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In operating theatres and other high pressure clinical environments, clear identification shouldn’t be a nice ‘extra’, it is a patient safety need. When staff cannot quickly recognise names and roles, communication becomes harder, escalation can be delayed and patients are left unsure who is caring for them. Reviews of patient safety repeatedly show that poor teamwork and unclear roles can contribute to avoidable harm. Danielle Checketts, Managing Director of Eco Ninjas, discusses why being able to identify staff by their names and roles is so important not only for the staff themselves but also patients. She explains how a simple idea, reusable hats with detachable name badges that can be removed before laundering, can support safety and teamwork. In theatre, everyone can look the same. Masks, gowns, visors and lead aprons often cover name badges, while lanyards are easily hidden or turned around. Theatre teams include surgeons, anaesthetists, students, agency staff and industry representatives, yet patients and colleagues are still expected to know who is who. When names, roles and seniority are unclear, questions may go to the wrong person, and valuable seconds can be lost. Even when introductions are made during the WHO surgical safety checklist,[1] names and roles can quickly be forgotten once a procedure is underway. In an emergency, it must be immediately clear who is who. This lack of clarity can lead to: Miscommunication at critical moments. Delays in escalation. Reduced patient confidence and psychological safety. Errors due to misunderstood roles or instructions. This isn’t just theoretical. Liz Fitzhugh, net zero lead and former theatre manager at University Hospitals Coventry & Warwickshire (UHCW), put it simply: “If a patient arrests and someone asks for the crash trolley, either everyone goes or no one goes.” In critical moments, teams need to be immediately identifiable so they can act without hesitation. Liz’s team at UHCW were among the first to introduce name and role theatre caps in 2019. It feels fitting that she was also the person who once asked me to write my name on my disposable cap with a marker pen, quietly sparking the idea that grew into this work. For years, poor identification in theatre has become accepted and been treated as normal. But it shouldn’t be. Patients want to know who is caring for them, and staff work more safely when names and roles are clearly visible. That is why the ‘theatre cap challenge’ gained momentum internationally, highlighting a simple idea: if the hat remains visible when wearing sterile attire, it can help make names and roles visible too. Patient perspectives: what matters most Patients consistently say they want to know who is in the room, who is leading their care and who they can turn to for reassurance. Feedback from surgical and maternity care journeys, including caesarean births, shows that visible names and roles help people feel safer, calmer and better able to engage in what is happening around them. Patients describe feeling more reassured when: Staff introduce themselves clearly. Visible names and roles help patients and colleagues remember who is who after introductions, rather than relying on memory alone. There is consistency in communication throughout their care. When identification is unclear, patients can feel anxious and excluded at the point they are most vulnerable. Visible names and roles do more than support courtesy, they strengthen communication, teamwork and reassurance for patients and families. Infection prevention, hygiene and practical constraints Efforts to improve identification must also align with infection prevention standards. Theatre attire cannot simply be adapted without considering contamination risk, laundering processes and the wider pressure to reduce reliance on single use items. The challenge with current approaches The current embroidered theatre caps improve visibility of names and roles, but they are difficult to manage at scale and fail to support consistent identification for all staff. Students, visitors and temporary staff are often excluded, and new starters can wait months before receiving one. They also create ongoing operational challenges, including time-consuming bespoke ordering, poor fit, loss and replacement costs, outdated roles, and complications with laundering. As Alan Dickens, Theatre Manager at MMUH Birmingham, explains: “Bespoke embroidered caps are hard to manage over time. When staff leave or change roles, the hats issued to them often leave with them or need replacing. This creates ongoing cost for the trust and delays in maintaining accurate identification.” Emerging responses across the NHS Several NHS organisations are now testing a more practical approach: reusable hats with detachable name badges that can be removed before laundering. This keeps identification visible while fitting more easily into real hospital systems. In Somerset, a pilot at Musgrove Park showed how a simple change can support safety and teamwork. Mr Andy Stevenson, orthopaedic consultant at Somerset NHS Foundation Trust, said: “In theatre, there can be a really high turnover of colleagues at times, with new people coming and going all the time. This can make it really difficult to know who is who, let alone what jobs they have. Some days, it will be the first time working with half the people in the room. The badge hats have helped to positively transform communication and safety.” A similar message has come from maternity services. Kathryn Harrison, delivery suite manager at Great Western Hospital, said: “Despite staff introducing themselves in the morning, remembering everyone’s name and role throughout the day is challenging, especially when more than 12 people can be in the room at any one time. The badge hats reinforce this critical stage in safe surgery, improve teamwork and communication, and help break down hierarchical barriers. They can be worn by all staff, students, birthing partners and even the patients wear them on our unit”. Building the evidence base There is growing research interest in identification in healthcare.[2][3][4] We have started to work with medical schools on exploring the impact on training environments, role visibility and communication. This is helping to strengthen the evidence base for scalable, system-wide approaches. Students can be included simply using a badge with their name and role alongside a standard fitted hat. Towards integrated, system-based solutions The challenges across current approaches show the need for solutions that fit existing NHS processes, including laundering and distribution, while also identifying temporary staff, visitors and students. The most effective solutions will improve safety without creating new inefficiencies. A call to action Clear identification in healthcare is not optional. It is a practical safety intervention. When people can immediately see names and roles, communication improves, hierarchy softens, patients feel more reassured and teams are better able to act quickly when it matters most. If the NHS is serious about reducing avoidable harm, improving teamwork and strengthening patient experience, visible identification should be part of the solution. Wearing a detachable badge on a reusable theatre cap sounds very simple but this is a small change that can make a very big difference to the safety of patients. References World Health Organization. WHO Surgical Safety Checklist. Kouba LP, Fabi A, Bayer S, et al. Labeled surgical caps improve perioperative patient safety and interprofessional communication in the operating room: a scoping reviewe. Patient Saf Surg, 2026; 20:(9). Liverpool University Hospitals NHS Foundation Trust (LUHFT) and Warwick Med. Case study – Switching to Reusable Theatre Caps. NHS England. Douglas N, Demeduik S, Conlan K. Surgical caps displaying team members' names and roles improve effective communication in the operating room: a pilot study. Patient Saf Surg 2021;15:27. doi: 10.1186/s13037-021-00301-w.

Promoting Learning, Safety, and Improvement in Surgical Teams Team Based Quality Reviews (TBQR) provide a structured, evidence-based approach to team learning in clinical practice. Building on existing processes such as morbidity and mortality (M&M) meetings and significant event analyses, TBQR supports whole-team reflection from the point of an event through to shared learning, meaningful actions, addressing unintended consequences and follow-up for improvement. This one-day course, developed in partnership with NHS Education Scotland, RCSEd and the GMC, equips healthcare professionals with the tools, frameworks, and strategies needed to embed TBQR into clinical practice. Participants will gain practical skills in implementation strategies, analysing events, identifying meaningful actions, and overcoming barriers—such as time, resources, and system alignment. Designed for colleagues leading or interested in safety reviews, or seeking to improve daily work practices, this course provides an opportunity to enhance the understanding, and application of Human Factors and Systems Thinking into practice. It explores how TBQR can be used not only to learn from harm, but also from success, innovation, and complexity in care delivery. This course provides delegates with an opportunity to join a wider network of professionals and learn from areas of good practice across the globe. By supporting collective learning and psychological safety, TBQR strengthens team performance, staff wellbeing, and organisational resilience, ultimately advancing safe, effective, and sustainable healthcare. Target audience: Surgeons and health care professionals leading safety reviews or team based review meetings, including mortality and morbidity meetings. Currently aimed at ST3 onwards but applications are encouraged from interested individuals. Register

Promoting Learning, Safety, and Improvement in Surgical Teams Team Based Quality Reviews (TBQR) provide a structured, evidence-based approach to team learning in clinical practice. Building on existing processes such as morbidity and mortality (M&M) meetings and significant event analyses, TBQR supports whole-team reflection from the point of an event through to shared learning, meaningful actions, addressing unintended consequences and follow-up for improvement. This one-day course, developed in partnership with NHS Education Scotland, RCSEd and the GMC, equips healthcare professionals with the tools, frameworks, and strategies needed to embed TBQR into clinical practice. Participants will gain practical skills in implementation strategies, analysing events, identifying meaningful actions, and overcoming barriers—such as time, resources, and system alignment. Designed for colleagues leading or interested in safety reviews, or seeking to improve daily work practices, this course provides an opportunity to enhance the understanding, and application of Human Factors and Systems Thinking into practice. It explores how TBQR can be used not only to learn from harm, but also from success, innovation, and complexity in care delivery. This course provides delegates with an opportunity to join a wider network of professionals and learn from areas of good practice across the globe. By supporting collective learning and psychological safety, TBQR strengthens team performance, staff wellbeing, and organisational resilience, ultimately advancing safe, effective, and sustainable healthcare. Target audience: Surgeons and health care professionals leading safety reviews or team based review meetings, including mortality and morbidity meetings. Currently aimed at ST3 onwards but applications are encouraged from interested individuals. Register

In this podcast episode, hosts Liz Jones and Darren Kilroy from RLDatix speak to Helen Hughes from Patient Safety Learning about how people, technology, and healthcare come together to create great experiences and support patient safety. The Connection: Where Tech Meets Humanity in Healthcare, is a podcast series from RLDatix, which explores the intersection of technology and human-centred care with the health and care sector. Key talking points from the conversation include: the true scope of patient safety why healthcare leaders must prioritise patient safety how to make patient safety everyone's job essential principles for electronic patient record system implementation.

On Friday 27 September 2024, Patient Safety Learning held its first Patient Safety Symposium, organised with the Patient Safety Management Network and Patient Safety Education Network. This blog provides an overview of the event, which focused on the application of Patient Safety Incident Response Framework (PSIRF) tools and methods.  Background First introduced in Autumn 2023, PSRIF is the new NHS approach to investigating patient safety incidents. At the core of this is the promotion of systems-based approaches for learning from incidents rather than methods that assume simple, linear identification of a single cause. If implemented effectively, these approaches can help us gain a clearer understanding of the causal factors of harm and lead to safety improvements. However, they also represent a complex innovation in the NHS’s approach to incident investigation, requiring appropriate training and support for those implementing them. How to use systems-based approaches to investigations promoted by PSIRF are regular topics of discussion at two of the biggest peer-support networks hosted by the hub: Patient Safety Management Network (PSMN) – this is an innovative network for patient safety managers and everyone working in patient safety. In just over three years this has grown to now over 1700 members. Patient Safety Education Network (PSEN) – a peer network for those in patient safety education and training roles with over 450 members. These networks provide a shared space to discuss new policies that impact their work, and to share knowledge and resources with their peers. A recurring theme that often emerges from these discussions is an appetite for more practical opportunities to learn about these new systems-based approaches to investigation. Planning the symposium Building on conversations in the Networks, we began planning earlier this year for a new event focused on implementing PSIRF tools and methods. Patient Safety Learning, working with Claire Cox (Chair of the PSMN), Chris Elston (Chair of the PSEN) began planning a symposium that would: Allow members of the Networks from different parts of the country, in different health settings, both inside and outside the NHS, to explore these issues in person. Help to increase understanding and discover the practical application of two of these approaches: Systems Engineering Initiative for Patient Safety (SEIPS) and AcciMaps. Help assess the value of case study based interactive training and the potential for future symposiums. Helping to bring this event to life, the medical technology company BD kindly agreed to host this at their Safety and Innovation Hub in Winnersh, Berkshire. This enabled us to hold the event for free, with members of the PSMN and PSEN invited to attend. Kicking off the day The event was opened with a short set of introductions by: Helen Hughes – Chief Executive of Patient Safety Learning Tracey Herlihey – Deputy Director of Patient Safety (Digital) at NHS England Claire Cox – Chair of the Patient Safety Management Network Tracey Herlihey, previously Head of Patient Safety Incident Response Policy at NHS England when PSIRF was introduced, reflected on how the framework had evolved over the past couple of years. She noted positive signs that PSIRF’s introduction had enabled people in different roles to start to talk more openly about patient safety incidents. This is particularly important as different roles can bring different perspectives on how to use PSIRF tools, allowing us to learn from each other. She also emphasised the real power and value of events such as this symposium, where people can be brought together to discuss how best to make PSIRF work for patient safety improvement. Before going into the day, all attendees were asked to follow a simple set of rules, based on how the PSMN and PSEN operate: Speak in plain English, no acronyms. Introduce yourself by your name and your place of work – no job titles, a flattened hierarchy where all voices are valued. Provide a safe space to ask questions/peer support. Feel free to network, make connections and steal ideas. These introductions were followed by a short icebreaking activity, before attendees headed into their first workshop of the day. Workshop 1: AcciMaps The first workshop began with a session on the history and principles of AcciMaps from Professor Mark Sujan. Mark is a Chartered Ergonomist and Human Factors specialist and has worked in patient safety and other safety critical industries for over 25 years. He is also Senior Science Investigation Educator at the Health Services Safety Investigations Body. Accimaps, or Accident Mapping, is a tool initially developed by Jens Rasmussen. Applied in patient safety, it involves creating a graphical presentation of factors within a system that contribute to the occurrence of a patient safety incident. These factors are arranged into a series of levels representing different parts of the system that the event took place in: Government policy and budgeting. Regulatory bodies and associations. Local area government planning and budgeting. Company planning. Physical processes and actor activities. Equipment and surroundings. Mark’s key reflection that resonated with many symposium participants was of the value of a different mindset in incident investigation, not just about the application of the tools such as Accimaps. Following Mark’s insightful and informative presentation, attendees were split into groups at tables and provided with a scenario of a patient safety incident that needed to be investigated. Though fictional, this was drawn from aspects of previous real-life cases. Each table was asked to consider the issues and produced their own AcciMap. Reflecting on this exercise, some key thoughts from attendees included: This approach could help to gain a viewpoint of the ‘bigger picture’ in which an incident occurs; it’s most definitely a reflection of the system in which an incident occurs and not just looking at the ‘people factors.’ There were some significant differences in the causal factors identified by different groups, reflecting the mix of expertise and roles in the room. This reinforced the value of a team-based approach to applying Accimaps and the value of educational events, working through simulations to inform learning and application. The value of using debriefing techniques in healthcare alongside this, and building this into the wider organisational culture—not just when incidents occur. Also taking an appreciative inquiry approach, looking for what went well within the scenario. Other systems-based approaches that could work alongside this, such as After Action Reviews and Swarm Huddles. Lunch break and escape room During the lunch break, attendees had the opportunity to participate in two patient safety ‘escape rooms’ in the BD Safety and Innovation Centre simulation suite, set up as a hazard identification exercise. Participants assessed the hazards in a community based setting and another in a hospital environment. This was a fun approach to a serious set of issues that generated much discussion. There was also an opportunity for patients to purchase a copy of a new book, Patient Safety: Emerging Applications of Safety Science, from Class Professional Publishing. This book brings together contributors from a variety of academic and healthcare professions, alongside those with lived experience, to help understand some of the emerging theories of safety science and their practical application. It is written by people who work in patient safety, including members of the PSMN and PSEN who were in attendance at the symposium. Workshop 2: SEIPS The afternoon workshop kicked off with an introduction to SEIPS by Nikki Fountain, Network member and Business Manager to the Chief Medical Officer at Great Ormond Street Hospital for Children NHS Foundation Trust. The symposium attendees were asked to carry out a SEIPS analysis after being shown a short video that illustrated a simulation of a routine and normal work scenario—taking blood in an ill-suited work environment. SEIPS is a framework for understanding outcomes within complex socio-technical systems. It is a conceptual tool that depicts the interactions between three key components: work system, process and outcomes. Patient safety incidents result from multiple interactions between work system factors. SEIPS prompts you to look for interactions rather than simple linear cause and effect relationships. Following Nikki’s introduction, attendees were split into groups at tables again and asked to carry out a SEIPS analysis of the scenario they had watched. Chris, Claire and Helen enjoyed creating the video although no acting awards are likely to be awarded! Reflecting on this exercise, some key thoughts from attendees included: While there were elements of good teamwork in the scenario, there was a notable trend of staff not recognising other colleagues becoming gradually overwhelmed. While nothing went ‘wrong’ in this scenario, the patient received the treatment required, observation showed that both the patient and staff member had a negative experience and there were potential risks in handling and supply of samples that could lead to problems. There were areas where there may be obvious quick fixes to put in place, but the challenge would be to make these sustainable under normal work pressures. There was a conversation about how patients could be involved in SEIPS style analysis, and how this would work in practice. Some reflections of SEIPS being used individually at trusts, when this is perhaps more effective as a group tool. End of day reflections Concluding the day, attendees reconvened in the main meeting space and shared reflections on the event, which included the following points: Great to have such a diverse range of participants at this event. One table featured student nurses, a representative from NHS England, a GP and a senior director from an independent trust. This was a genuine and much valued flattened hierarchy that enabled confident engagement and shared learning. You don’t need to wait for a safety incident to use these tools for safety improvement. Everyone can make a valuable contribution to patient safety discussions, both those in clinical and non-clinical roles. Different types of expertise are greater than the sum of the parts when pooled together. Appetite to see more system leaders/decision makers in the room for these type of events to underline the commitment to transforming how we approach incident investigation in trusts. Following the event we asked attendees to complete a short feedback form offering their reflections on the day. When asked what was their key takeaway learning, answers included: “The timeliness of utilisation of various tools, and the need to be aware of perceptions affecting the outputs from using the tools and the need for a multi-disciplinary approach.” “Mindset over method. Diversifying thinking. Accimapping for improvement rather than for incidents.” “Networking empowers. Great to hear that other organisations are struggling with similar issues, that proves that we are on a journey to change the safety culture.” “We're all in the same boat, it was great to hear how other organisations are embedding some of the learning tools.” “Thinking about the different tools being part of your learning response toolkit and that it's not either/or...you may want to use more than one tool and the same incident - different ways of looking at what happens and there is no one way or right way.” We also asked attendees if there were any PSIRF tools or approaches they would be more likely to implement at their organisation after attending this event. Responses included both Accimaps and SEIPs, the subject of both workshops, but also SWARM huddles which were discussed at several points across the day. Other general reflections from attendees included: “Really useful to have a space and down time for reflection, thinking and learning with and from peers. Great that the schedule was generous with time and only had 2 sessions and lengthy breaks to enable this.” “It was truly wonderful, so well thought out so engaging. Attending on my own and having table already mapped out was brilliant. The interaction. The lunchtime escape rooms and the ice breaker. Such a great networking opportunity. The best meeting in this field ever.” “Love the honesty in the room and sharing.” “It was an excellent networking opportunity, and I have since been in contact with a new peer. We have shared our current PSII reports and provided a critical friend approach to each other.” “A wonderful opportunity to network and learn from each other, really well considered agenda, and fabulous presenting. Felt like a family as we know each other virtually. The informal 'ness' of the setting allowed us to really network and get to discuss key issues we face. I really enjoyed listening and learning from the experts.” How to join a hub network You can join by signing up to the hub today. When putting in your details, please tick the relevant Network in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected]. The founders of each group have set the following criteria for who can join: Patient Safety Management Network – UK hub members in a health or care service provider organisation who have an active patient safety role. National NatSSIP Network – UK hub members involved in or leading NatSSIP/LocSSIP work in their organisation. Patient Safety Partner Network – UK hub members in a health or care service provider organisation who volunteer officially as a Patient Safety Partner. Patient Safety Education Network – UK hub members involved in patient safety education/ training in their organisations. The community excludes commercial training providers. Patient Safety Paediatric Leaders Network – UK hub members who are strategic-level decision makers in a specialist children’s hospital or unit with a leadership responsibility for patient safety and/or quality. You should have a role that reports to a member of the Executive and have been nominated by your CMO or CNO, and are committed to reducing avoidable harm and improving the quality and safety of paediatric care.

In this blog, Patient Safety Learning's Content and Engagement Manager, Stephanie O'Donohue highlights some of the common barriers to collaborating for safety. She argues that we need time and space to listen and build trust between different groups if we are to really harness the power of collective insight and make safety improvements.  When I joined Patient Safety Learning in 2019 I was shocked to discover there are 11,000 preventable deaths each year in the UK due to unsafe care. And deaths of course are not the only measure of harm. Unsafe care can also leave patients with chronic pain, psychological trauma, permanent damage and life-limiting repercussions. My role includes proactively seeking opportunities to engage, collaborate, listen and create content that will help to influence positive change around key safety issues. I work with patients, researchers, clinicians, charities, healthcare leaders and families who have an interest in patient safety and reducing harm in healthcare. It is always a privilege speaking to such a range of people driven by a desire to improve outcomes. Comms people like me often focus on making sure their content connects with key stakeholders, but my work has increasingly become about connecting stakeholders with one another. I mean this in both the traditional sense of introductions and also in the way I facilitate and create content. Because when it comes to those involved in patient safety, it has become clear to me that you are destined to fail if you don’t collaborate. If key voices are missing from around the table, your solutions will never be as whole or effective as they could be. So why doesn’t it happen more? Why don’t patients, frontline staff, decision makers and researchers just work together to approach safety issues with combined wisdom and insight? 5 common barriers to collaborative working in patient safety Defensiveness When patients, relatives and campaigning organisations seek answers and to share their experiences and insights around safety, they are too often met by a wall of defensiveness. Most of the time, these people are reaching out trying to help the system prevent harm from occurring. They are offering their time and input; it should be welcomed. If the response to this is to dismiss, deny or shut them out, their desire to work with the system can be replaced by a new sense of anger, frustration and injustice. Anger If people are consistently shut out of key and central conversations around patient safety of course they will become distrusting of the system, of course they will want to advocate loudly given any opportunity, of course they will want to call out the treatment they have had. This can influence the ferocity with which people engage with leaders and clinicians via public channels like podcasts, online conferences and social media. Unfortunately, this can reinforce a fear of inviting people in, even among those clinicians who want to hear from patients and be informed by lived experience. Lack of time Even when patients, clinicians and others do manage to come together, time often constrains the effectiveness of conversation. There is little opportunity to provide background, introduce individuals fully, understand their experiences and motivations, and establish shared aims. Lack of time to communicate and connect at the start of a collaboration can create very rocky foundations for what should essentially become a ‘team’. Fear We know from the NHS survey that many staff still do not feel safe to speak up when they have concerns. While other industries actively promote and welcome individual insights and wider conversations around risk and system safety, healthcare lags behind with individuals fearful to talk openly about avoidable harm or to share learning when things have gone wrong. Leaders need to walk the walk when it comes to sharing failures with candour, taking action to prevent future harm and developing a culture where staff feel safe raising concerns that, if acted on, could be life-saving. Strong and respectful lines of communication between the frontline and leaders have to exist to make sure no one is frightened to speak up for safety, and valuable insights do not get ignored. Leaders should also be consistently modelling and evidencing the value of patient engagement for safety, so that frontline staff feel inspired and safe to follow their lead. Absence of proactive engagement At Patient Safety Learning we do a lot of proactive engagement work. Because we understand the value of the insights and knowledge that exist outside of our team. And honestly, it’s not difficult. People respond really well to being approached in this way – often commenting on how refreshing it is to be invited in and to be heard. It shouldn’t be refreshing though, reaching out to those who have expertise outside of your organisation should be a given. The healthcare system should be investing time in actively seeking out and contacting researchers, patients and campaigners who can help them understand the bigger picture when it comes to patient safety issues. And not just when harm or inequality has been highlighted. It needs to be interwoven as a preventative measure, a way to manage risk. 4 ways to support collaboration in patient safety Make space for each other We all know resources are stretched but collaborating for patient safety takes time. Making time to listen to a patient’s experience is important. You may need to listen several times because that is part of making space for people at the table and being reminded that the human impact should be core to any safety project. Listening will help you understand motivation and any anger present, and respond with compassion and hopefully a desire to make a difference. Listening to the clinical perspective is equally important, we need to allow time to ask questions, translate medical terminology into plain English and for clinicians to explain the challenges they face in delivering safe care. Keep an open mind Constantly being dismissed by the healthcare system as a patient or campaigner can take its toll on your trust of individuals. But to move forward, an open mind is needed because there are people who will share your aims, motivations and are equally driven to help. Just as the system needs to let people in, those who have been harmed by unacceptable past interactions need to be open to those who genuinely want to collaborate moving forward. Not always easy to rebuild that faith but it opens up more opportunity for progress. Be curious Asking questions is one of the most powerful communication tools. It shows respect, interest and a desire to learn from others - three key components of good collaboration. If you want to know what the barriers are to someone implementing change – ask. If you want to know how an experience made someone feel – ask. If you want to know what each person in the room wants to achieve – ask. If you want to know how you can help – ask. If you’re not asking anyone any questions – ask yourself why! Invite people Use your channels to start conversations and ask people to share their insights at the beginning of any project. You will never have all the answers (and be wary if you think you do), reaching out to others will give you more of a chance of finding them. My reflections come from a communication perspective and from witnessing the power of collaboration when people come together for safety. We need everyone to speak up for safety but, more importantly perhaps, we need to acknowledge the time and space that is needed to really listen to each other.

This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the Independent Investigation into East Kent Maternity services. The investigation into maternity and neonatal services at East Kent Hospitals NHS Foundation Trust revealed a series of serious patient safety failings between 2009 and 2020, which resulted in avoidable harm to patients and deaths. In its formal report, published on the 19 October 2022, it stated that if nationally recognised standards had been followed, the outcome could have been different in 97 of the 202 cases reviewed. At the beginning of its response to the Investigation and its recommendations, the Government states that at a national level, the Minister for Mental Health and Women’s Health Strategy will chair a newly created maternity and neonatal care national oversight group. This will bring together the key people from the NHS and other organisations, including the CQC and HSIB, to look across maternity and neonatal improvement programmes and the implementation of recommendations from this and other maternity reviews, to ensure a joined-up and effective approach. Summary of the Government response to each of the recommendations Recommendation – The prompt establishment of a Task Force with appropriate membership to drive the introduction of valid maternity and neonatal outcome measures capable of differentiating signals among noise to display significant trends and outliers, for mandatory national use. NHS England (NHSE) has established a Reading the Signals Data Co-ordination Group, referred to in this report as the co-ordination group, who will bring together a series of data projects which aim to make sure the right data will be used in the right way to identify and support trusts who may be vulnerable to bad outcomes. NHSE have also formed a Maternity and Neonatal Outcomes Group, acting as a task force in response to the recommendation in the East Kent report. Chaired by Dr Edile Murdoch, this group has met and is progressing work towards the identification of outcome measures that will, as this recommendation states, differentiate signals among noise to display significant trends and outliers. Recommendation – Those responsible for undergraduate, postgraduate and continuing clinical education be commissioned to report on how compassionate care can best be embedded into practice and sustained through lifelong learning. Department of Health and Social Care (DHSC) will lead the response to this recommendation in a central coordination role involving relevant national partners, closely supported by NHSE. It will coordinate activity to: Map how compassionate care is currently being taught at all levels and across professions, whether this be formally or as part of in practice training. Share good practice and examples of how barriers have been overcome with all those responsible for training, from higher education institutions to those providing preceptorship and clinical supervision at trust level, on the embedding of compassionate care. Identify where gaps depend on national level change or coordination and work with relevant bodies or other government departments to consider how these could be addressed. This will also consider how the government, NHSE and other arm’s length bodies can influence and support sustainable system level change. Recommendation – Relevant bodies, including Royal Colleges, professional regulators and employers, be commissioned to report on how the oversight and direction of clinicians can be improved, with nationally agreed standards of professional behaviour and appropriate sanctions for non-compliance. DHSC will lead the response to this recommendation, in a central coordination role looking across the whole system. This work will be supported closely by NHSE. It will coordinate activity to: Map current responsibilities around oversight and direction. Share good practice and learning on proposed solutions to address gaps in roles and responsibilities in oversight and direction, and support for managing concerns about practice. Identify where gaps in oversight depend on national level change or coordination and work with relevant bodies or other government departments to consider addressing these. This will include examination of where regulators could contribute to identification of poorly performing trusts. Recommendation – Relevant bodies, including the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives and the Royal College of Paediatrics and Child Health, be charged with reporting on how teamworking in maternity and neonatal care can be improved, with particular reference to establishing common purpose, objectives and training from the outset. DHSC will lead the response to this recommendation in a central coordination role, with the close support of NHSE. It will coordinating reports that will: Provide evidence through experience and examine existing research on how and where teamwork is being done well. Bring together examples of good practice to support trusts and all those supporting teamwork to utilise as a resource of solutions to barriers and identified gaps. Consider whether, where gaps and barriers are identified, relevant bodies or government can support solutions. Recommendation – Relevant bodies, including Health Education England, Royal Colleges and employers, be commissioned to report on the employment and training of junior doctors to improve support, teamworking and development. DHSC will lead the response to this recommendation and be supported closely by NHSE. It will coordinate reports that will: Map how the support for junior doctors, and those who have yet to complete training including locums, is translated into practice, what access they have to development and how teamwork is embedded within this. Identify and share good practice and learning around proposed solutions to address gaps in roles and responsibilities for supervision for specific groups. Consider whether the government and its arm’s length bodies (ALBs) need to provide support to the system to address gaps and barriers. Recommendation –The Government reconsider bringing forward a bill placing a duty on public bodies not to deny, deflect and conceal information from families and other bodies. Recommendation – Trusts be required to review their approach to reputation management and to ensuring there is proper representation of maternity care on their boards. Recommendation – NHSE reconsider its approach to poorly performing trusts, with particular reference to leadership. The Government has provided one response to the above three recommendations which includes the following points: The government acknowledges the failure to adhere to this duty of candour that was so evident in this report and recognises the need for action in this area in order to make sure the duty is effectively applied and to create a culture of candour throughout organisations. When considering the broader recommendation made by Dr Kirkup for a bill to place a “duty on public bodies not to deny, deflect and conceal information from families and other bodies”, the government will set out its position in response to Bishop James Jones’ 2017 report on the experiences of the families bereaved by the Hillsborough disaster in due course. To help monitor when reputation management is superseding transparency of trust boards, the CQC, as part of its new inspections approach, will continue to consider trust leadership at executive team and trust board level as part of its key lines of enquiry, using the well led framework. In the 2023 to 2024 financial year, NHSE is commissioning a support programme for board safety champions to focus on developing the leadership, culture and processes needed for them and their teams to be able to use qualitative and quantitative data to improve maternity and neonatal safety in their organisations. Recommendation – The Trust accept the reality of these findings; acknowledge in full the unnecessary harm that has been caused; and embark on a restorative process addressing the problems identified, in partnership with families, publicly and with external input. In their response the Government note the actions that the Trust has taken following the publication of the report on the 19 October 2022, including that specific improvements in maternity and neonatology services will be overseen by a maternity and neonatal assurance group, reporting to the Trust’s board. Related reading 'Reading the signals': Maternity and neonatal services in East Kent – the Report of the Independent Investigation (19 October 2022) Prevention of Future Deaths Report: Harry Richford (3 February 2020) Patient Safety Learning: Will lessons be learned? An analysis of the systemic failures in the East Kent Maternity report (17 November 2022)

Marsha Jadoonanan, nurse and Head of Patient Safety and Learning at HCA Healthcare UK (HCA UK), spoke to us about a recent opportunity to learn from patient safety incidents involving wrong site anaesthetic blocks. She describes the new learning approach she and her colleagues used, which focused on engaging staff working in a variety of roles to create a safe space to focus on identifying ‘work as done’.

This one day virtual masterclass facilitated by Mr Perbinder Grewal, will focus on how to deal with difficult people. Do you have someone at work who consistently triggers you? Doesn’t listen? Takes credit for work you’ve done? Wastes your time with trivial issues? Acts like a know-it-all? Can only talk about themselves? Constantly criticises? We will discuss strategies and tools to improve communication and interactions with others. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/how-to-deal-with-difficult-people or email [email protected]. hub members receive a 20% discount. Email [email protected] for discount code.

Difficult conversations - Thursday 2nd February 2023 Difficult people - Tuesday 7th February 2023 Conflict management - Wednesday 15th February 2023 This 3 day intensive training course will provide an effective guide to improving your communication skills. With each day focusing on difficult conversations, managing difficult people, and conflict and conflict resolution the course will empower you with the skills to deal with difficult issues and difficult situations within your everyday practice. Day 1 - how to deal with and manage difficult conversations. With a focus on telephone and virtual consultations with patients this masterclass focuses on dealing with difficult conversations, The event will focus on speaking to patients in distress, understanding where patient safety issues arise, and managing unhappy patients and complaints. It will discuss strategies and tools to improve communication and interactions. Day 2 - how to with difficult people. Do you have someone at work who consistently triggers you? Doesn’t listen? Takes credit for work you’ve done? Wastes your time with trivial issues? Acts like a know-it-all? Can only talk about themselves? Constantly criticises? It will discuss strategies and tools to improve communication and interactions with others. Day 3 - conflict from how to manage different types of conflict through to conflict resolution This course is aimed at all healthcare staff from frontline staff through to senior managers in dealing with conflict with colleagues, staff, clients and patients. Further information and registration

The new NHS Patient Safety Syllabus has brought education and training to the fore to push patient safety in healthcare. Based on the syllabus this masterclass will focus on how Human Factors and Red Teams can be improve Patient Safety. Red Teams are defined as a team that is formed with the objective of subjecting an organisation’s plans, programmes, ideas and assumptions to rigorous analysis and challenge. We will look at the use of Red Teaming taken from the Ministry of Defence for supporting staff and teams faced with different problems and challenges in healthcare. For further information and to book your place visit www.healthcareconferencesuk.co.uk/conferences-masterclasses/red-teams-patient-safety or email [email protected] hub members can receive a 20% discount. Email [email protected] for discount code.

This virtual masterclass, facilitated by Mr Perbinder Grewal, will guide you in how to use Human Factors in your workplace. All medical and non-medical staff should attend. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. It can be used to assess why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. Perbinder Grewal is a Consultant Surgeon. He is a human factors and patient safety trainer. He leads on medical education both locally and nationally. He is a Member of the Faculty of Surgical Trainers at the Royal College of Surgeons of Edinburgh. He has a passion for training and medical education. He is a Module Tutor for the ChM in Vascular Surgery for the University of Edinburgh and Tutor for the ChM in General Surgery for the past 5 years. He has Postgraduate Certificates in Leadership and Coaching. Register

Throughout the COVID-19 pandemic health and care staff have been working in different ways and designing new ways to meet the needs of patients and service users, all while under a huge amount of pressure. This event from the King's Fund will take a look at some examples of those changes and how people working in health and care have been working remotely, flexibly and in an agile way to meet the demands created by the pandemic and to develop new and improved ways of working for the future. Sign up now to hear about: the role of visible, collaborative and inclusive leadership to support staff and allow innovation how to keep staff health and wellbeing a priority while also delivering change how teams across health and care were able to be upskilled and remain flexible for these new ways of working. Register