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“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.

Implications While this study shows that those referring patients to ICU could benefit from greater support, the decision support tool trialled in this study would need some adaptation to fit the time-pressured realities of the users. The process did seem to help clinicians articulate and communicate their reasoning for admission. Perhaps, as the authors say, if the tool were to be integrated into existing systems the perceived additional workload may be diminished. Another not insignificant finding is that although clinicians stated they valued patient’s wishes, in some cases there was a lack of patient and family involvement.

In this book, you will read stories illustrating the experiences of doctors, nurses and administrators who learned to use PROPEL to transform their professional life (and, for many, their personal life as well). You will learn how they were able to attain remarkable results with their teams, units and clinics: Wait times for chemotherapy infusion reduced 6 hours Staff turnover dropped 80% Paediatric MRI scheduling driven down from 14 weeks to 10 days Bone marrow transplant procedures increased by 50% Emergency department diversion due to psychiatric patient boarding virtually eliminated Patient fall rate cut by 70% Use of agency and travellers nurses abolished Patient satisfaction scores up 50%. The cumulative impact to the bottom line has been calculated to be millions of dollars. The most meaningful measure of PROPEL’s success, however, comes from the thousands of dedicated professionals who have expressed heartfelt gratitude for having learned how to recapture their joy for working in healthcare.

This guide from the US Betsy Lehman Center for Patient Safety was created to help organisations include the voices of those who use the healthcare system in their work and advisory groups including: expert panels, quality improvement committees, task forces, and Patient and Family Advisory Councils. The Six Essential Elements in this guide were gleaned from a number of reputable sources, as well as from recent experiences by the Betsy Lehman Center, including members of the public in our expert panels and other convening activities.

I am an avid fan of the show, Silent Witness; pathologists trying to find out how someone was killed just from the body. The deceased is the only witness to what actually happened. So, by looking at the surroundings is the only way of determining what might have happened. I also love watching 24 Hours in Police Custody. This is where they interview the person directly involved in the incident, the people around the time of the incident and the person who potentially did the crime: questioning, piecing together exactly what happened using statements, CCTV footage, verbal accounts of everyone involved. The art and science of investigation is clear. The experience and knowledge of the investigators is quite remarkable. Investigation in healthcare doesn’t seem to work like this. I am a newly qualified nurse. I have been qualified just over a year now. I reported my first Datix last month. I took over the care of a patient from a colleague. I was coming on to a night shift. My patient looked very unwell. I took his observations. He was scoring a 9 on the NEWS2. I put a medical emergency call out. Everyone came, they got him a bit better. They decided he was not going to do well as he was frail and had many comorbidities, they decided to keep him on the ward and if he deteriorated further, he was for palliation. I was pleased I had a plan for him, but I noticed that he didn’t have any observations taken for over 12 hours previously. So, I reported it as a Datix. I marked it as a serious incident. I was worried when I reported it as I didn’t know what to expect. When would someone from the investigation team come and see me? Would I have to write a statement? When would I get interviewed? Will I get into trouble? I waited. The patient passed away peacefully. I forgot all about the report I had made. Six weeks later I received an email. The investigation had taken place. But I wasn’t included. No one had asked me how I had found the problem, the circumstances around the problem or even asked me to be involved. Why? I’m not trained in investigation, but surely being directly involved in an incident I would be asked what had happened and be included in their investigation? The email I received was to inform me of the outcome. ‘’Lessons learnt - Always follow the policies regarding the observation, statement taken from staff involved, practice educator involved with training.’’ I didn’t give a statement. The member of staff who didn’t do the observations made a statement, but not me. The investigation was also ‘downgraded’. What does it take to be a serious incident? This man had no observations for over 12 hours while unwell in hospital. He deteriorated and it wasn’t recognised. I think this is serious. Have others who have worked in healthcare become immune to the seriousness of incidents? As for the lessons learned; what are these lessons? Telling people to do tasks isn’t good enough. I can’t help thinking that healthcare hasn’t got this process right. Is this the same for other hospitals?

On a couple of occasions when myself or other key listeners have been in the process of supporting staff in the SISOS calm zone, there has been a knock on the door. This knock speaks far louder than you or I ever could. The knock in it’s intensity says, "I disapprove". These occasions are rare but they do happen. One comment I overheard was, "if you can’t take the heat you shouldn’t be here". My answer to this attitude is onwards and upwards. The location of the room is in it’s favour because it isn’t isolated and is easily accessible without the need to change into or out of scrubs. This makes it available to other departments and also to the support staff, such as chaplaincy who visit us fairly frequently when we request. This clearly has had a positive effect on take-up. The room itself is simply furnished and is in sharp contrast to the clinical environment. A small windowless store room, triangular in shape, has been transformed into a sanctuary of calm and psychological safety. The makeover consisted of a woodland scene wall mural, a Himalayan salt lamp, a reclining chair, a small side table, a coffee table and two regular chairs. I’m frequently asked, "Can we use the calm zone as a prayer room?" The answer is yes, because we must aim to support staff in their working environment and, provided one group or another doesn’t claim the room as their own, then why not? None of us can know what someone else’s journey has been like. When we put on our shoes and leave our homes to come to work we also put on our professional fronts often masking our private lives. This became very apparent to me in the first week and is shaping how the framework for SISOS is evolving and the breadth of support we are now providing. Originally set up to provide emotional support for staff centrally or peripherally involved in safety incidents, we recognised that these incidents are fortunately rare. However, you don’t need to be involved in an incident to be affected emotionally and most of our take-up is supporting staff for none-incident related events. We had one such event recently that affected a large number of our staff because of the circumstances and the age of the patient. Following this event, myself and another 'key listener' were relieved of our clinical duties and we were able to provide emotional support over a couple of days. This put our model to the test and I'm pleased to say it passed. These are work-related events. The other side to take-up involves staff who are distressed because of none-work related issues. We deal with this by signposting staff to other support structures, such as our Employees Assistance programme and our mental health First Aiders Hub. What we discovered was staff were not prepared to accept SISOS simply as a support for ‘second victims’. They demonstrated a need for other kinds of support, such as domestic abuse, money worries, bullying, and they wanted support for these issues. They weren’t prepared to differentiate. We have developed other pathways to support staff holistically. Staff come to us at a rate of approximately three per week (theatre department) requesting a ‘SISOS’ – meaning, I need to talk, and that can be on any topic. The anonymity SISOS provides, because of the confidentiality and trust, is impacting favourably and staff are opening up. Patients too. Our badge wearing listeners have attracted the attention of several patients who have felt safe enough to open up about domestic abuse. The SISOS team have supported three such patients and have taken advantage of that small window of opportunity to hopefully help them to change their lives for the better. SISOS is now part of a broader staff support model at Chase Farm Hospital and we are working on various new arms for it, including a student nurse support arm. This happened directly as a result of a student nurse needing support out of university hours after witnessing a distressing event. Read my other blogs on SISOS: Part one Part two Part three If you are thinking about setting up a similar initiative in your trust, I would be happy to discuss SISOS further with you. Contact: carolmenashy@nhs.net