1. 1 Parliamentary and Scientific Committee: meeting on patient safety Jocelyn Cornwell The Point of Care Foundation October 13 th 2015

2. 2 The Point of Care Foundation vision and mission Our vision is radical improvement in the way we care and are cared for. We believe a truly patient-centred approach –focused on listening, understanding and responding to the needs of the whole individual – is essential to the delivery of the best possible quality of care. We deliver the vision by providing evidence and resources to support healthcare staff in the valuable work of caring for patients.

3. 3 We work at all levels of the system 1.We raise awareness, create and share evidence on staff and patient experience 2.We spread effective methods for supporting staff (Schwartz Rounds) and improving experience (partnering with patients to co-design services) 3.We innovate and nurture new thinking about practical solutions

4. 4 Incidents reported to the National Reporting and Learning System (NRLS). 778,460 incidents (Oct 2013 March 2014) Incidents reported occur in NHS trusts Data for primary care unavailable Reporting patient safety incidents 4

5. 5 None Low Moderate: unexpected or unintended incident results in further treatment; short term harm to one or more people Severe: unexpected or unintended incident resulting in permanent or long term harm Death Definitions of harm

6. 6 69% = no harm 25% = low harm 5% = moderate harm 1% = severe harm/death In the 6 months reported, roughly 8,000 patients suffered severe harm in the NHS, or an average of 25 per trust Of the 776,460 incidents reported 2013-2014

7. 7 Patients and their relatives suffer additional harm because of how they are treated Harms are mainly emotional and psychological ●fear, isolation and loneliness ● powerlessness ● anger and frustration ●loss of trust in health professionals Patients often require further treatment and care from the same organisation Some need immediate help with finances and other practical problems Suffering immediate, support may be needed for months and years What we know about severe harm to patients

8. 8 They suffer. Feelings include: Shame a sense of personal/professional failure feelings of incompetence loss of confidence in self and colleagues Loneliness isolation both personal and professional fear of the consequences both personal and professional depression The suffering is immediate and may be prolonged What we know about staff involved in such incidents

9. 9 The duty of candour New to the statute books Designed to achieve cultural change in NHS organisations Anxieties and mis-information in the service Implementation is a process not an event. It will take months and even years Implementation needs attention, structure, organisation and resources For patients, relatives and staff the duty of candour should mend and repair harm prevent against the avoidable suffering associated with the aftermath of incidents restore and build trust where it has been lost or is absent

10. 10 People who make an error (human error) are cared for and supported People who don’t adhere to policies (risky behaviour) are spoken to before they are judged People who intentionally put themselves or their patients at risk (reckless behaviour) are held accountable for their actions The aim should be to achieve a ‘just culture’

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13. 13 For Cameran, his parents, sisters and wider family Immediately following his birth How to cope with the baby being in intensive care + his two older sisters at home? Loss of trust Fear provoked by not knowing what is happening, a disturbing sense of secrecy No-one to talk to In the medium to long term The Trust did not do what it said it would do They were never given the name of someone to speak to When ordinary things go wrong at the hospital, anxiety about the consequences for Cam and about how to deal with them

14. 14 For the staff involved Individuals involved were suspended. One midwife did not return to work. At The Point of Care Foundation we know staff suffer Distress about having caused harm Shame, a sense of failure Lonely Afraid of consequences – personal and professional They lack competence They lack training They lack support in the short, medium and longer term

15. 15 Systemic solutions for patients and families For Cam and his family the damage sustained at the first, catastrophic meeting should not have happened. However it could have been repaired IF Someone – a reliable named person had taken responsibility (leadership) The trust had kept channels of communication open over years (governance) The trust had done what it said it would do (leadership / governance) His case notes and records were accurate, complete and always available when he goes back to the hospital(governance, administration)

16. 16 To be prepared for such incidents before, during and after they occur Disclosure support and training Mentoring in the short, medium and longer term Some may need access to psychological services To be treated fairly by the organisation and confident that they won’t be blamed or punished for making or reporting genuine mistakes Staff need

17. 17 Cameran with his father in 2014