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Recommendations from the study Just Culture: define an agreed vision of what Just Culture means to the Trust. Investigations: introduce incident management familiarisation training. Learning Culture: increase face-to-face communication of outcomes of investigations and incident review. Investigators: establish an incident investigation team to improve the timeliness and consistency of investigations and the communication and implementation of outcomes.

A high resolution image of the poster with full references can be downloaded by clicking on the attachment below. Organisational culture and patient safety (ver 2) (2).pdf

In 2015 the Government introduced a Freedom to Speak Up Guardian and a system of Local Speak Up Guardians in response to the recommendations made by Sir Robert Frances following the scandal at Mid Staffordshire. From the outset, this system has attracted significant criticism and the APPG has heard from whistleblowers who have been failed by local guardians sharing their experiences that included the disclosure of their identity to hospital management and boards – resulting in retaliation. The APPG has also heard from Local Guardians who were not supported and themselves the target of retaliation after supporting whistleblowers. Local Guardians in East Kent were described as, “dishonest” and that the Guardian system had failed in every case that had been investigated throughout the UK. Further evidence was provided of a tick box approach to the Duty of Candour introduced by the former Secretary of State for Health. The APPG was told that both the Guardian and Duty of Candour systems are beyond resurrection and that across the NHS there is no ownership of problems. All attempts to encourage speaking up have been hindered by a failure to introduce an effective and safe whistleblowing regime across the NHS, resulting in the NHS being unsafe for whistleblowers, making it unsafe for patients. The APPG were told that, in over 50 years of investigation experience, little has changed, and that “these issues are not new, nor are they confined to a small number of rogue hospitals”. That league table results are inaccurate because of a flawed regulatory system with no ownership of the problems and where the regulators are “caught up in the fraud”. The APPG was provided with a series of examples of what were described as “deep seated problems” relating to teamwork and culture, which resulted in the failure to join up clinical and ethical responsibilities. These responsibilities were described as being on separate tracks and a failure by the regulatory regime to identify or report on the impact of this has significant consequences for patients, whistleblowers and the future of the NHS, as demonstrated by the case of the Bristol Children’s Heart scandal brought to light by Dr Steve Bolsin 30 years ago. Dr Bolsin was shunned for exposing the failures that resulted in the death of so many babies because funding the unit was more of a priority that the lives of the babies (he has since made a successful career in Australia). In every case, a failure to listen to whistleblowers, followed by attempts to discredit the whistleblowers, and a deliberate cover up has proved in many cases fatal for patients. What has been proved time and time again is that The Public Interest Disclosure Act (PIDA) has made little or no difference to this failure to protect patients or whistleblowers or to learn and improve our NHS. Evidence provided to the APPG is of a lack of system-wide action and an absence of commitment to speaking up beyond excellent PR. It is unclear who, if anyone, is responsible for the monitoring and reporting on recommendations contained in investigation reports. In addition, there is no coherent process for triggering high-level independent reviews of major patient safety failings. This causes confusion, suffering and leads to missed opportunities. Mary Robinson MP, chair of the APPG for Whistleblowing, said: “We have a duty to support and protect whistleblowers because without them we cannot prevent more deaths like those in East Kent. My APPG is committed to making whistleblowing safe and will continue to press the Government to introduce the Whistleblowing Bill which will incentivise and normalise speaking up. I encourage everyone to write to their MPs and ask them to join the APPG and support the Whistleblowing Bill.” The Right Hon. Baroness Susan Kramer, said: “Doing nothing is not an option that we can afford. It’s time to put an end to ‘tick box culture’ and turning a blind eye to whistleblowers. Whistleblowing law must be meaningful, easily understandable and enforceable. The Whistleblowing Bill will do this and in doing so will save lives and protect our NHS.” Wendy Morden MP, member of the APPG for Whistleblowing, said: “I hear about problems when I am at the hairdresser because people are too afraid to speak up in their place of work. The Office of the Whistleblower will be the catalyst for meaningful change.” Dr Bill Kirkup, author of Reading the Signals Report, said: “I support the proposals set out in the Whistleblowing Bill because the NHS urgently needs an effective early warning system.”

Delphi study participants Participants were from the seven regions identified by NHS England. The study revisited several questions from round one to gather further knowledge and understanding of the responses received. The debrief was not undertaken due to all team members not being present, staff wanting to go home, current culture and list overruns. Key initial findings of Delphi study round two The second round facilitated a broader engagement in the literature, as well highlighting a number of reasons why full compliance has not yet been universally achieved. The Delphi study is intended to be an exploratory approach to inform a more in-depth doctoral research study intended to improve patient safety in the operating theatre, inform policy making and quality improvement. Participants felt that training on the checklist should be mandated and take place annually. They also felt that learning from other organisations was key, and that the NHS needs to revise how the checklist is currently being delivered by being more proactive and by providing the foundations of an electronic checklist to all NHS trusts. Participants felt that a lack of direction from senior NHS leaders and multidisciplinary team working may impact on why the checklist is not always completed. With regard to Local Safety Standard for Invasive Procedures (LocSSIPs) and their introduction, participants either strongly agreed or agreed that NHS trusts must be held accountable for ensuring they are implemented. Participants overwhelmingly felt that surgical fires (non-airway) should be classed as a Never Event. To ensure cyclical learning occurs, details of each and every Never Event should be provided to all NHS Trusts Context of the Delphi study The literature to support a greater understanding of the impact on the implementation of checklist is still emerging. The review to date is not intended to be exhaustive, but begins to frame further questions, identify some of the contextual issues and plan for the third and final Delphi round. The use of a Delphi study was born out of curiosity to see to what the theatre safety experts (matrons, managers and clinical educators) think of the current checklist since its introduction across England thirteen years ago. Contextually it can be anticipated that invasive procedures in the NHS and indeed in healthcare globally will continue to rise, in part as a result of the advancement of new supportive technologies, such as robotics and enhanced minimally invasive approaches. Furthermore, access to these treatments is more readily available to different patient groups whose needs and longer-term rehabilitation can be more complex and demanding. While in this regard clinical outcomes, quality of life, and indeed life expectancy can be improved and extended, this is only the case if surgery takes place within optimum conditions. Taking all other factors into consideration, the number of Never Events continues to remain a constant yet stubborn patient safety concern. Future work - Delphi study round three The author is not yet in a position to draw further conclusions as the final Delphi study round is aiming to draw together the results from the first and second rounds, as well as asking further research questions. In acknowledging that the participant rate was 16%, the study cannot claim to know how other Trusts are utilising the SSC. Given the timing and context in which the Delphi study was carried out, it is appreciated that other priorities could have had an impact on trusts' ability and willingness to participate. Nevertheless, it was perhaps surprising to discover over a decade after the initial launch, that there is a lack of direction/leadership and that lack of multidisciplinary team engagement is still an issue. LocSSIPs 2 are due to launch early in 2023 and in order for this to be successful, training must take place, but most importantly NHS England need to hold trusts to account for not introducing them. A long-standing debate around whether surgical (non-airway) fires should be classified as a Never Event was asked to the theatre safety experts, with an overwhelming response agreeing that this type of event should be added to the reportable Never Event list. The study has also raised questions that will be answered in the third Delphi round.

The report highlights six key themes, identified from discussions and good practice ideas, to help develop a safety culture: Leadership Continuous learning and improvement Measurement and systems Teamwork and communication Psychological safety Inclusion, diversity and narrowing healthcare inequalities It also provides a brief overview of three case studies, with links to full versions of these on the FutureNHS Collaboration Platform.