28/9/17 Patient Safety Learning. What will they do?

Last Thursday evening I attended the launch event for Patient Safety Learning. This is a new not for profit organisation set up by James Titcombe (Avoidably bereaved father and patient safety campaigner) and Jonathan Hazan (former CEO and Co-Founder of Datix)

Along with other attendees who have lost loved ones as a result of failures in their care, I was excited and intrigued to find out what this organisation, co-developed by one of our fellow avoidably bereaved colleagues, was going to offer.

I had high hopes before the event, believing this is just what we need, an independent organisation set up to help, support, train, the NHS but not part of the NHS, that is the brainchild of someone who has actually been through the agony and trauma of losing someone and having to fight the system for every scrap of information about how that came to be, and for the necessary learning to take place.

Surely an organisation, with leaders who ‘get it’ and will not be held back by the politics of working within the NHS or one of its regulators can really help drive the obvious culture shift that’s needed for some of the policies, procedures and statutory requirements that have already been introduced, and those currently being developed, around learning from deaths in the NHS are to be utilised in the way they are intended.

The launch event served to further build by optimism and enthusiasm that James, Jonathan and the diverse range of expertise on the steering committee will deliver. (You can watch all of the presentations given at the launch here https://www.pscp.tv/w/1ZkJzOmkjpvxv )

James’ presentation reminded us just how many times now since 2001, 16 years ago, as part of reviews, investigations, inquiries, and patient campaigns recommendations have been made about

• Carrying out independent, robust, thorough investigations when things go wrong
• Being open and honest with patients and/or their families when things go wrong and involving them as equals throughout the investigation process
• Adopting a systems wide approach to learning from events, that does not scape goat individual front line staff and gets to the bottom of all of the reasons why a harm event has occurred
• Ensuring learning from harm events is meaningful and results in implemented changes that genuinely will make a difference, and that this learning is widely shared

Patient safety learning has been born from the frustration that James, Jonathan, the steering group members and no doubt the huge majority of NHS workers patients and families feel at seeing these same themes emerge over and over again, creating pockets of local improvement but no real system wide change.

It is certainly true that I personally feel completely fatigued by the repetitiveness of recommendations, but no tangible difference appearing to be made in terms of families experiences once something has gone wrong.

I am encouraged to see that this group are joining forces with Maria Dineen from Consequence UK, to offer training to NHS staff in how to properly engage with families when things go wrong, and make them moral equals within the investigation process, and training on how to actually carry out those investigations properly so that all the learning is identified, and turned into actual objectives to be met going forward. (I recommend you watch Marias presentation in the web recording of the launch event, where she talks about investigations needing to result in ‘objectives’ and not ‘recommendations. Appears obvious once she says it!)

One of the really big bug bears of mine, and the many other families I have been in contact with over the almost 7 years since I lost Jasmine, is that any learning and implemented changes that have come from our children’s deaths has been restricted to the trust where it happened. In some cases the learning isn’t even trust wide, just shared within that particular department. It has always seemed to me an outrage that another child would need to be caused similar harm for another trust 30 miles away to learn the same lessons and make the same changes that occurred after Jazzie died. This has never been good enough for me, and I find it to be actually insulting that there wouldn’t be wider learning from what happened to my child than just within the departments in which the failures occurred.

So, I am very excited to see that this very issue is one of the most prominent on the agenda for Patient Safety Learning. They have the fabulous expertise of Dr Carl Macrae to make use of and promise to develop a platform that does share learning from incidents, improvement strategies borne from these and their effectiveness. This in my view is exactly what is needed. It has to, if utilised fully, result in more efficient and effective learning across the board and from a family’s perspective it will help deliver the much needed ‘legacy’ for the person who was affected by the harm, that their suffering will drive changes that make the wider NHS safer for others, not just a small pocket.

Another word we hear time and time again is “culture” . Patient safety learning say they are dedicated to improving the response of NHS staff and organisations to harm events and given the people within the group I believe this will be a big priority for them. I am encouraged that James, Jonathan and the steering group are committed to working with families who have experienced harm to make sure their experiences are shared to influence safer care.

I recently had the pleasure of working with Murray Anderson Wallace, a member of the steering group on the series of pod casts that he has produced that can be found on the Patient Safety Learning website. I am pleased there has already been lots of positive feedback on them on twitter, and there is a planned twitter chat coming in the near future. (There was a recent suggestion that there could be a comments section on the website for people to respond, share thoughts and ideas, and start discussion. James is looking into that.)

It was my privilege to meet Murray and get to know him. He is the real deal when it comes to simple human decency, compassion and understanding. He understands the complexities that get in the way of doing the right thing in the aftermath of harm, and he makes no bones about the way things are currently done being appalling.

Murray had free reign to do what he wanted with the podcasts , and he has done an amazing job of highlighting in a captivating and informative way the key issues at play.

You can listen to the podcasts here https://www.patientsafetylearning.org/resources/podcasts

The podcasts use a fictional scenario to explore the real issues. That scenario is obviously the result of a great deal of thought and consideration on Murray’s part, as it perfectly captures the experience that pretty much all families go through when there has been a harm incident.

In his talk at the launch event, Murray described the current response of the NHS to harm events as ‘frankly, shameful’
He reminded the audience that (like the family in the podcast) the majority of families are not listened to in the aftermath of a harm event. Their voice is not a moral equal to the NHS employees. They are ignored.

And yet, he pointed out, it is patients and/or their families that are responsible for the biggest steps forward that have been achieved in terms of acknowledgement and learning from harm that have occurred in recent years.

In a recent tweet thread, Maria Dineen, owner of Consequence UK, and a member of the Patient Safety Learning steering group, said;

“Nothing in life worth fighting for is easy. Grit, determination, tenacity, right action, right attitude. Staying the course whatever comes”

To date, in the majority of cases, when a serious harm event has occurred it is the families that have had to “stay the course”, finding the grit, determination, tenacity, right action and attitude to force investigation to uncover the answers they so desperately need and for any meaningful safety improvements or learning to come out of their experience.
To date, a great many patient safety focused NHS employees, the brave whistleblowers, have had to find that same grit and determination in the face of the most disgusting of responses from their employers.

I talk in the podcasts about how to be a healthcare professional you must surely be a compassionate caring kind individual and a courageous one. I wonder where does that kindness and courage go when things go wrong?

In his presentation, James spoke about how, in 2016, 8 years after the death of his son Joshua, and 8 years later than it should have happened, Morecambe Bay finally carried out a proper, deep investigation into Joshua’s case. They published all of their findings, including a report into a questionable exit deal the maternity risk manager had been given, despite legal threats from the RCM not to do so. He made the following observation, which to me, is one of the most important of the evening, if we are to start seeing the culture shift needed for kindness and courage to shine through when things have gone wrong.

“Sometimes, being a leader is about being courageous and doing the right thing, not necessarily what the legal system tells you to do.”

For the ‘shameful’ way in which families and some staff are currently treated in the aftermath of a harm event to ever change, I believe we need more Managers, Chief Executives, PR and Legal teams to start doing what is right, even if it goes against everything they have been used to or found easier in the past.

“Nothing in life worth fighting for is easy. Grit, determination, tenacity, right action, right attitude. Staying the course whatever comes”

Let’s start seeing more of those at the top of these organisations, and those who, let’s be honest, are usually the ones responsible for the additional harm families are caused when things go wrong in most cases, demonstrating some grit, determination, tenacity, right action, and right attitude.

Those at the top of Morecambe Bay, who did finally do the right thing in 2016, are now being celebrated for their actions. James and his family, are starting to heal. Once there were no more secrets, people were no longer afraid of what they could or could not say, James was able to meet with staff members directly involved in Joshua’s care, and have open conversations about what happened. He says it brought some forgiveness, and was a healing moment for him and the staff.

This, is the type of response we need people at all levels and in all departments of NHS organisations to be dedicated to right from the start. Thorough, robust, deep investigation, involving the family, without fear of what might be found or exposed, embracing the learning and ensuring no further harm to those that have already suffered. Sincere apology, promises that their loved one will never be forgotten, the learning that has come will result in objectives that will be met, and continually met, and monitored to ensure this. All of this information shared for the benefit of the wider NHS.

Patient safety learning’s project focuses are there to support those at every level of the organisation achieve this kind, courageous, humane, response to harm events for the benefit of patients, families, and staff going forward.

• Partnering with Maria Dineen of Consequence UK to develop and provide proper training for investigators, to ensure those tasked with investigating harm events have the necessary skills and accreditation to do a thorough, robust, deep investigation, involving families properly, right from the start.

• Development of a platform to share learning from incidents nationally. Risk managers can find out what other organisations have put into place following harm events, pick out best practice and implement this in their own institutions

• Driving the culture change needed for a kind, caring, courageous and fair response from every level of the organisation in the aftermath of harm. Treating staff and families fairly. Seeing families as equal moral partners. The podcasts are a valuable tool already available to provoke discussion and drive changes in these areas

• Praising and incentivising NHS Individuals and organisations who provide evidence of
1)Patient safety improvement projects linked to reporting systems or investigation of patient safety incidents, events, near misses and examples of good practice
2) Engaging patients and their families in safety improvement
3) Improving the environment in which staff are able to raise safety concerns

• Developing ways to ensure data captured about incidents is used in a meaningful way that leads to genuine improvements in patient safety and learning. Dr Alison Leary gave some excellent examples of the ways in which data can be used more meaningfully in her presentation, and quite rightly discussed that staff who can see genuine change coming from using data entry systems regarding incidents will be more enthused by and engaged with the process.

At the launch event Murray Anderson Wallace said…

“We have talked about how to do the right thing for years. It’s time for radical change. It’s time to turn up the volume.”

The patient safety learning team clearly want that volume to be deafening. I hope NHS organisations, individuals, patients and families will embrace them, and grasp the opportunities they are offering to support some radical changes.

Please approach them for support and partnership with projects and ideas focused on real and meaningful change, as they explicitly invite you to do on their site.

I wish the team every success

Joanne Hughes
Mothers Instinct