement team. Help design systems that make it easier for you to do the right thing. Do not make assumptions. Work as imagined is not the same as work done; make sure you always test any process in practice and confirm that what you think is the case is actually happening. Regularly audit your practice. Celebrate good practice and share your experiences. Take on board feedback and learn from it; be willing to change practice. When outcomes are not as expected, openly discuss and learn, to enable you and your team to reduce the risk of the same thing happening again. -
Content ArticleThe being fair tool will support decision-making for patient safety incidents referred to workforce, and to ensure that staff are not treated unfairly after a patient safety incident. In rare circumstances a learning response may raise concerns about an individual’s conduct or fitness to practise. It is in these specific circumstances that the being fair decision-making tool can help decide what next steps to take.
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EventuntilInvestigating incidents and accidents is crucial for safety management in high-risk industries. While it is just one component of safety management, it is an essential one. Thoughtful incident analysis promotes learning, enhances safety, and fosters a proactive safety culture. The London Protocol is a method for analysing healthcare incidents, revealing the strengths and weaknesses of the healthcare system. By closely examining a single patient’s journey, valuable insights about the broader system can be gained. Originally published in 2004, it has been widely used around the world. Find out more about the updated 2024 version of the London Protocol In this workshop, you will learn about the updated London Protocol 2024, which has been refined for today’s healthcare landscape. We will cover its history, theoretical background, and our approach to learning from clinical incidents and patient experiences. We will focus on engaging patients and families and supporting everyone affected by incidents. Additionally, we will discuss the importance of fewer, more thorough investigations to drive broader improvement initiatives. There will be opportunities for questions and open discussions on any topics raised. Register .
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Content ArticleMartha’s Rule is a key patient safety initiative to ensure patients, families, carers and hospital staff’s concerns about a worsening health condition are listened to. This can help detect deterioration early, so action can be taken to prevent more serious health problems. Effective communication is crucial to the success of Martha’s Rule. NHS England has launched a Martha’s Rule communications toolkit providing trusts with a range of resources to support them to: raise awareness of Martha’s Rule among hospital staff, patients, families, and carers support staff to understand their role in implementing Martha’s Rule, ensuring they feel confident to escalate concerns and ask for additional support when necessary empower patients and families to voice concerns about deteriorating health and to seek rapid reviews when needed.
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News ArticleA senior nurse was struck off over allegations of sexual assault and harassment, after a colleague reported him to a regulator when a hospital refused to refer her case. The colleague, also an NHS nurse, first raised a complaint against Niyi Okegbola with managers at South London and Maudsley NHS Hospital four years ago, alleging he sexually assaulted her on trust premises. But after an 18-month investigation, the colleague, Holly*, was told the case against Mr Okegbola “did not meet the threshold”, and he would be returning to work. She then referred the matter to the Nursing and Midwifery Council, which struck off Mr Okegbola after finding 35 different allegations proven against him over actions that were “sexually motivated” toward her and four other staff from 2019 to 2022. The NMC tribunal found it was more likely than not that he had touched or attempted to touch the breasts of two people working at the trust. The panel added he had “breached professional boundaries” on numerous occasions and “repeatedly [harassed] more than one colleague over a prolonged period of time”. Speaking for the first time since Mr Okegbola was struck off, Holly has accused the trust of having a “culture of acceptance” and failing to protect female staff. Holly, whose name has been changed, told The Independent: “There is a complete lack of awareness about these things happening in the NHS. It’s very much hidden under the carpet, I felt like they [the trust] didn’t know how to handle this." Read full story Source: The Independent, 5 May 2025
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Content Article
In this blog, Clare Wade, Patient Safety Learning's Director, draws attention to the impact toxic cultures have on staff and how, sadly, most often nothing is done about it. Clare shares her own personal reflections from past experiences in her career. There is a clear link between toxic cultures and patient safety, and while there are no easy answers these behaviours must be acknowledged, challenged and cured if the NHS is to survive. I’ve personally experienced toxic culture and behaviour on many occasions, but I found two examples particularly tough to navigate. The first was more than 20 years ago when I worked clinically in a trust largely staffed by the local population where most colleagues were either related or friends; I lived some distance away and commuted in. I’d witnessed troubling behaviour from one senior time-served nurse several times, but one day I heard a blatant, serious breach of patient confidentiality between her and another patient. I was shocked and initially didn’t know what to do. I raised it with the nurse involved who laughed at me, and then the sister in charge who told me to just forget it. After much deliberation, I went to the matron in charge of the department. Conversations took place behind closed doors and eventually I was hauled into trust HQ for a formal meeting, alone—the nurse was nowhere in sight. I was accused of causing upset and the nurse had denied any wrongdoing. In no uncertain terms it was made clear that I should keep my head down and mouth closed if I wanted to remain in post. From that day on my time was made miserable, colleagues closed ranks, stopped talking to me and I was ostracised until the day I left the trust. Later in my career, at a different trust, a new director was recruited to lead my department. From the start something felt off as several senior leaders quickly left their roles. It became obvious that the director was a bully; we largely worked in open plan offices, and the director thought nothing of shouting at and belittling people in front of everyone, even other directors and the CEO. It was impossible for senior colleagues not to know what was happening, but no action was taken. The situation worsened with many people taking sick leave or leaving the trust completely. I came under fire as the director didn’t agree with how I led my team or how we worked, even though our performance was excellent. An external consultant was brought in to identify issues with my practice and help build a case against me. The consultant admitted this to me and said they couldn’t find anything wrong to report back. At the time I had a mentor relationship with a senior board member, and I chose to confide in them with the hope of gaining some insight into how I might be able to better deal with the situation. I didn’t know until sometime later, but my mentor was informing the director about our conversations. As time passed, the behaviour worsened and, although many colleagues were experiencing it too, it was obvious I was on my own in wanting to speak up. I was encouraged to go to a senior HR colleague who would be empathetic, so I did and eventually the director agreed to mediation. I was so nervous ahead of the meeting, but it went ahead and to my surprise the director admitted to some of the allegations and agreed some actions. If I thought my treatment had been bad to this point, I had no idea what was to come. It felt like open season with the director’s full toxicity focussed on me. Derogatory rude emails would be sent daily, raising my anxiety as they landed in my inbox. Meetings where we were both present made me feel sick; they would think nothing of singling me out in front of everyone for their derision and nastiness. The barrage was constant and debilitating, affecting every part of my life and breaking my confidence. One day I couldn’t take any more so left work early and crawled into bed at home where I felt safe. I decided to call the senior HR colleague who had facilitated the previous mediation to ask for an update about the agreed actions. I was absolutely shocked to my core at their reaction, they shouted down the phone that I’d had my opportunity to air my grievances, nothing more was going to happen, the director wasn’t going to be held accountable for the agreed actions and I just needed to forget it and get on with my job. Was I naive to expect a different response? I hit rock bottom, felt scared to go into work and knew I had to get out of there for my health and sanity. Even when I left, the impact followed me to my next role; my confidence and resilience were shot and took a long time to rebuild. The director stayed in post for another couple of years until there were so many grievances that the CEO had to act. The sickening part is that after a period of ‘gardening leave’ the director secured another senior role in another trust in the area so will be perpetrating the same toxic behaviour onto others. I know there are thousands of experiences throughout the NHS just like mine and, unfortunately, in many organisations culture and behaviours aren’t improving. This problem is endemic and has decades of history behind it. There is a clear and acknowledged link between toxic cultures and patient safety. Within the NHS Patient Safety Strategy, NHS England states that: "positive patient safety and healthy organisational culture are two sides of the same coin. A culture in which staff are valued, well supported and engaged in their work leads to safe, high-quality care." In order to improve the care delivered to our loved ones, friends and ourselves, the NHS must take action to improve its culture. Forget the financial situation and the waiting lists, this is the most pressing and wicked problem facing our health service today; it permeates throughout everything and unless it is acknowledged, challenged and cured no other interventions will work. Money doesn’t solve toxic cultures, neither does restructuring the NHS for the umpteenth time. Sadly, some colleagues have taken their own lives because of the toxicity they have endured, this needs to stop now. There are no easy answers here but if we don’t put this right the NHS won’t survive. Share your story Have you worked in a toxic culture? Have you tried to speak up? Have you examples of a good team culture? Add your comment below (you will need to be a hub member and signed in) or contact us at [email protected] and we can share your story anonymously. Related reading on the hub Speaking up for patient safety: A new interview series about raising concerns and whistleblowing Speaking up as an agency nurse cost me my career My experience of speaking up as a healthcare assistant in a care home- Posted
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News Article
Hospital criticised for ‘poor’ and ‘defensive’ investigations
Patient Safety Learning posted a news article in News
A hospital trust has been criticised for its “poor” and “defensive” investigations into three deaths, which a coroner has linked to care by a single surgeon. Heidi Connor, senior coroner for Berkshire, investigated three deaths that occurred within three months at Royal Berkshire Foundation Trust. Each death followed surgery by consultant colorectal surgeon Daniel McGrath, whose “management” of each case was criticised by experts cited by the coroner. The coroner’s prevention of future deaths report about the death of Lorraine Parker, who died most recently of the three on 30 March 2024, was published last week and examined the trust’s death investigations processes across each of the three cases. Ms Connor found the trust’s structured judgement reviews - which investigate care failings following a patient death - to be “at best, poor” and “at worst, defensive”, and warned the trust that its overall death investigation process “is not working well”. In addition, the coroner questioned “whether the trust has done enough to deal with the concerns about this particular surgeon” following the three deaths. There is no note of a restriction on Mr McGrath’s practice according to the General Medical Council register. However, Royal Berkshire told HSJ it has “worked closely with the coroner and the GMC” on measures to oversee his work. He has also been removed from surgical duties. Looking at how the trust handled investigations into the three deaths, the coroner’s report noted the trust did not carry out a “detailed [Patient Safety Incident Response Framework] report”, which supports responses to patient safety incidents, into any of the deaths. Read full story (paywalled) Source: HSJ, 1 May 2025 -
Content ArticleLorraine Parker’s death was the third within three months at Royal Berkshire Foundation Trust following surgery by the same consultant colorectal surgeon. With the permission of both families, the coroner referred to two previous inquests – Mr MR (date of death 4 March 2024), and Mr ME (date of death 28 December 2023) – to focus on the trust’s death investigation processes, and how efficient they have been in terms of picking up issues following each of these deaths. The coroner instructed independent colorectal surgery experts to comment on the management, using two different experts for the three cases. The coroner made the following findings: In the case of Mr ME, a significant surgical error was made when a healthy part of the bowel was removed instead of the area with the cancer, resulting in a much more extensive operation and Mr ME dying around 5 weeks later. This was discussed in a morbidity and mortality meeting, which ends with the simple phrase “await coroner’s report”. A structured judgment review was carried out by a consultant colorectal colleague on 4 May 2024, over four months after the death. According to this review, all of the care given to Mr ME was either “good” or “excellent”. A further structured judgement review took place. It would appear that none of the colorectal surgeons was willing to carry this out, resulting in the need for a gastroenterologist to conduct a second review in July 2024, by which time the surgeon had already been suspended from major operative work. It is important to note that in a clinical governance meeting in February 2024 (ie before either of these structured judgement reviews) it was noted that there were “no learning points identified” in relation to Mr ME’s case. In the case of Mr MR, a structured judgement review took place conducted by a consultant surgical colleague. This report was poor and the coroner wrote to the Chief Medical Officer about it after the inquest. It has the look of the briefest of reviews and tick box exercises. Again, all of the management is referred to as “good”. Mr MR’s case was not discussed during the March 2024 morbidity and mortality meeting, despite the fact that a later death (Lorraine Parker’s, on 30 March 2024) was discussed then. Mr MR’s case did not go to a morbidity and mortality meeting discussion until May 2024. The reasons for this remain unclear. In Lorraine’s case, there was a morbidity and mortality meeting discussion in March 2024 (or perhaps shortly thereafter). The April clinical governance meeting minutes refer to Lorraine’s case and again state “no learning points”. None of these three cases has been the subject of a detailed PSIRF report. Matters of concern On the evidence from the three inquests referred to, the Royal Berkshire Hospital’s death investigation process is not working well. Evidence of delayed morbidity and mortality meetings with no clear system for ensuring that these discussions happen timeously. There is little (if any) record of areas of concern identified at meetings – whether at morbidity and mortality meetings or clinical governance meetings. There is delayed escalation of concerns. Structured judgement reviews are at best, poor, and at worst, defensive. Delayed or no scrutiny of cases being reported to the coroner because the cause of death is unnatural, given that medical examiners are not funded to scrutinise those cases. Opportunities for early learning are therefore being lost. Systems of collating and providing medical records and clinical governance records to the coroner (and presumably to others involved in death investigation) are unreliable. The coroner is concerned about whether the trust has done enough to deal with the concerns about this particular surgeon, not just in the Berkshire area, but more widely.
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News Article
NHS managers must undergo ‘cultural intelligence training’ says watchdog
Patient Safety Learning posted a news article in News
NHS managers should receive “cultural intelligence training” to tackle issues such as “the legacy of the British Empire” and improve the experience of overseas recruits, the National Guardian’s Office has recommended. The NGO’s report examined the experience of international recruits to the NHS, with a particular focus on their willingness to speak out about concerns. It found overseas staff face disproportionately higher scrutiny, are given limited support and are often penalised before they have had time to settle into their role. International recruits often felt “invisible”, the report concluded. The report states the responsibility for adapting, including the implications for speaking up, was often on overseas-trained staff and “a lack of cultural intelligence” was a “repeated theme”, according to the body which leads, trains and supports a network of Freedom to Speak Up Guardians in England. It said this highlighted the need for better understanding and outreach by employers. The NGO calls for “a meaningful approach to cultural competence” which goes “beyond superficial gestures like cultural exchange days”. It stated that: “A two-way process of cultural intelligence is needed, where organisations actively seek to understand and adapt to the experiences and perspectives of overseas-trained workers.” Most FTSU Guardians said training on speaking up was available in their organisations, however, only 16.9% surveyed said their organisations provided training to managers on how to support overseas-trained workers. More than half said they did not know if any such training existed. The report recommends NHS England includes “cultural intelligence training” for NHS staff, managers and leaders as part of its Leadership and Management Framework programme by April 2026. Read full story (paywalled) Source: HSJ, 1 May 2025 -
Content ArticleOverseas-trained healthcare workers are reluctant to speak up about issues such as patient safety fearing it could lead to losing their right to work in the UK, according to a review from the National Guardian Freedom to Speak Up Listening and learning: Amplifying the voices of overseas-trained workers, a review of the speaking up experiences of overseas-trained workers in England highlights the unique challenges faced by NHS workers trained outside the UK when speaking up. Overseas-trained workers are a vital part of the NHS workforce. The National Guardian Freedom to Speak Up review sheds light on their experience, looking at the specific issues faced by overseas-trained workers in speaking up. The report also highlighting examples of good practice. The review finds that overseas-trained workers experience additional barriers to speaking up compared to domestically trained colleagues. To make it easier for overseas-trained workers to speak up, we are calling for action to: Make recruitment and retention guidance support speaking up. Design speaking up arrangements that work for everyone. Use better data to understand and improve experiences. Build cultural competence and awareness to remove barriers to speaking up.
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