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A set of eLearning modules designed to educate and update clinicians on the importance of involving families wherever possible during mental health crises to improve patient care, avoid harm and reduce deaths. They were developed as a partnership between Oxford Health NHS Foundation Trust and Making Families Count, with funding from NHS England South East Region (HEE legacy funds).   The resources have been co-produced by people with lived experience as patients, family carers and clinicians, supported by an Advisory Group drawn from a wide range of expertise, tested in eleven NHS Trusts and independently evaluated.   The resources can be downloaded by NHS Trust Learning and Development teams to support a Trust-wide approach to essential learning and training.   Through short film and audio scenarios and case studies, Life Beyond the Cubicle shows why it is so important to involve family and friends, helps clinicians reflect on why they don’t do so routinely, and how they can overcome these barriers. The resources are engaging and interactive. The modules are: Introduction (includes guidance on how to use this resource) Module 1: Why do families and friends matter? Module 2: Assumptions and expertise Module 3: Feelings and fears Module 4: Confidentiality and Information Sharing Module 5: Safety planning Resources for family and friends They are free to the health and social care workforce. Further reading on the hub: Safer outcomes for people with psychosis Patient Safety Spotlight interview with Rosi Reed, Development and Training Coordinator at Making Families Count The future has been around for too long—when will the NHS learn from their mistakes?

NHS Horizons uses SenseMaker to gather and analyse stories of real-time, day-to-day experiences to facilitate improvement in complex environments. SenseMaker is the complexity research tool that enables not only the mass data collection of rich and deep descriptions of people’s experiences, but also uses a framework incorporating “triads” and “dyads” to allow participants to categorise what their stories mean to them. The process starts with a SenseMaker survey (or a series of surveys) and ends with a Sensemaking workshop.

This book published by the US Food and Drug Administration (FDA) looks at risk communication—the communication approach used for situations when people need good information to make sound choices. It is distinguished from public affairs (or public relations) communication by its commitment to accuracy and its avoidance of spin. Effective risk communication between healthcare professionals and patients is important to ensure patient safety, and in various chapters of the book, the authors look at how to maximise effective communication in healthcare scenarios.

The Serenity Integrated Mentoring (SIM) model is described as "an innovative mental health workforce transformation model that brings together the police and community mental health services, in order to better support 'high intensity users' of Section 136 of the Mental Health Act (MHA) and public services." The SIM model is part of a 'High Intensity Network' (HIN) approach, which is now live in all south London boroughs. In this hub post, Steve Turner highlights the benefits and risks of this approach and seek your views on it. Background In 2018, SIM was selected for national scaling and spread across the Academic Health Science Networks (AHSNs). The High Intensity Network (HIN) has been working with the three south London Secondary Mental Health Trusts: The South London and Maudsley NHS Foundation Trust, Oxleas NHS Foundation Trust and South West London and St George’s Mental Health NHS Trust, and the Metropolitan Police, London Ambulance Service, A&E, CCG commissioners, and the innovator and Network Director of the High Intensity Network. The model can be summarised as: A more integrated, informed, calm approach in the way we respond to individuals that have unique needs during a crisis and A better form of multi-skilled, personalised support after the crisis event is over. So in July 2013 the Serenity Integrated Mentoring (SIM) model of care was proposed. This is how it works: SIM brings together all the key urgent care agencies involved in responding to high-intensity crisis service users around the table, once a month. This multi-agency panel selects each individual based on demand/risk data and professional referrals. They use a national 5-point assessment process to ensure that the right clients are chosen and in a way where we can ensure a delicate balance between their rights as an individual but our need to safeguard. Selected individuals are then allocated to a SIM intervention team. The SIM team is led principally by a mental health professional (who leads clinically) and a police officer (who leads on behaviour, community safety, risk and impact). The team supports each patient, to better understand their crises and to identify healthier and safer ways to cope. In the most intensive, harmful or impactive cases, the team also does everything it can to prevent the need for criminal justice intervention. Together, the mental health clinician, the police officer and the service user together create a safer crisis plan that 999 responders can find and use 24 hours day. The crisis plan is then disseminated across the emergency services. The SIM team reinforces these plans by training, briefing and advising front line responders in how to use the plans and how to make confident, consistent, higher quality decisions. What are the benefits and risks of this approach? Benefits: It is claimed that this is a more integrated, calm and informed approach to responding to individuals in crisis and the HIN provides "better multi-skilled, personalised support after a crisis event was over". The HIN website states: "Across the UK, emergency and healthcare services respond every minute to people in mental health crisis and calls of this nature are increasing each year. But did you know that as much as 70% of this demand is caused by a small number of ‘high-intensity users’ who struggle with complex trauma and behavioural disorders? These disorders often expose the patient to higher levels of risk and harm and can simultaneously cause intensive demand on police, ambulance, A&E departments, and mental health crisis teams." Risks: This approach has been subject to strong criticism from some users of mental health services, mental health clinicians and mental health support organisations. Concerns have been raised about whether the HIN/SIM approach is safe, effective or appropriate. I believe we need an open and inclusive discussion about High Intensity Networks, with users of mental services leading the debate. As a former mental health nurse in an Assertive Outreach team I'm keen to learn: How users of services were involved in the initial development of the model? What are the similarities and differences between High Intensity Networks and an Assertive Outreach model? How this approach compares with approaches in other countries? How users of services are involved in evaluating and adapting the model? What the specific benefits are for users of services and are there any risks to this approach? Does this lead to a long term improvements for users of services? I hope people will feel able to contribute openly to this discussion, so we can learn together. #HighIntensityNetwork #mentalhealth

For some time now I've been looking to find out more about mental health services in Trieste, Italy. Then I met Vincenzo Passante Spaccapietra, co-host of the Place of Safety? podcast series. This has enabled me to learn more about the closure of the mental institutions in Trieste, Italy, and the work of Franco Basaglia.  I was keen to find out what really took place, what this really means in practice and how we can adopt this model in the UK. We were delighted to have become involved and to have recorded a couple of podcasts. I recommend this resource to everyone interested in safe, compassionate, patient led mental health care. "Many voices are not heard in British mental health care (and beyond), significant flaws are overlooked. If you are not satisfied with the status quo or just curious, follow us!" Here's a sample of some of the podcasts: Episode 33 - Basaglia's International Legacy: From Asylum to Community... review Episode 8 - Lived experience in Trieste, a mental health system without psychiatric hospitals, with Marilena and Arturo Episode 25 - Clinical Psychology vs Psychotherapy in Italy and the UK Episode 18 - The Trieste model cannot be exported to the UK because... let's unpack the main objections Episode 27 - Substance dependency, colonialism and sexism with Dr Sonia Soans (@PSYfem) Episode 26 - From the horse's mouth...patient & nurse teaching together as equals Listen to all the podcasts from link below.

Part 6 of this series of blogs about human factors and investigations in healthcare discusses the 'How' and the 'Why'. How did the person die or was injured is different from understanding why it happened? At first this appears to be a pedantic, minor issue, but, as (hopefully) we shall see from this blog, it’s a vital distinction. Question How did the plane crash? Answer It was hit by a missile. Question Why was a missile launched, is a vastly different question. Question How was it that the pedestrian was hit by the car? Answer It was due to the driver not seeing them – but why did they not see them is the question.  Without the why – you can’t do the intervention. Most investigations done stop at the how – few get to the why, especially in medicine, especially with root cause analysis. Let's start with a summary of where we are in the blogs. I’m told our reader likes the summary (a Mrs Trellis of North Wales). In part one we decided why we investigate an incident and what an incident was. In part two we decided that two investigators (or more) collect facts together in a more accurate way than one would. In part three we gazed into each other’s eyes and concluded that facts are our friends and where they might come from. We decided interviews and photos give us good facts. In part four we were introduced to what human factors is, and what it is all about and how western psychology is about exploiting the worker! In part five we thought that facts are time dependent and men of my age should not wear shorts outside a restaurant/come damaged aircraft. We discussed how dependent witness memories are on the elapsed time for the effective retrieval of information. These blogs, therefore, are asking simple investigation questions of Who, What, When and Why, and basic questions about what can humans do (human factors). So here we are back to the powerful question ‘Why’ but this time, rather than "why investigate an event?", we are asking "why did this event happen?". Most investigations stop at the point of understanding how the person was injured or died. The how they died does not give you enough data to prevent it occurring again. Knowing, for example, that an elderly, lone rail passenger unfamiliar with the station died from head injuries after falling on a platform with the investigation team concluding that ‘they lost their balance and fell backwards’ does not help understand why this happened or how to prevent its reoccurrence. Why did it occur that day, to that person, on that platform? Might an intervention based on the question ‘How’ be that no one over 60, who is unfamiliar with the station and travelling alone, be prohibited from travel. The important question is why and not how. Likewise, a pedestrian is found dead by the side of the road after a collision with a van. How did they die? Well head trauma after collision with a van. How did that occur? The driver said that at night it was too dark to see the running pedestrian. Indeed, at the reconstruction it was very dark. But after 25 questions of ‘why’ came the critical ones. Why was a person out running in near total darkness without a light? Why could the van driver not see them? Why was there no light (torch etc) found with the pedestrian so they could run without falling into the numerous pot holes? Why that van and why that pedestrian. The why (in this case) comes from human factors research into perceptual thresholds of how much light needs to hit the retina for the cognitive process to start. Long story, but the answer to why was a murder disguised as a traffic accident. Which takes us back to my first blog – what’s an accident – this was not a rare random event with multiple causes. It had one cause – top tip sleeping with a colleague’s partner is not a good idea. Unless you answer why, then there is no intervention and that ‘why’ is ‘why’ we do this. Becoming a 5-year-old The skill of an investigator in human factors is to keep asking the question Why (and perhaps not to insist an infographic is needed). Like my 5-year-old self. Why can’t I ride my bike to the next town… But why, but why. The police car brought me back last time – I was not lost. This may explain why a disproportionate number of my friends are clinical psychologists! Case studies Two case studies. Let’s stick to rail. I can do why are anaesthetics rooms so small, but I’ll get all emotional! If I’m found dead in an alley it’s a hospital facilities manager wot did it. Case One A train station where there are 17 serious incidents on a single set of steps down to platform 1. It’s a traditional Victorian design urban station with access at street level and platforms below the booking hall. All platforms are connected by a glass overpass. No other platform (there are six) has an issue. One case is a fatality. How did they occur? The answer is – the person fell down the stairs. Head injuries and broken legs (not the same person!) are common. The ‘how ‘is answered. The why is not. Why did they fall down the stairs we asked. “There are stairs and people will fall down them” came the reply. Why? “Well there are stairs and people will fall down them”. But why these stairs, why this platform, and why 17 people? Well, came the reply, we will have to put a poster up telling people ‘these are stairs.’ Why did they fall we asked? We have a poster telling people how not to fall down them and how to use stairs (hold the handrail) they replied. We asked as a five-year-old would – why do you think these people have problems with these stairs? So, let’s think of the why questions after some facts. Might be worth also predicting that posters are the sign of defeat and result from only asking ‘how’. Also, putting posters above stairs, so that people look at them and not the stairs, is another classic failure of understanding human performance. Some facts Timetable information shows platform 1 is the city bound platform. Observations indicate that people descend the stairs very rapidly when there is a train present at the platform. Secondary observations come to understand that running starts at the ticket office overlooking the glass passageway over to the platform. Incident data reveals peak at rush hour above that of exposure (rise in passenger numbers). Only platform 1 can been seen from the walkway and the ticket office. The ‘why’ hypotheses was that as people became aware of the train arriving at the city bound platform, they made a run for it. We interviewed several of those injured. Most common statement from the predominantly local people was “I knew I would miss the train as I could see it at the platform, so I ran”. The remedy was to put plastic obscuring film over the glass walkway so you could not see if a train was at the platform. No cognisance of a train’s presence = no rapid stair descents. Only journeys into the city appear to be highly time dependent. Outcome After 11 years, no incidents on the stairs, no aggression to the ticket office staff (give me my ticket now!) and posters removed. Why – we asked ‘why’ not ‘how’. Removing ‘safety’ posters is always a good idea. I’m still trying to find out what an internal brand consultant is – they were against the removal of posters. Answers if you know what these are and how they make the world better please. Case 2 At a train station, there were 27 falls ‘down the steps’ of which four were citizens from the USA. These citizens of America are after the compensation for ‘foreseeable’ injury in the US courts. Think expensive when compared to compensation claims in the UK. As above, ‘the how’ was they were injured by a fall. Why at this station? Why these people? Some facts Incident data revealed all those falling down the stairs were visitors to the area (based on address supplied). Plans of the Victorian station reveals it’s a small (four platform station) with over 80 different exit route combinations, via three underpasses. Exit here is time-critical – it’s near an airport with a connecting bus. There are over 130 signs containing over 900 words of advice. Observations and interviews showed that perhaps passengers lost spatial and situational awareness (more in later blogs) and became disoriented. CCTV images showed one passenger was walking up and down the platform twice, then walking through one of the underpasses six times, before they injured their arm when the bag got caught in the handrail and they ‘went down, way down, the steps’ ( from Incident report). Our initial hypothesis was that a lost and disoriented passenger with bags will find stairs more of a challenge than one who is not. Remedy We removed most of the signs on the platforms and underpasses and replaced with one type of exit sign. Whether its exit to the airport or exit to the pub it’s still an exit. Locals – not represented at all in the data – know which of the combination of exits will get them to the pub. Outcome No incidents in 12 years, and the platform staff last year took rail executives around ‘their’ station telling them how easy it was to prevent slips, trips and falls because “someone asked why”. Why, and multiple causes Early on in our blog life together we said that accidents have multiple causes. In healthcare we are not sure how many variables there are and even the extent of the problem. We also described that the cause is about the ‘environment’, the ‘human’, the ‘system of working’ or the ‘equipment’. We decided together this determines ‘who should investigate’. Engineering failings are done by engineers, for systems failures investigations by nursing staff are recommended. Well here the ‘Why' word repeated on the first day is the solution to find out who should investigate. When do you know you have possibly stopped asking why too early? The common reasons for stopping asking the question ‘why’ is when you get to one of the following conclusions: 1. Its human error. 2. It’s the person who had the incidents fault – but remember organisations fail not people. If you get these conclusions, keep going and ask your friendly human factors person for help. Remember, one of the limits of investigations is that you can’t ask questions about things you don’t know about – obvious really, but that’s why there should be two of you and perhaps one of those is a human factors person. A major failing in root cause analysis is this fact is always overlooked. 3. I cannot ask ‘why’ anymore without getting asked to leave the building/the NHS/the human race… The solution is to ask questions using the Socratic method. More later when we think about logic – but the Greek philosophy types nailed it many centuries ago (just like they invented human factors in medicine; ergonomics they called it). Citing Professor Wiki once more and to appeal to the midwifes among you, the Socratic method is: “a form of cooperative argumentative dialogue between individuals, based on asking and answering questions to stimulate critical thinking and to draw out ideas and underlying presuppositions. It is named after the Classical Greek philosopher Socrates and is introduced by him in Plato's Theaetetus as midwifery (maieutic) because it is employed to bring out definitions implicit in the interlocutors' beliefs, or to help them further their understanding”. Again, this is part of the human factors persons training and why we ask the questions in the way we do to members of the investigation team (sorry). There is a management consultancy (boo hiss) methodology called the ‘5 why method’, and its creeps into the root cause analysis nonsense (more boos). But just asking why without the Socratic teachings tends to just annoy people. Exploring ‘Why’ as an equal to the person you are talking to is more respectful and gets better data, and you should not get thumped. Who asks why and to whom? In later blogs we shall chat about interviewing witnesses. This blog is about the internal dialogue in the investigation team or, if there is just one of you, the internal monologue. Asking why to a witness is generally not the thing to do. Its common in healthcare but the witness cannot report Why, they only know the How. Witnesses provide facts, the team finds answers from those facts ('Where do facts come from?'). Summary The ‘Why’ word is very powerful when added to a blank sheet of paper and a pen in the hand of the investigator and means that you focus on the outcome and not on a process. As replies to my earlier blogs – about how healthcare is all about process and not outcomes – well one word and some paper mean you can just focus on prevention. And dear reader why we investigate is to prevent it occurring – in the words of Metallica – 'Nothing else matters'. And finally... The station (discussed above) where elderly people represent the dataset. All falling backwards on platform 1 and our initial (yours and mine dear reader) remedy was to exclude over 60s from it unless they were trained. Suggestions of why and what questions would you ask. Comments below. (See Why investigate? Part 7 for the answer.) Follow 0 Posted by MartinL Top tip – no one was running and all very cognisant of the train times, and all but one sober. Happy if you want to test out the Socratic method now. Posters, as a solution, are not permitted. Read the other blogs in this series Why investigate? Part 1 Why investigate? Part 2: Where do facts come from (mummy)? Who should investigate? Part 3 Human factors – the scientific study of man in her built environment. Part 4 When to investigate? Part 5 Why investigate? Part 7 – The questions and answers Why investigate? Part 9: Making wrong decisions when we think they are the right decisions Why investigate? Part 10: Fatigue – Enter the Sandman Why investigate? Part 11: We have a situation Why investigate? Part 12: Ethics in research

This perspective published in the The New England Journal of Medicine examines the problem of racial disparities and the COVID-19 pandemic. The Chowkwanyun and Reed highlight the importance of viewing the data emerging from the crisis in the appropriate socioeconomic and deprivation contexts to protect against ineffective compartmentalisation of the populations being affected. 

The Health & Safety Laboratory (HSL) Safety Climate Tool (SCT) measures the perceptions of the workforce on health and safety issues, offering a unique insight into the safety culture within an organisation. It can be applied across industries of all sizes, from SMEs to large complex organisations. Multi-site companies can also use it to look at the strengths and weaknesses of different sites or business units. The HSL SCT is delivered on a CD-ROM, which you install onto a suitable computer to allow you to produce a customised questionnaire that is then run across your organisation. Once the questionnaire survey has been run, the tool produces a series of automated charts that allow detailed analysis of the findings. (HSL is an agency of the Health and Safety Executive.) Key benefits of tool Raises the profile of Health & Safety – engages the workforce to talk about health and safety issues. Captures sensitive information – participants respond anonymously. Enables active management of health and safety - allows companies to highlight both areas of concern and good practice. Provides a baseline measure - can help you evaluate whether health and safety initiatives have had the desired effects on performance. Key features Generates paper and HTML versions of the questionnaire. Quick wizard guides the user through easy set up to produce the survey. The survey can be tailored towards the organisation, for example by incorporating the company logo and supporting Management statement and by tailoring terminology within the SCT statements. Allows for up to 9 demographic questions and an additional 6 open questions. The software automatically analyses the data to produce a series of charts and also allows detailed filtering to further interrogate your findings

The health literacy field has evolved over several decades. Its initial focus was on individuals who had poor literacy skills. Now there is a broad recognition that everyone—not just those with limited literacy—face challenges in understanding health information and navigating the healthcare system. Acknowledging that the healthcare system is overly complex, healthcare organisations have started to take responsibility to ensure that everyone, especially the vulnerable, is able to find, understand, and use health information and services. The Agency for Healthcare Research Quality (AHRQ) provides national health literacy leadership. AHRQ’s health literacy work spans from developing improvement tools, to designing professional training and education, to funding and synthesising health literacy research. You can find health literacy improvement tools, educational and training, and publications on the AHRQ Health Literacy website.

All human activity, along with associated emergent problematic situations and opportunities, is embedded in context. The ‘context’ is, however, a a melange of different contexts. In our attempts at understanding and intervening, rarely do we spend much time trying to understand context, especially as it applies to the current situation, and how history has influenced where we are. Instead, we tend to: a) make assumptions about context, but not make these explicit, resulting in different unspoken and untested assumptions; b) limit contextual analysis to proximal, ‘obvious’ or uncontroversial aspects; or c) jump to a potential solution (or a way to realise an opportunity), shortly followed by planning for this intervention (which has the important function of helping us to feel in control, thus relieving our anxiety – at least temporarily). An approach Steven Shorrock has found useful is to spend time considering contextual influences (e.g., on decision making, at multiple levels of organisations) on problematic situations or potential solutions, more explicitly. He shares this in his latest blog.

In order to inform clinical and research practice in secondary care in light of the COVID-19 pandemic, an online survey was used to collect public opinions on attending hospitals. The survey link was circulated via the National Institute for Health Research (NIHR) Public Involvement (PPI) Leads network and social media. Data collection included self-identified risk status due to comorbidity or age, and 100 point Likert-type scales to measures feelings of safety, factors affecting feelings of safety, intention to participate in research, comfort with new ways of working and attitudes to research. Results for feelings of safety scales indicate two distinct groups: one of respondents who felt quite safe and one of those who did not. *Note: This article is a preprint and has not been peer-reviewed.  Implementation of COVID-19 related safety measures such as social distancing, use of PPE and cleaning were strongly supported by most respondents. There was ambivalence around less certain measures such as regular staff antigen and antibody testing. Respondents were most likely to participate in research related to their own condition, COVID-19 research and vaccine research, but less likely to participate in healthy volunteer research, especially if suffering from a pre-existing comorbidity identified with increased risk or were female. There was general agreement that participants are comfortable with new ways of working, such as remote consultation, though women and BAME respondents were less comfortable. Findings raise concerns for health inequalities already impacting some groups in the pandemic. The role of clinical necessity and personal benefit support the reopening of services in line with clinical necessity. Moderate caution in respect of vaccine research relative to patient-participant research presents a challenge for pending recruitment demands, and would benefit from qualitative research to explore themes and concerns in more depth and support development and targeting of key messaging.

Coroners are independent judicial officers who investigate deaths reported to them. They will make whatever inquiries are necessary to find out the cause of death, this includes ordering a post-mortem examination, obtaining witness statements and medical records, or holding an inquest. The web page includes information on: Which deaths are reported to the coroner What happens next after a death is reported About identifying the body Coroner liaison officers Post mortem examinations Post mortem results Returning the body Funeral arrangements Inquests

In The Silo Effect, the author uses an anthropological lens to explore how individuals, teams and whole organisations often work in silos of thought, process and product. With examples drawn from a range of fascinating areas - the New York Fire Department and Facebook to the Bank of England and Sony - these narratives illustrate not just how foolishly people can behave when they are mastered by silos but also how the brightest institutions and individuals can master them.

Thrombosis UK is a charity and a leader in: Identifying, Informing & Partnering the NHS, healthcare providers and individuals to work to improve prevention of venous thromboembolism (VTE) and the management and care of unavoidable VTE events. This short video explains how a blood clot might form, what the risks are and how they might be treated.

In this article in the APSF newsletter, Jeffrey Cooper discusses the importance of the anaesthetist and surgeon relationship and why a healthy collaborative relationship is vital for patient safety. He suggests a number of practical relationship building principles. "I’m not promising you a rosy world if you work at this. But I think it’s worth your time for your patients’ safety to try as much as you can. Doing nothing will mean nothing will change. If your efforts succeed, you’ll have made a huge advance for patient safety, and you’re likely to find more joy and meaning in your professional daily life."

Medical terms can be difficult to understand, none more so, than terms which are around cancer. To ensure patients, staff and relatives are clear on what is being said to them the National Cancer Institute (NCI) has complied a dictionary of cancer terms for everyone to access.

World Cancer Day every 4 February is the global uniting initiative led by the Union for International Cancer Control (UICC). By raising worldwide awareness, improving education and catalysing personal, collective and government action, people are working together to reimagine a world where millions of preventable cancer deaths are saved and access to life-saving cancer treatment and care is equal for all – no matter who you are or where you live.  Created in 2000, World Cancer Day has grown into a positive movement for everyone, everywhere to unite under one voice to face one of our greatest challenges in history. Each year, hundreds of activities and events take place around the world, gathering communities, organisations and individuals in schools, businesses, hospitals, marketplaces, parks, community halls, places of worship – in the streets and online – acting as a powerful reminder that we all have a role to play in reducing the global impact of cancer. This year's World Cancer Day's theme, 'I Am and I Will', is all about you and your commitment to act. Through positive actions, together we can reach the target of reducing the number of premature deaths from cancer and noncommunicable diseases by one third by 2030. Talking openly about cancer and our experiences makes a huge difference in increasing understanding, overcoming stigma and reducing fear. This page give you access to numerous stories from around the world from people living with and have experience of living with cancer.

Every four days a person takes their life in prison, and rising numbers of ‘natural’ and unclassified deaths are too often found to relate to serious failures in healthcare. The lack of government action on official recommendations is leading to preventable deaths. Deaths in prison: A national scandal exposes dangerous, longstanding failures across the prison estate and historically high levels of deaths in custody, and offers unique insight and analysis into findings from 61 prison inquests in England and Wales in 2018 and 2019. The report details repeated safety failures, including mental and physical healthcare, communication systems, emergency responses, and drugs and medication. It also looks at the wider statistics and historic context, showing the repetitive and persistent nature of such failings. The report by INQUEST sets out the following recommendations to improve safety and prevent future deaths: 1. Halt prison building, commit to an immediate reduction in the prison population and divert people away from the criminal justice system. 2. Prison staff, including healthcare staff, require improved training to meet minimum human rights standards to ensure the health, well-being and safety of prisoners. 3. Ensure access to justice for bereaved families through the provision of automatic non-means tested legal aid funding for specialist legal representation to cover preparation and representation at the inquest and other legal processes. Funding should be equivalent to that of the state bodies/public authorities and corporate bodies represented. 4. Establish a ‘National Oversight Mechanism’ – a new and independent body tasked with the duty to collate, analyse and monitor learning and implementation arising out of post death investigations, inquiries and inquests. This body must be accountable to parliament to ensure the advantage of parliamentary oversight and debate. It should provide a role for bereaved families and community groups to voice concerns and provide a mandate for its work. 5. Ensure accountability for institutional failings that lead to deaths in prison. For example, full consideration should be given to prosecutions under the Corporate Manslaughter and Corporate Homicide Act, where ongoing failures are identified and the prison service and health providers have been forewarned. The reintroduction of The Public Authority (Accountability) Bill would also establish a statutory duty of candour on state authorities and officers and private entities.

Frailty is increasingly recognised as a critically important policy and quality of care issue in healthcare systems. There is clear evidence that frail older people are at increased risk of acute illness. These heightened risks mean that frailty is associated with high mortality and high healthcare utilisation. It is a key consideration in clinical decision-making. However, frailty is a contested concept, both in definition and measurement terms. Identification of frailty is complex and issues of over-diagnosis and over-treatment are increasingly garnering attention. This report from the New South Wales Agency for Clinical Innovation draws on scientific literature, empirical data and experiential evidence from patients, carers and clinicians regarding over-diagnosis and over-treatment in frail elderly patients. Underlying reasons for over-diagnosis and over-treatment include professional, cultural, organisational, health system, patient and carer and technology issues. A shift towards balanced care that supports realistic expectations and delivery models informed by research, empirical and experiential knowledge is required to address issues related to over-treatment and over-diagnosis.

Sidney Dekker says when there has been an incident of harm, we need to know "who is hurt, what do they need, and whose obligation is it to meet that need?" In this blog, commissioned by Patient Safety Learning, Joanne Hughes, hub topic lead, develops our understanding of the needs of patients, families and staff when things go wrong.  Using Joanne's expertise and informed by her personal experience and engagement with many others who have suffered second harm, this blog discusses the care needs for harmed patients, their families and for staff when things go wrong. It aims to highlight the chasm between what is needed and what is currently delivered. “After he died, the little plastic ID band that was around his tiny wrist should have been slipped onto mine. There was nothing more that could have been done for him, but there was plenty that needed to be done for me. I needed an infusion of truth and compassion. And the nurses and doctors who took care of him, they needed it too." Leilani Schweitzer[1] When someone is hurt, it is reasonable to expect the healthcare system to provide care to alleviate symptoms or to cure. It is also reasonable to expect those providing the care to be adequately trained and supported to do so. Yet, when harm is caused by healthcare, the spectrum of harm suffered is not well understood, care needs are not fully recognised and, therefore, the care needed to facilitate optimum recovery is not being provided.[2] In fact, with outrageous frequency, at a time when exceptional care is so desperately needed, those hurting describe how they are further harmed from ‘uncaring’ careless and injurious responses. Healthcare harm is a ‘double whammy’ for patients Healthcare harm is a ‘double whammy’. There’s the primary harm itself – to the patient and/or to those left bereaved – but there is also the separate emotional harm caused specifically by being let down by the healthcare professionals/system in which trust had to be placed.[3] This additional emotional harm has been described as being the damage caused to the trust, confidence and hope of the patient and/or their family.[4] Trust – you rely on professionals to take responsibility for what you cannot do yourself. Confidence - you believe that the system will protect you from harm. Hope – you have the conviction that things will turn out well. Anderson-Wallace and Shale[4] For the patient and family to be able to heal from healthcare harm, appropriate care must be provided not only for the primary injury and any fall out from this, but also this additional emotional injury (being let down by healthcare) and any fall out from that. For example, a parent who loses a child as a result of failures in care will need help to cope with the loss of their child and all of the processes that occur as a result. But they will also need support to cope with having had to hand over responsibility for their child’s safety to healthcare professionals, only to be let down, and all the feelings and processes associated with that. Much needs to happen to restore that parent’s trust, confidence and hope in our healthcare system and the staff within it. This is different to the parent of a child who has passed away from an incurable illness despite exemplary healthcare. A parent let down by healthcare has specific additional care and support needs that need to be met to help them cope and work towards recovery. Healthcare harm also causes emotional harm to the staff involved In 2000, Albert Wu introduced the phrase ‘second victim’ in an attempt to highlight the emotional effects for staff involved in a medical error and the need for emotional support to help their recovery.[5] The term has recently been criticised, since families should be considered the second victim,[6] and the word victim is believed “incompatible with the safety of patients and the accountability that patients and families expect from healthcare providers.”[7] While the term itself may be antagonistic, or misrepresentative, the sentiment – that staff involved in incidents need support to cope with what has happened, and to give them the confidence to do what is needed to help the patient/family heal – certainly stands. When staff are involved in an incident of patient harm, they may lose trust in their own ability and the systems they work in to keep patients safe, and they may worry about their future.[5],[8] They need care and support in order to recover themselves and, crucially, so that they feel psychologically safe and are fully supported to be open and honest about what has happened. They need to feel able to do this without fearing personal detrimental consequences for being honest, such as unfair blame or a risk to their career. This is essential to the injured patient/family receiving the full and truthful explanations and apologies they need in order to regain trust, confidence and hope, and, ultimately, to heal as best they can. So, in addition to patients and families there should be a ‘care pathway’ for staff involved in incidents of harm. A google search on ‘second victim’ reveals a wealth of research on the emotional effects of medical error for staff involved and the best ways to provide support for this, and this is resulting in the emergence of staff support provision to aid recovery.[9] In contrast, very little research has been done into the emotional effects and support needs of families and patients. How is ‘care’ for emotional harm given? The ‘treatment’ of the emotional harm has been described as ‘making amends’ – by restoring trust, confidence and hope.[4] Once a patient has been harmed by healthcare, every interaction (physical, verbal or written) they have with healthcare after that will either serve to help them heal or to compound the emotional harm already suffered. Trew et al.[10] describe harm from healthcare as a “significant loss” and conclude that “coping after harm in healthcare is a form of grieving and coping with loss”. In their model, harmed patients and families proceed through a ‘trajectory of grief’ before reaching a state of normalisation. Some can move further into a deeper stage of grief and seemingly become stuck in what is referred to as complicated grief. They can display signs of psychiatric conditions "if there are substantial unresolved issues, or where there is unsupportive action on the part of individuals associated with the healthcare system and the harm experience”. At the point of the harmful event, the patient/family experiences losses, including a drop in psychological wellbeing. From this point on, healthcare staff and organisations have opportunities to respond. If the response is supportive it may be helpful for the patient/family in coping with the losses. If the response is not supportive, this may cause ‘second harm’ complicating the healing process, leaving the patient/family with unresolved questions, emotions, anger and trust issues. The patient’s psychological wellbeing and ability to return to normal functioning are severely affected. “Most healthcare organizations have proved, in the past at least, extraordinarily bad at dealing with injured patients, resorting at times, particularly during litigation, to deeply unpleasant tactics of delay and manipulation which seriously compounded the initial problems. My phrase ‘second trauma’ is not just a linguistic device, but an accurate description of what some patients experience.” Charles Vincent[11] There is no shortage of individuals who have suffered extensive ‘second harm’ sharing their experiences in the hope this will lead to better experiences for others and some help for themselves to recover. Many are, wrongly, being ‘written off’ as historical cases that can no longer be looked at. This cannot be right – when these people are suffering and need appropriate responses to heal their wounds. The extent of suffering that exists now, in people who have been affected by both primary trauma and then second harm from uncaring defensive responses, or responses that have not taken into account the information patients and families themselves have, or relevant questions they ask, is no doubt nothing short of scandalous. There is a pressing urgency for the NHS to stop causing secondary trauma to affected patients and families. ‘Patient safety’ has to start applying to the harmed patient and their family members’ safety after an adverse event, and not just focus on preventing a repeat of the event in the future. Yes, future occurrences must be prevented, learning is crucial, but so is holistically ‘looking after’ all those affected by this incident. If they are not looked after, their safety is at risk as their ability to heal is severely compromised; in fact they are in danger of further psychological trauma. These same principles apply to affected staff. Avoiding second harm: what happens now and what is needed? This series of blogs will highlight that every interaction a harmed patient or family member has with staff in healthcare organisations (not just clinical staff) after a safety incident should be considered as ‘delivery of care’. With this view, the ‘care interaction’ should be carried out by someone trained and skilled and supported to do so, with the genuine intention of meeting the patient/families’ needs and aiding the patient/family to recover and heal (restore trust, hope and confidence). The interaction / response must not cause further harm. Stress or suffering, and the content of the interaction, for example a letter, should not have been compromised, as often occurs, by competing priorities of the organisation to the detriment of the patient/family. Thus, these blogs will look at: The processes that occur after an incident of harm (Duty of Candour, incident investigation, complaint, inquest) with the aforementioned focus. The care the patient and family need and the obligation (that ought to exist) to meet that need. Processes that are core to the package of ‘care’ to be provided to the harmed or bereaved and to be delivered by skilled and supported ‘care providers’. The blog series will seek to show that meaningful patient engagement in all of these processes is crucial for restoring trust, confidence and hope; therefore, aiding healing of all groups in the aftermath of harm. “It is important to respect and support the active involvement of patients and their families in seeking explanations and deciding how best they can be helped. Indeed at a time which is often characterised by a breakdown of trust between clinician and patient, the principle of actively involving patients and families becomes even more important.” Vincent and Coulter, 2002[3] It will also consider the additional care and support needs that might need to be met alongside these processes in a holistic package of care, such as peer support, specialist medical harm psychological support and good quality specialist advice and advocacy. It will describe what is currently available and what more is needed if healthcare is to provide adequate care for those affected by medical error in order to give them the best chance of recovery. Alongside this, the needs of the staff involved will also be considered. We welcome opinion and comments from patients, relatives, staff, researchers and patient safety experts on what should be considered when designing three harmed patient care pathways: for patients, families and staff. What is the right approach? What actions should be taken? How can these actions be implemented? What more needs to be done? Join in the discussion and give us your feedback so we can inform the work to design a harmed patient care pathway that, when implemented, will reduce the extra suffering currently (and avoidably) experienced by so many. Comment on this blog below, email us your feedback or start a conversation in the Community. References 1. Leilani Schweitzer. Transparency, compassion, and truth in medical errors. TEDxUniversityofNevada. 12 Feb 2013. 2. Bell SK, Etchegaray JM, Gaufberg E, et al. A multi-stakeholder consensus-driven research agenda for better understanding and supporting the emotional impact of harmful events on patients and families. J Comm J Qual Patient Saf 2018;44(7):424-435. 3. Vincent CA, Coulter A. Patient safety: what about the patient? BMJ Qual Saf 2002;11(1):76-80. 4. Anderson-Wallace M, Shale S. Restoring trust: What is ‘quality’ in the aftermath of healthcare harm? Clin Risk 2014;20(1-2):16-18. 5. Wu AW. Medical error: the second victim: The doctor who makes the mistake needs help too. BMJ 2000;320(7237):726-727. 6. Shorrock S. The real second victims. Humanistic Systems website. 7. Clarkson M, Haskell H, Hemmelgarn C, Skolnik PJ. Editorial: Abandon the term “second victim”. BMJ 2019; 364:l1233. 8. Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care 2009;18(5):325-330. 9. Second victim support for managers website. Yorkshire Quality and Safety Research Group and the Improvement Academy. 10. Trew M, Nettleton S, Flemons W. Harm to Healing – Partnering with Patients Who Have Been Harmed. Canadian Patient Safety Institute 2012. 11. Vincent C. Patient Safety. Second Edition. BMJ Books 2010.

The aorta is the largest artery in the body. Acute dissection occurs when a spontaneous tear allows blood to flow between the layers of the wall of the aorta, which may then rupture with catastrophic consequences. There are about 2,500 cases per year in England, with around 50% of patients dying before they reach a specialist centre for care and 20-30% of patients dying before they reach any hospital. This Healthcare Safety Investigation Branch (HSIB) report highlights the difficulty which can face hospital staff in recognising acute aortic dissection. Although sudden severe chest or back pain is the most common symptom, the picture can vary or mimic other conditions, which may lead to an incorrect diagnosis or delays in recognising a life-threatening condition which needs urgent treatment. Safety recommendations HSIB have made two safety recommendations to help improve the recognition of acute aortic dissection: The first is to add ‘aortic pain’ to the list of possible presenting features included in the triage systems used to prioritise patients attending emergency departments. The second recommends the development of an effective national process to help staff in emergency departments detect and manage this condition.

In the worst moment of your life, what would you need? In 2017, Jen Gilroy-Cheetham’s life changed forever. Just six months after having her second child, she was diagnosed with a rare neuroendocrine tumour and was advised that she would need to undergo open surgery to have half of her stomach removed. Complications led to one of the darkest and scariest times of Jen’s life, as she was put into a hospital ward feeling unwell, vulnerable and unsafe. Now recovered, Jen shares her experiences as a patient from a hospital bed - or audience member - watching all of the healthcare staff around her - actors on a stage - doing everything they could to make her feel safe. In reliving her journey to recovery, Jen highlights what’s needed within a healthcare setting to make patients feel safe. Jen feels that highlighting what’s worked well to help her to feel safe and what needs to change is valuable and may help others in the future.