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Advocacy is a free and confidential service. Advocates are independent to the NHS. The NHS Complaints Advocacy service is there to: Give you information about different NHS complaints processes. Help you understand the different options you have in raising your concerns. Offer you support to help you think about your complaint and what you want to get from making your complaint. Help you make your complaint if you want us to. If you would like an advocate to assist you now or would like to talk to someone about advocacy, please contact the Helpline on 0300 330 5454. You can complain about any aspect of NHS care and services but might include: poor treatment or care the attitude of staff poor communication waiting times lack of information failure of diagnose a condition. NHS Complaints Advocacy can only support you if your complaint is about NHS funded healthcare. There are some limits on what can be achieved using the NHS Complaints Procedure. Where the outcome you are looking for is more likely to be achieved through another route, we can explain this and give you information about who best to contact instead. We can support you to make this contact, where required.

Professor Ted Baker, CQC’s Chief Inspector of Hospitals, said:“It is important that organisations learn from incidents and take action to mitigate any risks when patients are exposed to ionising radiation from x-rays, radiotherapy or radiopharmaceuticals as part of their diagnosis or treatment." “The number of errors involving patients is small in the context of the many millions of procedures undertaken each year involving radiation. That said, in too many cases errors happen as a result of inadequate checks, poor communication, or because of a simple failure follow procedures around radiation protection." The report includes recommended actions that providers can take to improve compliance with the regulations and the quality and safety of care for patients. It also shares examples of good practice to help leaders and healthcare professionals identify where they can make improvements in their own services.

The findings demonstrate some significant positive improvements since 2016, such as the increase in the proportion of respondents who receive helpful feedback and learning as a result of reporting incidents. From the feedback given by survey participants, the following key improvements will help enable the community pharmacy sector to continue improving incident reporting levels and the culture in pharmacies: simpler reporting tools training for pharmacy staff on incident reporting ensuring that all pharmacy staff receive feedback and learning they find helpful fostering an open culture of sharing and learning.

Emotional and other long-term impacts of harmful events can have profound consequences for patients and families. Stakeholders designed a path forward to inform approaches that better support harmed patients and families, with both immediately actionable and longer-term research strategies. '[There's the] long-term responsibility of the institution, that we don't talk about....If we [had] some sort of [understanding of the] trajectory of the harm, [we could ask] What roles do institutions play at different parts? [What roles] should they play?'

A flower does not think of competing with the flower next to it. It just blooms. (Zenkei Shibayama) My original presentation of SISOS to the department where I work (theatres) had a huge impact and colleagues recognised the need for it and wanted it. Strong leadership and commitment is essential. I have faced challenges along the way and so far have managed to keep going, but it hasn’t always been easy. I will talk about those challenges as I go. There have been times when I have questioned why I’ve kept going and every so often that question is answered. At a recent conference where I presented a poster, a beautiful human being, kind, intelligent, dedicated to saving lives, looked me in the eyes and said, "How do you support second victims?" and then proceeded to weep uncontrollably. Needless to say I took their willing hand and we shared tea together in a quiet spot. Their incident happened 4 years ago and no blame was attached. This beautiful human being was not an F1 but a consultant. Ironically two days later at work, a consultant suggested that consultants as a group don’t need support because "We have years of experience, we can manage". It’s fair to say that as a group, experienced consultants have challenged the need for this initiative more than other groups and some have been very cynical. However on the whole they have been supportive and welcoming of it. Following my original presentation and the positive feedback from my colleagues, the first thing I did was to form a working group of very senior staff. Nothing would have been possible without their belief and their buy-in. We examined our Trust policy and looked at existing resources; for example, we have an Employee Assistance Programme, which provides professional counselling free of charge to our staff. It was important to see what we as an organisation could provide without incurring additional cost. My experience has been that although support is there in theory, in reality staff were not necessarily accessing it and so one of our roles as Listeners is to improve accessibility. As a group we looked at safety, including the safety of our Listeners and how we support them. Guidelines were produced and training provided. We recognise that we are not experts and that this is still a relatively new initiative for us and one which is evolving. In my next blog I will talk about setting up the SISOS Calm Zone, our safe space. For further information please contact me: carolmenashy@nhs.net

The majority of studies identified active failures (errors and violations) as factors contributing to patient safety incidents. Individual factors, communication, and equipment and supplies were the other most frequently reported factors within the existing evidence base. This review has culminated in an empirically based framework of the factors contributing to patient safety incidents. This framework has the potential to be applied across hospital settings to improve the identification and prevention of factors that cause harm to patients.

The Yorkshire Contributory Factors Framework (YCFF) is a tool which has an evidence base for optimising learning and addressing causes of patient safety incidents by helping clinicians, risk managers and patient safety officers identify contributory factors of PSIs. Incidents that occur in a hospital setting have been well studied and all contributory factors have been mapped. Based on this research, a team of practicing clinicians with human factors experts has adapted the evidence to a two page framework. The YCFF includes all sixteen domains of the evidence-based domains. The document suggests questions that you might want to ask of those involved in the incident. The underlying aim of this tool is not to ignore individual accountability for unsafe care, but to try to develop a more sophisticated understanding of the factors that cause incidents.

FallStop is a quality improvement programme, developed in 2016, when we found there was a high number of falls at one of our hospitals and a failure to learn from serious incidents. The same site had performed poorly in the National Audit of Inpatient Falls in 2015 and we knew we needed to make a change. Our aim was to reduce the incidence of falls and harm and embed falls prevention into everyday practice, by engaging clinical staff to identify patients at risk and implement harm prevention strategies. We chose target wards, on a rolling programme, starting with areas with a high number of falls and those where serious falls had occurred. Integral to the success of FallStop is for wards to understand and own their data and culture. We discuss their fall incidents, rates and falls risk assessment audit results for the previous year. The focus is for each area to decide what they need and want to improve, which we do with their Falls Link Workers and Ward Manager. To support the programme we recruited, to work with the nursing team, a single FallStop Associate Practitioner, whose primary role is to deliver a comprehensive training session to clinical staff. This covers completion of our Falls Risk Assessment and Care Plan, use of harm prevention strategies and post fall care. Over 1,000 clinical staff have received the full training, but the FallStop Associate Practitioner also supports clinical induction sessions every 2 weeks for new clinical staff, by providing a falls awareness session. A thorough falls risk assessment and development of a comprehensive care plan is the most important part of preventing falls and this is emphasised during training. The programme has evolved and we have used innovative ways to improve all aspects, including keeping the data simple. Wards can self -audit their compliance with risk assessments and post fall care by using quick and simple electronic audits and have immediate results in colourful bar and pie charts. We also created a Falls Dashboard for overall Trust data, which is now being further developed to enable wards to drill down to their own data. Results One of the things we sometimes find is that staff do not think that falls is a problem in their area. By sharing their data, discussing serious incidents and talking about training they become much more self-aware and are able to set and own their own goals. In 2016-2017 (pre FallStop) the Trust fall rate was 5.79 per 1000 occupied bed days with the problem hospital rate at 5.55. 2017- 2018 (practitioner in post and programme being rolled out) the Trust rate was 5.34, problem hospital rate at 5.48. In 2018-2019 (FallStop implemented), Trust rate at 5.05, problem hospital rate at 5.13. The avoidable hip fracture incidents have halved from 8 in the previous year to 4 in this year. Next steps We are now helping wards to triangulate their own data. If they can see that staff have received FallStop training and that the number of falls and harms have decreased, they are able to recognise the value of the programme for their patients and team. We have listened to our staff and are developing the Trust’s Falls Steering Group. Whilst it will continue to be chaired by the Deputy Chief Nurse, a representative body of band 7 clinical staff (usually, but not restricted to, Ward Managers) will become members. These are all volunteers who are passionate about preventing falls. We hope that this will enable a cohesive ward to board approach where we can all understand the issues facing clinical staff, whilst keeping clinical staff aware of local and national expectations. It has already improved understanding and is breaking down the barriers. As a result we are planning events for staff to ‘drop in’ and discuss falls and present their own ideas. To celebrate staff achievements we are about to implement ’FallStop Friends.’ Our friends will be presented with certificates and appear in our Trust news and Twitter feed. When we developed FallStop we wanted a unique branding and came up with our own logo. It is widely known across the Trust and we have shared this concept with our peers at other hospital Trusts. We use it for all our communication tools, from reports to desktops, posters to risk assessments. Our next step is to choose what to do with our prize. We have decided to listen to our clinical staff at ‘drop ins’ and find out what they think makes a difference. We will then choose one or two of their ideas to help the Falls Prevention Team visit a hospital, team or service which is successfully addressing the chosen idea. We are committed to continue to develop FallStop locally and share our experience to support our peers in other Trusts with their own programmes.

The Journey In the changing rooms where I worked as a scrub nurse, I overheard a group of nurses discussing the distressed state of a young doctor. There had been a never event in their theatre that day and the young doctor was the operating surgeon. Moved to tears I wanted to go and put my arms around that doctor but I didn’t feel that I had ‘permission’. ‘It was none of my business, what if I made things worse?’ So I dumped my scrub suit into the laundry bin, put my theatre shoes away and went home. I’m a theatre nurse but more importantly I’m a mother, the mother of a young doctor and that night fearful for the surgeon’s safety I was unable to rest. If it was my daughter I would have wanted someone to be there for her. Galvanised by a mother’s strength, I vowed that nothing could or would hold me back and so the next morning I wasted no time in knocking on my matron’s door. "I was worried about that young doctor last night", I said. "So was I", said my matron. "I rang her and she’s coping’". I was relieved to hear this but as I turned away I realised that there was an urgent need for timely, accessible structured support for when things go wrong. I reflected on an incident that had happened to me and I asked myself this question: What would have helped me, at one o’clock in the morning, all those years ago, when I sat alone in a hospital tea room: devastated, anxious, ashamed, guilty, having flashbacks and feeling like the worst nurse on the planet? I had let my patient down. Two things came out of those reflections. Firstly, I had craved the companionship and compassion of my colleagues because I knew that they above all people would get it. They would understand how this situation could possibly have arisen without attaching blame. Secondly I recognised the need for a safe space, a place where my dignity could have been protected and I could have shared this experience in privacy. As far as I was concerned, my name was in neon lights, I was the failed nurse, there to be gawped at. These two experiences, the young doctor’s and my own were the catalyst for SISOS. Safety Incident Supporting Our Staff. Chase Farm Hospital now has 24-hour support for staff affected by adverse events. The model which I’ve developed is known as the 365 second victim support model and sets out a framework to provide support at various levels from trained peers through to professional help. The care which we can now give our second victims is compassionate, non- judgmental and happens in a dedicated safe space, where experiences are shared in confidence. Empathy, respect and compassion assist in emotional healing. Following a successful audit I’m delighted to say that this model is now being rolled out Trust wide. My passion is that all of our colleagues deserve access to this kind of care. I recognise that it won’t be easy but I will not be deterred, will you? Read part two and part three of my blog series where I continue the journey and talk about the challenges faced. For further information please contact me: carolmenashy@nhs.net Further reading: Hirschinge, LE et al. Clinician Support: Five Years of Lessons Learned. Patient Safety & Quality Healthcare. March/April 2015. Willis D, et al. Lessons for leadership and culture when doctors become second victims: a systematic literature review. BMJ Leader 2019;1–11.

The forYOU Team’s five-year experience in providing clinician support has yielded many valuable insights into this aspect of MUHC’s patient safety culture. Organisational awareness of the second victim phenomenon and an institutional response plan are critical steps in minimising the suffering of the institution’s healthcare clinicians. From this experience, the authors strongly encourage healthcare facilities to develop a comprehensive plan and provide accessible, effective support for all clinicians experiencing the second victim phenomenon.

The results of this study show that poor organisational culture and leadership negatively influences and hinders doctors who make mistakes. Leaders who promote and create environments for open and constructive dialogue following adverse events enable the concept of fallibility and imperfection to be assimilated into new ways of learning. Guilt and fear are the most consistently reported psychological symptoms along with a perception of loss of professional respect and standing. Doctors often carry unresolved trauma for several years causing them to constantly relive an event. Unchecked, this can lead to poor relationships with colleagues and impact greatly on their ability to sleep and performance at work. The review concludes that a prevailing silence, exacerbated by poor organisational culture, inhibits proper disclosure to the first victim, the patient and family. It also impedes a healthy recovery trajectory for the doctor, the second victim. Leaders of organisations have a vital strategic and operational role in creating open, transparent and compassionate cultures where dialogue and understanding takes place for those affected by second victim phenomenon.