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Found 313 results
  1. Content Article
    In this episode, we hear from Sue Allison who blew the whistle on a Senior Radiologist within her department who repeatedly failed to diagnose women who had breast cancer at NHS Morecambe Bay Trust. She explains her battle to overturn her NDA at employment tribunal and the ‘insidious bullying’ that followed after blowing the whistle on concerns about patient safety. She is joined by Samantha Prosser an experienced employment law litigator from BDBF LLP who has specialist experience in advising private and NHS consultants from leading hospitals on private and NHS whistleblowing and discrimination claims.
  2. News Article
    Norah Bassett was hours old when she died in 2019, after multiple failings in her care. What can be learned from her heartbreaking loss? The maternity unit at the Royal Hampshire county hospital in Winchester was busy the evening when Charlotte Bassett gave birth. When the night shift came on duty, a midwife introduced. “She was very brusque,” Charlotte, 37, a data manager, remembers. “She said, ‘We’ve got too many people here. I’ve got this and this to do.’” Charlotte tried to breastfeed Norah, but she wasn’t latching. The midwife told Charlotte to cup feed her with formula. She didn’t stay to watch. Charlotte poured milk from a cup into Norah’s rosebud mouth. Blood came out. It was staining the muslin. The midwife didn’t seem concerned. “I was drowning my child, who was drowning in her own blood. And there was no one there to say: this isn’t normal,” Charlotte says. The Health Services Safety Investigations Body (now HSSIB but at the time known as HSIB), which investigates patient safety in English hospitals, produced a report into Norah’s care in 2020. One sentence leaped out to Charlotte and her husband James. “An upper airway event (such as occlusion of the baby’s airway during skin-to-skin) may have contributed to the baby’s collapse.” In other words, it was possible that Charlotte might have smothered her daughter. “So Charlotte spent four years in agony,” says James, “thinking it was her.” Dr Martyn Pitman remembers the night Norah died, because it was unusual. A crash call, for a baby born to a low-risk mother. It played on his mind, because eight days earlier, on 4 April 2019, Pitman, a consultant obstetrician and gynaecologist, had presented proposals for enhanced foetal monitoring to a meeting of the maternity unit’s doctors and senior midwives. Pitman, 57, who is an expert in foetal monitoring, felt the proposals would prevent more babies suffering brain injuries at birth. “We’re not that good at detecting the high-risk baby, in the low-risk mum,” he says. Another doctor would later characterise the meeting as “hideous … hands down the worst meeting I’ve ever been to. Martyn … was being set upon.” A midwife felt the animosity in the room was “personal towards Martyn”, and was “appalled” by the “unprofessionalism that I saw from my midwifery colleagues”. James and Charlotte join an unhappy club: a community of parents whose children died young, after receiving poor care, and were told their deaths were unavoidable, or felt blamed for them. “I’ve spoken to so many families,” says Donna Ockenden, who authored a 2022 report into Shrewsbury’s maternity services, “who have been blamed for the eventual poor outcome in their cases. This has included being blamed for their babies’ death.” She has also met the families of women blamed for their own deaths. “This never fails to shock me,” she says. Read full story Source: The Guardian, 26 March 2024
  3. Content Article
    In this report, Patient Safety Learning analyses the results of questions in the NHS Staff Survey 2023 specifically relating to reporting, speaking up and acting on patient safety concerns. It raises questions as to why there has been so little progress despite policy intention in this area. It concludes by setting out the need to improve the implementation, monitoring and evaluation of work seeking to create a safety culture across the NHS. This article contains a summary of the report, which can be read in full here or from downloading the attachment below.
  4. News Article
    An NHS watchdog has apologised to 29 doctors at Scotland's biggest hospital for not fully investigating their concerns about patient safety. A&E consultants at Glasgow's Queen Elizabeth University Hospital wrote to Healthcare Improvement Scotland (HIS) to warn patient safety was being "seriously compromised". They offered 18 months' worth of evidence of overcrowding and staff shortages to back their claims. But HIS did not ask for this evidence. The watchdog also did not meet any of the 29 doctors - which is almost every consultant in the hospital's emergency department - to discuss the concerns after it received the letter last year. Instead, it carried out an investigation where it only spoke to senior executives at NHS Greater Glasgow and Clyde before then closing down the probe. HIS has now issued a "sincere and unreserved apology" to the consultants and upheld two complaints about the way it handled their whistleblowing letter about patient safety. One consultant who signed the letter told BBC Scotland: "We'd exhausted all our options and thought HIS was a credible organisation. "We offered to share evidence of patient harm. We were shocked that they ignored this and didn't engage with us as the consultant group raising concerns." Another consultant added they were "shocked at their negligence." Read full story Source: BBC News, 25 March 2024
  5. News Article
    The Government has failed to implement a number of recommendations from significant inquiries into major patient safety issues, years after they were agreed to, according to an independent panel. The report, commissioned by the Health and Social Committee in the wake of the Lucy Letby case, voiced concerns about “delays to take real action”. As part of its investigation, the panel selected recommendations from independent public inquiries and reviews that have been accepted by government since 2010. Nine or more years have passed since these recommendations were accepted by the government of the day These covered three broad policy areas – maternity safety and leadership, training of staff in health and social care, and culture of safety and whistleblowing – and were used to evaluate progress. The panel gave the Government a rating of “requires improvement” across the policy areas. One of the recommendations was rated good. The report said that “despite good performance in some areas” the rating “partly reflects the length of time it has taken for the Government to make progress on fully implementing four of the recommendations which were accepted nine years ago, or longer”. “Progress is imminent in several areas, which is reassuring, but we remain concerned about the time it has taken for real action to be taken,” it added. Read full story Source: The Independent, 22 March 2024 Read Patient Safety Learning's response to the report: Response to Select Committee report: Evaluation of the Government’s progress on meeting patient safety recommendations
  6. Content Article
    The Health and Social Care Select Committee’s Independent Expert Panel produces reports which assess progress the Government has made against their own commitments in different areas of health and care policy. On the 22 March 2024 they published a new report evaluating the implementation of accepted recommendations made by inquiries and reviews into patient safety. This blog sets out Patient Safety Learning’s response to its findings.
  7. Content Article
    NHS Boards are required under the National Whistleblowing Standards (the Standards) to publish annual whistleblowing reports setting out performance in handling whistleblowing concerns.
  8. News Article
    A group representing hundreds of clinicians has applied to contribute to the Lucy Letby inquiry, to challenge NHS culture around whistleblowing. Their experiences of raising concerns should inform the inquiry, they say. Letby murdered seven babies and attempted to murder another six while working at the Countess of Chester NHS trust between June 2015 and June 2016. The public inquiry is examining how the nurse was able to murder and how the hospital handled concerns about her. "The evidence of this group relating to how whistleblowers are treated, not just at one trust but across the UK, is of huge significance," Rachel di Clemente, of Hudgell Solicitors, acting for the clinicians, said. The group, NHS Whistleblowers, comprising healthcare professionals across the UK, including current and former doctors, midwives and nurses, has written to Lady Justice Thirlwall's inquiry, asking for them to be formally included as core participants. The inquiry has stated it will consider NHS culture. And the group says "a culture detrimental to patient safety" is evident across the health service. "NHS staff who have bravely spoken up about patient-safety concerns or unethical practices deserve to have their voices heard," Dr Matt Kneale, who co-chairs Doctors' Association UK, which is part of the group, said. Read full story Source: BBC News, 21 March 2024
  9. Content Article
    These principles underpin how NHS services must approach concerns that are raised by staff, students and volunteers about health services.
  10. Content Article
    In this blog, Steve Turner reflects on why genuine patient safety whistleblowers are so frequently ignored side-lined or victimised. Why staff don’t speak out, why measures to change this have not worked and, in some cases, have exacerbated the problems. Concluding with optimism that new legislation going through Parliament offers a way forward from which everyone will benefit.
  11. News Article
    NHS doctor Chris Day has won the right to challenge a tribunal decision which raises questions about information governance in NHS hospital trusts and the use of digital evidence by employment tribunals. Day blew the whistle on acute understaffing at a South London intensive care unit linked to two patient deaths in 2013. His decade-long legal campaign has since exposed the lack of statutory whistleblowing protections for nearly 50,000 doctors below consultant level in England. An appeal tribunal in February refused Day the right to challenge key aspects of an earlier tribunal ruling that cleared Lewisham and Greenwich NHS Trust (LGT) of deliberately concealing evidence and perverting the course of justice when one of the trust’s directors “deliberately” deleted up to 90,000 emails midway through a tribunal hearing in July 2022. Day’s high-profile case nevertheless continues to raise questions about information governance practices in NHS hospital trusts and the degree of scrutiny applied to digital evidence retention and disclosure practices at UK employment tribunals. The 2022 tribunal heard that LGT communications director David Cocke had attempted to destroy up to 90,000 emails and other electronic archives that were potentially critical to the case as the hearing progressed. However, any remaining documents among the tens of thousands of emails and electronic archives, which NHS trust lawyers told the tribunal had been “permanently” destroyed, are likely still to exist and be recoverable, according to an expert consulted by Computer Weekly. Read full story Source: Computer Weekly, 19 March 2024
  12. News Article
    Hospitals are cynically burying evidence about poor care in a “cover-up culture” that leads to avoidable deaths, and families being denied the truth about their loved ones, the NHS ombudsman has warned. Ministers, NHS leaders and hospital boards are doing too little to end the health service’s deeply ingrained “cover-up culture” and victimisation of staff who turn whistleblower, he added. In an interview with the Guardian as he prepares to step down after seven years in the post, Rob Behrens claimed many parts of the NHS still put “reputation management” ahead of being open with relatives who have lost a loved one due to medical negligence. The ombudsman for England said that although the NHS was staffed by “brilliant people” working under intense pressures, too often his investigations into patients’ complaints had revealed cover-ups, “including the altering of care plans and the disappearance of crucial documents after patients have died and robust denial in the face of documentary evidence”. Read full story Source: The Guardian, 17 March 2024
  13. Content Article
    In this Guardian interview, Rob Behrens, the outgoing NHS Ombudsman for England, says that too much unsafe care is still happening in the health service and that a culture of cover up makes it hard for bereaved families to find out the truth about their loved one's death. He describes the NHS as a complex institution run by mostly excellent, committed staff that is beset by cultural issues and a focus on limiting reputational damage at the expense of transparency and fair treatment of staff who speak up.
  14. News Article
    A nurse has warned that she has been “crushed and silenced” over a battle with the NHS and the nursing regulator to investigate claims that she was sexually harassed by a colleague at work. Michelle Russell told Nursing Times of the “eight-year nightmare” she has endured since coming forward about her experiences and that she said had recently led her nursing career to come to an end. “Knowing what’s happened to me is not going to make it easier for anybody else to speak out" She has argued that “speaking up is not encouraged” in the NHS and that her case would discourage other nurses from coming forward about sexual harassment. Ms Russell said: “Anybody who has been around me would be able to see the emotional impact of all of this on me. “I’ve lost my job for highlighting a public safety concern.” The national guardian for the NHS told Nursing Times sexual harassment was a “patient safety issue” and warned that staff continued to face difficulties when speaking out. It comes as the latest NHS Staff Survey this month revealed that almost 4% of nurses and midwives had been the target of unwanted sexual behaviour in the workplace by another member of staff in the last 12 months. Read full story Source: Nursing Times, 15 March 2024
  15. Content Article
    The NHS will always need whistleblowers as healthcare is complex, rapidly changing and dangerous. However, whistleblowers continue to be treated very poorly by the health service, as this Private Eye special report highlights. The report looks in detail at several whistleblowing cases and how attempts to cover up mistakes and wrongdoing have resulted in patient deaths and devastated the careers and personal lives of staff who speak up for patient safety.
  16. News Article
    A trust which last year was ordered to pay a whistleblowing nurse nearly £500,000 must now give a surgeon £430,000 to compensate him for the racial discrimination and harassment he faced after raising patient safety concerns. Tribunal judges previously upheld complaints made by Manuf Kassem against North Tees and Hartlepool Foundation Trust and have published a remedy judgment this week setting out the levels of damages the NHS organisation must pay. The judgment comes just over a year after a former senior nurse at the trust was awarded £472,600 for unfair dismissal after she warned high workloads had led to a patient’s death. Mr Kassem raised 25 concerns regarding patients’ care during a grievance meeting in August 2017. He alleged patients had “suffered complications, negligence, delayed treatment and avoidable deaths”. A trust review concluded appropriate processes were followed in the 25 cases. However, the tribunal ruled Mr Kassem was subjected to detriment after making the protected disclosure. According to the judgment, Mr Kassem was subsequently removed from the on-call emergency rota and his identity as a whistleblower was revealed by clinical director Anil Agarwal. In September 2018, he was the subject of a disciplinary investigation following several allegations against him made by colleagues and others, which concerned “unsafe working practices,” “excessive working hours,” and “potential fraudulent activity.” The investigation lasted 17 months and none of the allegations against Mr Kassem were upheld or progressed to a disciplinary hearing. Read full story (paywalled) Source: HSJ, 15 March 2024
  17. News Article
    Staff whistleblowers have raised concerns over patient safety at one of Northern Ireland's biggest health trusts. Information received by UTV under Freedom of Information shows that most of the worries from health workers at the Belfast Health Trust relate to the Royal Victoria Hospital. Belfast Health Trust said any concerns raised by staff are investigated. The Royal College of Nursing NI was due to hold a webinar with members on Tuesday evening to discuss concerns members have about safety of patients being treated on corridors. The RCN's Rita Devlin said that the number of concerns raised with health trusts through the whistleblowing policy is only the tip of the iceberg. The concerns included unsafe staffing levels, bed shortages, boarding of patients, ED overcrowding, alleged drug dealing on a hospital site, staff sleeping on night duty, lack of mental health beds and the quality of staff training. The Belfast Trust said all staff are encouraged to make management aware of issues giving them concern through the whistleblowing process. The Trust added: "Any concern we receive is subject to a fair and proportionate process of investigation. "Whistleblowing investigations are of a fact finding nature and all relevant learning is shared as appropriate and taken forward by the Trust." Read full story Source: ITVX. 12 March 2024
  18. News Article
    The Health and Social Care Committee has launched a new inquiry to examine leadership, performance and patient safety in the NHS. Inquiry: NHS leadership, performance and patient safety MPs will consider the work of the Messenger review (2022) which examined the state of leadership and management in the NHS and social care, and the Kark review (2019) which assessed how effectively the fit and proper persons test prevents unsuitable staff from being redeployed or re-employed in health and social care settings. The Committee’s inquiry will also consider how effectively leadership supports whistleblowers and what is learnt from patient safety issues. An ongoing evaluation by the Committee’s Expert Panel on progress by government in meeting recommendations on patient safety will provide further information to the inquiry. Health and Social Care Committee Chair Steve Brine MP said: “The role of leadership within the NHS is crucial whether that be a driver of productivity that delivers efficient services for patients and in particular when it comes to patient safety. Five years ago, Tom Kark QC led a review to ensure that directors in the NHS responsible for quality and safety of care are ‘fit and proper’ to be in their roles. We’ll be questioning what impact that has made. We’ll also look at recommendations from the Messenger review to strengthen leadership and management and we will ask whether NHS leadership structures provide enough support to whistleblowers. Our Expert Panel has already begun its work to evaluate government progress on accepted recommendations to improve patient safety so this will build on that. We owe it to those who rely on the NHS – and the tax-payers who pay for it – to know whether the service is well led and those who have been failed on patient safety need to find out whether real change has resulted from promises made.” Terms of Reference The Committee invites written submissions addressing any, or all, of the following points, but please note that the Committee does not investigate individual cases and will not be pursuing matters on behalf of individuals. Evidence should be submitted by Friday 8 March. Written evidence can be submitted here of no more than 3,000 words.  How effectively does NHS leadership encourage a culture in which staff feel confident raising patient safety concerns, and what more could be done to support this? What has been the impact of the 2019 Kark Review on leadership in the NHS as it relates to patient safety? What progress has been made to date on recommendations from the 2022 Messenger Review? How effectively have leadership recommendations from previous reviews of patient safety crises been implemented? How could better regulation of health service managers and application of agreed professional standards support improvements in patient safety? How effectively do NHS leadership structures provide a supportive and fair approach to whistleblowers, and how could this be improved? How could investigations into whistleblowing complaints be improved? How effectively does the NHS complaints system prevent patient safety incidents from escalating and what would be the impact of proposed measures to improve patient safety, such as Martha’s Rule? What can the NHS learn from the leadership culture in other safety-critical sectors e.g. aviation, nuclear? Read full story Source: UK Parliament, 25 January 2024
  19. News Article
    A surgeon sacked by a hospital after raising safety concerns has accused the trust of a cover-up after a patient was partially blinded during an operation. Juanita Graham, 41, lost the sight in her left eye during an operation at Bath's Royal United Hospital (RUH) in 2019. She is now suing the trust. Serryth Colbert said he was put down as the lead author on an investigation into the incident, but said he "did not write a word" of it. Mr Colbert has described the hospital investigation into Mrs Graham's operation as "deeply flawed". The surgeon, who specialises in the head, neck, face and jaw, has made several serious allegations about patient safety at the RUH, and believes these claims led to him being regarded as a troublemaker and dismissed in October 2023. Mrs Graham, from Trowbridge, said she was still traumatised by the operation on her eye. "I remember coming round, seeing the time and felt like a gush and I couldn't see," she said. "The next time I remember waking up again, I thought it was my partner but it was a surgeon and he was crying. I said 'what's gone wrong?'". After the operation, a Root Cause Analyses (RCA) report produced by the trust said the hospital was not to blame, although it did say the risks could have been explained more clearly to Mrs Graham. Mr Colbert, whose name was added as the lead investigator, said his only involvement in the report was when he was called on the phone by a nurse, who he said did the RCA, to explain what the operation involved. The 48-year-old surgeon said: "I have been put down here to my amazement as the lead author on this. "That is not correct. I did not write a word of this. "The conclusion is the root cause of the complication was down to a bit of paperwork which could have been performed a bit better. "The root cause was not down to paperwork. It was all covered up... that was indefensible." Read full story Source: BBC News, 29 February 2024
  20. Content Article
    In this interview for inews, Professor Ted Baker, Chair of the new Health Services Safety Investigations Body (HSSIB), talks about the role of HSSIB in identifying system-wide safety issues in the NHS. He discusses why we need new approaches to tackling patient safety problems and outlines the importance of considering how the wider system leads to human error. He also talks about the impact of bullying on NHS staff, describing his own experiences as a junior doctor, which nearly led him to give up his career. He also describes the vital role of whistleblowers in making changes that genuinely improve patient safety, highlighting the problems currently facing staff who speak up for patient safety.
  21. News Article
    Whistleblower Dr Chris Day has won the right to appeal when a a Deputy High Court Judge Andrew Burns of the Employment Appeal Tribunal granted permission to appeal the November 2022 decision of the London South Employment Tribunal on six out of ten grounds at a hearing in London. The saga which has now being going on for almost ten years began when Dr Day raised patient safety issues in intensive care unit at Woolwich Hospital in London. The Judge said today this was of the “utmost seriousness” and were linked to two avoidable deaths but their status as reasonable beliefs were contested by the NHS for 4 years using public money. In a series of twists and turns at various tribunals investigating his claims Dr Day has been vilified by the trust not only in court but in a press release sent out by the trust and correspondence with four neighbouring trust chief executives and the head of NHS England, Dr Amanda Pritchard and local MPs. This specific hearing followed a judgement in favour of the trust by employment judge Anne Martin at a hearing which revealed that David Cocke, a director of communications at the trust, who was due to be a witness but never turned up, destroyed 90,000 emails overnight during the hearing. A huge amount of evidence and correspondence that should have been released to Dr Day was suddenly discovered. The new evidence showed that the trust’s chief executive, Ben Travis, had misled the tribunal when he said that a board meeting which discussed Dr Day’s case did not exist and that he had not informed any other chief executive about the case other than the documents that were eventually disclosed to the court. Read full story Source: Westminster Confidential, 26 February 2024
  22. Content Article
    In this article, investigative journalist Scilla Alecci reports on a court case brought against medical tech company Medtronic by a US whistleblower. Former Medtronic sales representative Leanne Houston alleges that between 2016 and 2018 she witnessed the company engaging in “unlawful conduct” by offering several US hospitals free equipment in exchange for the exclusive use of Medtronic products. She also claims that the company failed to acknowledge and deal with reports from surgeons that one of its surgical staple devices was causing harm to patients.
  23. Content Article
    This report aims to understand the NHS response to racism, what trusts and healthcare organisations do about it and how effective they are at addressing it. It brings together key learning from a number of significant tribunal cases and responses from 1,327 people to a survey about their experiences of raising allegations of racism within their organisations.
  24. News Article
    An integrated care board (ICB) has found its handling of whistleblowing “not fit for purpose”, after a complaint about safety incidents not being properly investigated. A report by North West London ICB, obtained by HSJ, states: “The whistleblowing policy is not fit for purpose and requires immediate updating. The [Freedom to Speak Up] Guardian has been left blank and the policy does not include key components of best practice.” It also found the “whistleblower should have been provided with a substantive response to their concerns within 28 days” but in fact waited 98 working days, “due to delays with starting the whistleblowing component of the grievance”. The ICB reviewed its processes after a complaint from a staff member who raised concerns early last year about “a lack of, or poor, response” to reported patient safety incidents in the system, which are meant to be routinely reviewed by ICBs “prior to closure”. Read full story (paywalled) Source: HSJ, 15 February 2024
  25. News Article
    A senior surgeon has raised concerns about the way whistleblowers are dealt with, claiming he was sacked after speaking out. Serryth Colbert told the BBC that following attempts to "stop wrongdoing", he was investigated by the trust at Bath's Royal United Hospital. As a result, he said he was dismissed for gross misconduct in October 2023. The RUH said it has "never dismissed anybody for raising concerns and never will". It added that Mr Colbert's dismissal related to "significant concerns about bullying" and its investigation into his conduct was "thorough" and "robust". Mr Colbert said he raised safety concerns without regard for the impact it might have on his career. "It was never a question in my mind. This is wrong. I'm stopping the wrongdoing. I stand for justice. I stand to protect patients," he said. The BBC has seen no evidence his most serious concern was ever investigated and Mr Colbert is now taking the RUH to an employment tribunal. Read full story Source: BBC News, 9 February 2024
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