Firstly, just to reflect briefly on some personal experience. In 2008 my wife and I suffered the avoidable loss of our second child Joshua, due to failures in his care at Furness General Hospital (FGH) in Cumbria. Joshua’s death later became part of a much wider investigation into the safety of maternity services which concluded in March 2015. The investigation report found a ‘lethal mix’ of failures ‘at almost every level of the system’. Shockingly, the first event that should have acted as an unmistakable alarm that serious safety issues were developing, happened with the preventable death of a baby girl more than 4 years before Joshua was born. Tragically, rather than responding with openness, honesty and a commitment to learn from what happened, the organisational and system response at the time was to bury the problem.
The family was told that the death of their daughter was ‘just one of those things’. Care at the unit carried on as if nothing had happened. This led to opportunities to prevent future tragedies being missed and Joshua’s avoidable death. Discovering this was one of the hardest aspects of coming to terms with our loss of Joshua. Whilst I believe we all have the capacity to understand and forgive unintentional mistakes, no matter how catastrophic the consequences, it is much harder to reconcile such events knowing that not only could they have been prevented, but that had the organisation behaved honestly and ethically, things would almost certainly have been different.
The struggle that families at Morecambe Bay experienced in getting to the truth and the resistance to learning and changes experienced is far from unique. This is well summarised by Dr George Julian in the foreword to the recent Care Quality Commission report, ‘Learning, Candour and Accountability.’
“When a loved one dies in care, knowing how and why they died is the very least a family should be able to expect. Yet throughout this review process we have heard from families who had to go to great lengths themselves to get answers to these questions, who were subjected to poor treatment from across the healthcare system, and who had their experiences denied and their motives questioned.”
The policy landscape around investigating and learning from patient safety events including patient deaths in the NHS is currently in flux. In April 2017, the new Healthcare Safety Investigation Branch (HSIB) became operational and earlier this year, NHS England published guidance on learning from deaths produced by the National Quality Board. The foreword to the guidance highlights that its purpose is to help initiate a standardised approach that will need to evolve as the whole system learns. There will be no overnight solutions, but there has never been a time of so much focus on finding solutions to tackle these issues.
These initiatives are to be welcomed but we also believe more can be done to ensure a whole system approach to responding to harm and improving patient safety that is less fragmented. We believe that our new organisation can play an important and unique role in helping to achieve this, through working with staff and patients, with a specific focus on culture change and collaboration to share patient safety learning.
We are fortunate to have the support of a steering group of world class people who will provide expert advice and guidance as we develop and grow. We will aim to work closely with patients, staff and organisations on projects that will make a difference.
Sharing Patient Safety Learning
We will create a platform to help those involved in patient safety work to share the learning from patient safety incidents and investigations, sharing safety improvement strategies and sharing evidence on the effectiveness of these strategies. We are pleased to announce that we are working with Dr Carl Macrae, an influential patient safety researcher, to develop this platform.
Improving the response to harm
We will work with healthcare providers to involve patients and families in investigations, ensuring their input makes a difference. As part of this work, we are pleased to present a series of three podcasts produced in partnership with Professor Murray Anderson-Wallace. These podcasts explore what quality looks like in the aftermath of healthcare harm and consider the role of systems thinking and the function of blame when things go wrong. These podcasts are available to listen to here. We hope these will be widely listened to and are used to contribute to conversations and debate around making things better.
Growing patient safety capability and capacity
We believe that high quality training in incident investigation and other aspects of patient safety is vital to allow healthcare organisations to learn, grow and change. Only this week a report from NHS Resolution looking at claims relating the brain injury during childbirth, highlighted a lack of family involvement and staff support through the investigation process. The report found that the quality of root cause analysis was generally poor and focused too heavily on individuals and that recommendations made were ‘unlikely to reduce the incidence of future harm’. The provision of training in these areas is a key objective of Patient Safety Learning. Read the full report here.
To help deliver this objective, we will partner with Consequence UK to design and deliver training in investigations and other related aspects of learning from things that go wrong in healthcare and social care. Consequence UK has an excellent reputation as an independent investigations consultancy and provider of effective investigations training to healthcare organisations.
Celebrating patient safety culture and learning
We believe that learning from things that go wrong in order to create safety improvement strategies that really work needs to be encouraged and celebrated. We know from use of phrases such as ‘I’ll Datix You’ that this often isn’t the culture staff on the front line experience. Read more about culture here.
To encourage change in this area we have created an awards scheme to help incentivise healthcare workers to come up with new ideas and test the effectiveness of both traditional and innovative approaches to patient safety learning. This is a new approach that will shine a light on excellent practice in this important area. No other awards focus so directly on culture and learning.
The awards will take place annually and will be open to all healthcare providers. Each organisation can submit up to a maximum of three nominations in each of the following categories:
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
Each year, a winner and a runner up will be selected in each category. Winning entries will receive a Patient Safety Learning award presented at our annual event and a share of a prize fund.
More details of the awards scheme and how to submit an entry will be provided on our website shortly.
The launch event
To mark to launch of Patient Safety Learning we are holding an evening event on 21 September in London. Speakers at the event include Professor Alison Leary, Professor Murray Anderson-Wallace and Dr Carl Macrae with a keynote talk being delivered by Julie Bailey, whose campaigning on behalf of those affected by the tragic events at Mid Staffordshire NHS Foundation Trust fundamentally altered the patient safety landscape in the UK. We will live stream the presentations from 6pm on 21st September. More information will be posted on the Patient Safety Learning Twitter account @ptsafetylearn.
The next steps
Over the next six months we will be working to develop the projects described here. There is a lot to do and we will need time to grow, learning ourselves as we do. For more information, register to receive our our newsletter (below) and follow us on twitter @ptsafetylearn
Want to join us? Let us know how you’d like to engage with our work, to develop and share best practice. Please send you details to [email protected]
Patient Safety Learning
Working together towards safer healthcare