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Showing results for tags 'Organisational culture'.
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News Article
Bullying on NHS maternity units and poor training a risk to safety, MPs told
Patient Safety Learning posted a news article in News
Doctors and midwives working in maternity services face higher levels of bullying than any other part of the NHS, MPs have been told. According to the General Medical Council, trainee doctors in maternity services report more than twice the level of bullying seen in the rest of the NHS while the Nursing and Midwifery Council said midwives were also more likely to be bullied. MPs on the Commons health select committee heard that the culture in some maternity units was a major barrier to improving safety and tackling poor care. In an evidence session as part of an ongoing inquiry into maternity care, MPs were also warned the lack of properly funded training was forcing some midwives to pay out of their own pocket. The inquiry by the committee was launched last year after repeated maternity scandals at the Shrewsbury and Telford Hospitals Trust and East Kent Hospitals University Trust. Giving evidence to the committee, Charlie Massey, chief executive of the General Medical Council said: “We do see in our data some quite troubling data around bullying." “If you are an obstetrics or gynaecology trainee, we see in our national training survey each year that some 14% report that they have experienced bullying – and that’s against an average for all trainees of 6%. You see more than double the rate of bullying in obstetrics and gynaecology than you do elsewhere.” Read full story Source: The Independent, 20 January 2021 -
Content ArticleIn the two weeks before his death Robbie was seen seven times by five different GPs. The child was seen by three different GPs four times in the last three days when he was so weak and dehydrated he was bedbound and unable to stand unassisted. Only one GP read the medical records, six days before death, and was aware of the suspicion of Addison's disease, the need for the ACTH test and the instruction to immediately admit the child back to hospital if he became unwell. The GP informed the Powells that he would refer Robbie back to hospital immediately that day but did not inform them that Addison's disease had been suspected. The referral letter was not typed until after Robbie had already died and was backdated to the day following the consultation. In a statement after Robbie's death this GP stated: "An Addisonian crisis is precipitated by an intercurrent illness and the stress it induces." Dyfed-Powys Police investigated Robbie's death between 1994 and 1996 but asserted, supported by the Crown prosecution Service in Wales, that there was no evidence of crimes committed by the GPs who, incidentally, were retained by this police force as police surgeons. Following a complaint by Will Powell (Robbie's father) in 1998 against the Deputy Chief Constable of Dyfed-Powys Police, regarding the inadequacies of the criminal investigation, a second criminal investigation was agreed, which commenced in January 1999. As with the first criminal investigation, there was a gross failure to adequately investigate the criminality of the doctors. This resulted in Will Powell making a formal complaint against the Chief Constable of Dyfed-Powys Police in late 1999. This complaint against the Chief Constable resulted in Dyfed-Powys Police appointing an outside police force to review Robbie's case in 2000. Detective Chief Inspector Robert Poole [DCI Poole] from West Midlands Police was appointed. DCI Poole’s investigation report, entitled 'Operation Radiance', which was based on the documents provided to Dyfed Powys Police in March 1994, by Will Powell and his solicitor, was submitted to CPS York in March 2002. This report put forward 35 suggested criminal charges against five GPs and their medical secretary. The listed charges were: gross negligence manslaughter forgery attempting to pervert the course of justice conspiracy to pervert the course of justice. DCI Poole's investigation also resulted in a disciplinary inquiry by Avon & Somerset Constabulary into Will Powell's allegations of misconduct against Dyfed-Powys Police officers with regards to their two inept criminal investigations between 1994 and 2000. Dyfed-Powys Police was found to have been 'institutionally incompetent' but no police officer was made accountable. In April 2003, Will Powell met representatives from the CPS in London, who accepted there was sufficient evidence to prosecute two GPs and their secretary for forgery and perverting the course of justice. However, they would not prosecuted because of (1) the passage of time, which was caused by a decade of cover ups between 1990 and the appointment of DCI Poole in 2000, (2) Dyfed Powys Police had provided the GPs with a letter of immunity, and (3) the available evidence had been initially overlooked by the police and the CPS, between 1994 and 2000, for a variety of reasons. Following a 2013 adjournment debate, in the House of Commons, the Director of Public Prosecutions subsequently agreed, in October 2014, that there would be an independent review of the decisions made by Crown Prosecution Service, in 2003, not to prosecute, when there was sufficient evidence to do so. The reviewing Queen's Counsels have been provided with a report, written by myself ( a healthcare IT professional, former head of IT in an NHS trust and clinician) on major anomalies in Robbie's Morriston Hospital computerised records, which were erased during the first criminal investigation between 1994 and 1996. The review has not been concluded six years on. The letter below (and also attached) from the English and Welsh Ombudsman was sent on 10 November 2020 sets out the case for a Public Inquiry.
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News ArticleA nurse who was threatened by colleagues for speaking out about care failings at Mid Staffordshire Foundation Trust has said bullying remains a “real problem” in the NHS. Helene Donnelly has told MPs that more than 10 years on from the scandal – commonly known as Mid Staffs – she was still seeing “echoes” of what she experienced happening across the country. “Although it is in the minority, as we saw at Mid Staffs the results can be absolutely catastrophic” She called for the development of a national body to improve workplace cultures in the NHS and “stamp out bullying once and for all”. The inquiry into poor standards of care and deaths at Mid Staffordshire indentified issues around staff behaviour, inadequate staffing levels and skills, and lack of effective leadership and support. Ms Donnelly told a Health and Social Care Committee hearing today that there were “real negative behaviours” at the trust that created a “real bullying culture of fear and intimidation”. “There was not a culture that encouraged and enabled staff to speak up and if they did as I did, we were bullied and threatened,” said Ms Donnelly, who now holds the roles of ambassador for cultural change and lead Freedom to Speak Up Guardian at the organisation where she works. Read full story (paywalled) Source: The Nursing Times
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Patient Safety Movement: Improving patient safety using CANDOR
Sam posted a calendar event in Community Calendar
The approach to resolution of adverse events in hospital and healthcare organisations has remained subpar for decades and open and honest communication is often compromised in favour of litigation. Models like CANDOR have been recognized as essential to transparency, person-centeredness, and healthcare quality and safety. The impactful implementation of CANDOR into organisational culture requires commitment, prioritisation, involvement from all, and event analysis for continuous improvement. Register -
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Safety climate survey – are we getting better? (12 June 2019)
Patient Safety Learning posted an article in Culture
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New training for NHS maternity staff to boost babies safety
Patient Safety Learning posted a news article in News
Hundreds of senior midwives are to be given new training to help improve culture and leadership across 126 NHS trusts. Patient safety minister Nadine Dorries said a new £500,000 maternity leadership programme would be rolled out later this year aimed at giving senior staff running maternity wards the skills and knowledge they need to boost culture and safety. Its one step towards improving the working relationships between midwives and obstetricians and follows the damning report by the Ockenden inquiry into decades of poor care at Shrewsbury and Telford Hospitals Trust. The report, published last month, highlighted leadership on maternity wards as a key factor in cases at the trust which led to preventable baby deaths and cases of neglect over many years. Announcing the fund, Nadine Dorries said: “The shocking and tragic findings of the Ockenden Review highlighted the importance of strengthening maternity leadership and oversight as well as fostering more collaborative approaches within maternity and neonatal services. “I’m pleased to announce a new training programme for NHS maternity leaders, which will empower nurses, midwives and obstetricians to get the best out of their teams, and deliver safe, world-class care to mothers and their babies.” Read full story Source: The Independent, 12 January 2021 Government press release -
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Private hospital in Bradford placed in special measures over patient safety
Patient Safety Learning posted a news article in News
A hospital for men with learning disabilities has been placed in special measures after the Care Quality Commission (CQC) identified “serious risks to patient safety”. The CQC said it had also suspended its current rating of “good” for caring for Cygnet Woodside, Bradford, West Yorkshire, following an inspection in September. The commission said it carried out the unannounced inspection following allegations of abuse by staff towards a patient, which are subject to an ongoing police investigation. The hospital said it was “disappointed” with the CQC’s assessment, stressing that the inspection was triggered by its own management notifying the commission of a concern it had identified. It said the report “does not provide an entirely accurate representation” of the hospital. Dr Kevin Cleary, the CQC deputy chief inspector of hospitals and lead for mental health, said: “Our latest inspection of Cygnet Woodside found that the hospital was not ensuring its patients’ safety.” Cleary added: “The service showed warning signs that increased the likelihood of a closed culture developing. This would have put people at serious risk of coming to harm if we didn’t take action.” He said care was compromised because there was not always the right number or skill level of staff looking after patients. Read full story Source: Guardian, 23 December 2020 -
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Content ArticleWhat you'll get from this report Insights from doctors and medical students who have experienced bullying and harassment. Evidence of the impact of bullying and harassment in the workplace. Recommendations in three key areas to combat bullying and harassment.
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News ArticleStrong leadership, challenging poor workplace culture, and ringfencing maternity funding are key to improving safety. That’s the message from two leading Royal Colleges as they respond to the independent review of maternity services at Shrewsbury and Telford NHS Trust led by Donna Ockenden. The RCOG and the Royal College of Midwives (RCM) have today welcomed the Ockenden Review and its recognition of the need to challenge poor working relationships, improve funding and access to multidisciplinary training and crucially to listen to women and their families to improve learning and to ensure tragedies such as those that have happened at Shrewsbury and Telford NHS Trust never occur again. The Colleges have said that the local actions for learning and the immediate and essential actions laid out in this report must be read and acted upon immediately in all Trusts and Health Boards delivering maternity services across the UK. Commenting, Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, said: “This report makes difficult reading for all of us working in maternity services and should be a watershed moment for the system. Reducing risk needs a holistic approach that targets the specific challenges of fetal monitoring interpretation and strengthens organisational functioning, culture and behaviour." Read press release Source: RCOG, 10 December 2020
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NHS urged to publish delayed report on hospital 'witch-hunt'
Patient Safety Learning posted a news article in News
The NHS is under pressure to publish a delayed review into a bullying scandal at Matt Hancock’s local hospital that involved senior clinicians being asked to provide fingerprint samples in a “witch-hunt” for a whistleblower. The “rapid review” into West Suffolk hospital, which Hancock had to recuse himself from because of his friendship with the boss at the trust, was ordered in January and had been due for completion in April. Its publication was put back to this month because of the coronavirus pandemic. But it is now not expected until spring. The Doctors’ Association UK suspects the conclusions are being sat on because they make embarrassing reading for the trust’s chief executive, Steve Dunn, described by Hanock as a “brilliant leader”. A consultant who chairs the hospital’s medical staff committee wrote to the NHS’s regional director for the east of England, Ann Radmore, last week warning that senior medics felt the hospital could not move on until the review was published. The NHS East insists the review will be published as soon as possible, but a source confirmed this is likely to be “spring next year”. -
News Article
NHS must review ‘all disciplinary procedures’ by March following nurse’s suicide
Patient Safety Learning posted a news article in News
Trusts have been urged to reflect on their disciplinary procedures, and review them annually where required, following the death of a senior nurse who took his own life after being dismissed. NHS England’s chief people officer Prerana Issar has written to trust leaders to highlight Imperial College Healthcare Trust’s new disciplinary procedures, which were put in place following Amin Abdullah’s suicide. Mr Abdullah, a senior nurse at Charing Cross Hospital in west London, was suspended in September 2015 before being let go from his job that December. He died in February 2016 after setting himself on fire. An independent investigation criticised both the trust and its staff and concluded he had been “treated unfairly”. The summary report produced by the trust was labelled a “whitewash”, which “served to reassure the trust that it had handled the case with due care and attention”, and the delay of three months between the events and hearing were “troubling”. The report, which also criticised the delays as “excessive” and “weak” in their justification, said Mr Abdullah found the delay “stressful” and caused him to become “distressed”. In the letter sent on Tuesday, seen by HSJ, Ms Issar said: “The shared learning from Amin’s experience has demonstrated the need for us to work continuously and collaboratively, to ensure that our people practices are inclusive, compassionate and person-centred, with an overriding objective as to the safety and wellbeing of our people… our collective goal is to ensure we enable a fair and compassionate culture in our NHS. I urge you to honestly reflect on your organisation’s disciplinary procedure…" Read full story (paywalled) Source: HSJ, 3 December 2020
