Transcript Slide 1
Housekeeping
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Fire Procedure
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Francis Portal
The Twitter hash tag is #talkfrancis
Technology
Question 1
What was the most
interesting thing to
happen on your journey
here today?
Question 2
Are you committed to stay until
the end of the event to develop
an action plan for your board to
drive improvement?
Welcome and Introduction
Debbie Arnot, Interim Director, NHS NW
Leadership Academy
Learning for the whole system
Introduced by
Steve Connor, Deputy Director, MIAA
LESSONS FROM STAFFORD
Robert Francis, QC. Chair
The Mid Staffordshire NHS Foundation Trust,
Public Inquiry
Notes on Hospitals, Nightingale F, 3rd ed 1863, Longman Green Roberts & Green
Tolerance of the Intolerable
Florence Nightingale, Notes on Nursing (1860) pages 92-93
Some Figures
• > 1 million pages of documentary material
• > 250 witnesses
• 139 days of oral hearings
• Terms of reference announced 9 June 2010
• Report handed to Sec of State 5 February 2013
• Costs £13 million to November 2013
• AN Other Inquiry: £40 million before oral hearings....
• 1781 pages
• 290 recommendations
And don’t forget…
• Inquiry announced July 2009
• Report published February 2010
• 2 volumes
• 133 witnesses gave oral evidence
• +/- 900 experiences summarised
• 18 recommendations
What’s it about…
To examine the operation of the commissioning,
supervisory and regulatory organisations and other
agencies, including the culture and systems of those
organisations in relation to their monitoring role at
Mid Staffordshire NHS Foundation Trust between
January 2005 and March 2009 and to examine why
problems at the Trust were not identified sooner,
and appropriate action taken.
…and not about
There is a tendency when a disaster strikes to try to seek out
someone who can be blamed for what occurred, and a public
expectation that those held responsible will be held to account.
All too frequently there are insufficient mechanisms for this to
be done effectively. A public inquiry is not a vehicle which is
capable of fulfilling this purpose except in the limited sense of
being able to require individuals and organisations to give an
explanation for their actions or inaction.
Public Inquiry Report Para 106
But who is important?
But who is important?
Union reps office
CEO office
Cooling
towers–
Badenoch
Inquiry 1986
Warning signs not put together
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Patient stories
Mortality
Complaints
Staff concerns
Whistleblowers
Governance issues
Finance
Staff reductions
Neglected patients, neglected records
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We entrusted my mother into this hospital to be cared for, to be looked after. But
when you think about it, logically, 31st October she was admitted, she died on 6th
November and within those few days this hospital let her fall over three times and
she had been admitted because she was unstable on her feet. Well, as we thought,
immobile. We don’t know she was walking about in the wards until we received
incident reports and as I said we were never ever made aware by any of the nursing
staff that there was a problem. [Evidence of patient’s son]
There is no accurate completed incident form relating to your mother’s fall on EAU on
2 November 2008. The three completed incident forms contain misleading and
inaccurate information. A review of the nursing and medical records has identified
the recording of the three falls which your mother sustained. Unfortunately the
entries for the first fall do not give an accurate time of the fall, which in turn are
misleading, because the entries span over two consecutive dates. [Reply to
complaint]
This episode indicates serious lapses in the Trust’s duty to care for the safety of an
obviously vulnerable patient. [my conclusion]
Who looks out for those without supporters?
I think that is fine as long as it isn’t dependent upon [this],
because there are a lot of people who do not have relatives who
are fit and able to go in and so what happens to them? You see,
the most vulnerable are going to be the ones who, because they
have little support or they don’t have relatives who can go in and
help, what happens? I mean, we helped others in the ward, didn’t
we, while we were there. We were going round and we were
taking lids off drinks and we were helping to put things in reach.
Evidence of a family asked to help feed their elderly relative – 1st report page 90
Friendly Infection
She had got a cloth, like a J-cloth, and she cleaned the
ledges and she went into the wards, she walked all round
the ward with the same cloth, wiping everybody’s table and
saying hello, wiping another table and saying hello. Came
out of there, went into the toilets and lo and behold, she
cleaned the toilets with the same cloth, and went off into
the next bay with the same cloth in her hand. You can’t
believe what you saw, you really couldn’t believe what you
saw.
A visiting relative in 2006
A patient death
One “Incident” can tell it all…
Extract from Trust investigation report into a patient death in April 2007
Extract from Trust investigation report
The suffering of neglect
Neglectful abuse
Barriers to complaint
Fear of Trouble
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Some of them were so stroppy that you felt that if you did complain, that they could be
spiteful to my Mum or they could ignore her a bit more.
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There would have been a lot of little incidents that just made you feel uncomfortable and
made us feel that we didn’t want to approach the staff. I did feel intimidated a lot of the
time just by certain ones.
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You have rushed the blood through, I said to the sister, and she said, ... I have had to come
in and give the blood and don’t moan... because I have had no break today. That’s what
she said, and she probably hadn’t had a break. So I didn’t mention the frusemide to her
because she was obviously fraught.
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I think he felt as though he didn’t want to be a nuisance. Because of their attitude in the
beginning when he first mentioned about the epidural, he felt as though it was a waste of
time of saying that he was in pain.
“Action Plans” no answers to complaints
Mid Staffordshire report page 273
Pressures on staff
I mean in some ways I feel ashamed because I have worked
there and I can tell you that I have done my best, and
sometimes you go home and you are really upset because
you can’t say that you have done anything to help. ...
although you have answered buzzers, you have provided the
medical care but it never seemed to be enough. There was
not enough staff to deal with the type of patient that you
needed to deal with, to provide everything that a patient
would need. You were doing – you were just skimming the
surface and that is not how I was trained.
A nurse
Result: You walk away
The nurses were so under-resourced they were working
extra hours, they were desperately moving from place to
place to try to give adequate care to patients. If you are in
that environment for long enough, what happens is you
become immune to the sound of pain. You either become
immune to the sound of pain or you walk away. You cannot
feel people’s pain, you cannot continue to want to do the
best you possibly can when the system says no to you, you
can’t do the best you can.
A doctor who started in A&E in October 2007
…Or not “rock the boat”…
Perhaps I should have been more forceful in my statements, but I was
getting to the stage where I was less involved and I was heading to
retirement … I did not have a managerial role and therefore I did not
see myself as someone who needed to get involved. Perhaps my
conscience may have made me raise concerns if I had been in a
management role, but I took the path of least resistance. In addition …
most of my patients were day cases and there was less impact on those
patients. There were also veiled threats at the time, that I should not
rock the boat at my stage in life because, for example, I needed
discretionary points or to be put forward for clinical excellence awards
Evidence given to the Public Inquiry
Why wasn’t all this exposed?
• Patients not heard or listened to
• Impact on patients of concerns, reorganisations,
information not thought about
• Cumulative effect of concerns ignored
• Resources, support and expertise for monitoring absent
• Assumptions that others dealing with it
• Safety related information not shared
• Barriers to information sharing
System’s business not patients
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Standards which missed the point
Focus on finance, corporate governance, targets
Regulatory gaps
Balancing “bad” news with “good”
Assuming compliance not fearing non compliance
Accepting positive information, rejecting the
negative
“Disappointing” news
Health
Basic care for elderly 'lacking‘
Basic care for the elderly in hospitals and care homes in England is still not good enough, the
regulator says. The Care Quality Commission report, based on a snapshot of services, found about
a third failed to meet all the standards for nutrition and dignity. It cited examples of call-bells being
left unanswered, bad manners and a lack support at meal times.
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'Disappointing'
In total, 50 hospitals were inspected by the CQC, with only 33 meeting all of the five relevant
standards.
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CQC chief executive David Behan said the findings were "disappointing". "Safe, good quality care is
not complex or time-consuming," he added.
Nick Triggle, BBC Health Correspondent 9 March 2013 Last updated at 03:38
©2013 Robert Francis QC
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…or is it institutional abuse?
Dot Gibson, of the National Pensioners Convention, said: "One
report after another shows that we still cannot guarantee that
when an older person goes into hospital or a care home that they
will have their dignity respected. This is tantamount to
institutionalised abuse. Where else in our society would we tolerate
such neglect without a huge public outcry?“
Care Minister Norman Lamb said he expected "swift action" to be
taken where services were not up to scratch. "We want Britain to be
the best country in the world to grow old in - but we have a lot of
work to do," he said.
©2013 Robert Francis QC
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Recommendations
Involve patients, public, staff
Common values
Fundamental standards
Openness, transparency and candour
Compassionate, caring, committed nursing
Strong patient centred healthcare leadership
Accurate, useful and relevant information
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Values – Clarity and Commitment
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Put patients first
– Staff put patients before themselves
– Staff do everything in their power to protect patients from
avoidable harm
– Openness and honesty with patients regardless of
consequences for themselves
– Direct patients to where assistance can be provided
– Apply NHS values in all their work
Make NHS Constitution the shared reference point for values
All NHS and contractors to commit to NHS value
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Organisations do not need to wait to
be told what to do
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Recommendation 1: report on acceptance and
implementation
Commitment to NHS values by staff and contractors [R7-8]
Standard procedures [R11]
Reporting of concerns to be encouraged and supported
[R11-12]
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Compassionate caring
Committed Nursing
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Aptitude assessment on entry
Hands on experience a prescribed requirement
Standards of training standards, assessment , appraisal for core
values and competence to deliver
Named nurse [and doctor] responsible for each patient
Code of conduct and common training standards for HCSWs
Registration requirement for HSCWs plus power to
disqualify/share info re concerns
Reward good practice; recognise special status of care of elderly
Review Knowledge & Skills Framework
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Nurses do not have to wait to be
told what to do
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Nurse leadership reinforcing values, standards and delivery
Recruit for values and compassion
Training and supervision in humane, skilled and
compassionate hands on care
Support and supervision for HCSWs and other team
members
Report and pursue concerns
©2013 Robert Francis QC
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Fundamental standards
Why wait for regulations?
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Prescribed medication must be given
Patients must be provided with appropriate food and drink
and help to consume it
• Patients and equipment must be kept clean
• Assistance to go to the lavatory must be given
• Consent for treatment must be obtained
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Fundamental standards
Guidance
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NICE to provide evidence based guidance and procedures
which will enable compliance with fundamental standards in
each clinical setting.
NICE also to provide evidence based means of measuring
compliance
Guidance to include measures for staff numbers and skills in
each clinical setting required to enable compliance with
fundamental standards.
But some tools exist now...
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Candour
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Statutory obligation and sanction
– Healthcare provider organisations under a duty to inform patient
Statutory sanction
– Wilful obstruction of these duties should be a criminal offence
– Deliberate deception of patients in performing duty should be a criminal
offence
BUT organisations can insist on candour NOW
– No censoring of critical internal reports and full information for patients
– Welcome information about concerns
– No tolerance of victimisation of those raising concerns
– Offer balanced information to the public
– Offer whole truth to regulators and commissioners [and insist on the same
from others?]
Offer swift remedies and help to patients who have been harmed
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Openness
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Welcome complaints and concerns
Ban gagging clauses
Genuinely independent investigation of serious cases
Involve complainants , staff in investigation
Real feedback to all
Real consideration by Trust Board
Information on actual cases shared with commissioners,
regulators, and public
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Transparency
• Honesty about information for public
• Balanced information in quality accounts about
failures as well as successes
• Independent audit of quality accounts
• Truth not half truths to be told to regulators
• Ensure no misleading information to regulators
• CQC to police information obligations including
information on enhanced quality standards
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Strong Patient centred leadership
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Recruit and train for values
– Support professional development
– Voluntary accreditation
Leadership by example
Code of conduct prioritising patient safety and wellbeing,
candour
Hold staff to account for serious breach and deficiencies
Involve and listen to those you serve
©2013 Robert Francis QC
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Accurate useful relevant information
• Individual and collective responsibility to devise
performance measures [R262-267]
• Patient, public, commissioners and regulators to
have access to effective comparative performance
information for all clinical activity
• Improve core information systems
©2013 Robert Francis QC
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LOOK ‘EM UP!
©2013 Robert Francis QC
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Extract from written evidence of Mr Street WS0001000717
LESSONS FROM STAFFORD
THE END!
Robert Francis QC
Learning for clinicians
Introduced by
Deborah Arnot, Interim Director, NHS NW Leadership
Academy
What went wrong at
the frontline and why?
Professor Tricia Hart, Chief Executive, South Tees NHS
Foundation Trust and Clinical advisor to the Mid
Staffordshire NHS Foundation Trust Public Inquiry
“I would rather be kept alive in the altruistic
atmosphere of a large hospital than expire in a gush of
warm sympathy in a small one.”
“The medical profession is not an easy one to handle. It
is composed of eminent men and women who have
devoted themselves to it, but do not appear to bring
the same collective sagacity to bear upon the
profession as they do upon their individual patients.”
Aneurin Bevan
“The NHS is a novel experiment. It is an attempt on the
part of the British society to reconcile two normally
conflicting interests, centralised financial responsibility
and decentralised administration at the periphery.”
“How could all this happen and we not see it?”
Culture:
The way we do things round here when no one is looking!
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Inwardly focused
Complacent
Resistant to change
Resistant to innovation
Little staff development
Accepting of low standards
Low professional self esteem
What are your thoughts?
Wall of shame
‘‘Everyone’s behaviour is a reflection of the
culture of the organisation they work for”
Our focus must be on how we can create a
culture across the NHS where every member
of staff provides the best, most compassionate
care for every patient, every time, and delivers
services we would be happy to receive
ourselves or for our family and friends.
The opportunity
to improve the
way the team
works
The resources
I need to
deliver quality
care
The support I
need to do a
good job
A worthwhile
role with the
chance to
develop
When you are
part of a
culture you
have an
opportunity
to influence it
290 recommendations
“The greatest danger for
most of us is not that our
aim is too high and we
miss it, but that it is too
low and we reach it”
- Michelangelo
Mahatma Ghandi
1869 - 1948
“Keep your thoughts positive because your thoughts
become your words. Keep your words positive because
your words become your behaviour. Keep your
behaviour positive because your behaviour becomes
your habits. Keep your habits positive because your
habits become your values. Keep your values positive
because your values become your destiny.”
-Mahatma Gandhi
Question
Are you currently assured at the
board on the quality of care in
every clinical area where care is
delivered e.g. every ward?
Question
If you answered YES what gives
you that assurance?
Question
If you answered NO how can
you get that assurance?
Tea and coffee break
(15 minutes)
Learning from patients and
relatives when it all goes wrong
Introduced by
Steve Connor
When it all goes wrong
Martin Bromiley
Airline Pilot and Chair, Clinical Human
Factors Group
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Good clinicians don’t make
mistakes
We do stuff to patients
Good people find ways to get the
job done whatever
Paperwork and audit assures us
we are safe
We did our best but sometimes
these things happen
We must achieve good
outcomes, safety & experience
©2013 Robert Francis QC
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Good clinicians don’t make
mistakes
We do stuff to patients
Good people find ways to get the
job done whatever
Paperwork and audit assures us
we are safe
We did our best but sometimes
these things happen
We must achieve good
outcomes, safety & experience
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Human error is normal, systems &
behaviours help avoid/trap/mitigate
Patients are part of the solution
Good people stick to SOP’s and say
when SOP’s don’t help
Watching behaviours and training
assure us
Safety is a scientific, evidenced
created outcome
Each person is trusted to prioritise
based on the circumstances
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Clinical Human Factors
“enhancing clinical performance through
an understanding of the effects of
teamwork, tasks, equipment, workspace,
culture, organisation on human behaviour
and abilities, and application of that
knowledge in clinical settings”.
Ref CHFG from Dr Ken Catchpole
What key things can you do?
What key things can you do?
Name an animal who’s
name begins with “R”
What key things can you do?
• Investigate thoughtfully, learning is the goal
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Investigation:
Patients want to learn what happened & want to
make sure this doesn’t happen to anyone else
Clinicians involved want to make sense of what
happened and never want this to happen again
You want to make sure this never happens again; and
so improve the reliability and efficiency of the
organisation
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Limitations of RCA in practice:
Confusion over learning and blaming
Involvement of management/regulator
Potential use of evidence by
management/regulator/victim/Police
No requirement for investigators to be trained
Overly focussed on “being open”
Often dependent on “complaints”
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Investigation practice in UK transport:
Independent of management structure
Focus on what happened & learning, not on those involved
Looks at all casual factors, not just “root cause”
Evidence and final published report not admissible in Court
Anonymous report publically & easily accessed
Includes technical and human factors specialists
©2013 Robert Francis QC
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What key things can you do?
• Investigate thoughtfully, learning is the goal
• Encourage the experts to design systems that
make it easy to do the right thing, every time
©2013 Robert Francis QC
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Systems:
Keep systems as simple and easy to follow as
possible
Encourage/role model for good non technical
behaviours (e.g. situational awareness,
decision making, team working, leadership)
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What key things can you do?
• Investigate thoughtfully, learning is the goal
• Encourage the experts to design systems that
make it easy to do the right thing, every time
• GOYA and listen, aim for collaborative decision
making
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What key things can you do?
• Investigate thoughtfully, learning is the goal
• Encourage the experts to design systems that make it
easy to do the right thing, every time
• GOYA and listen, aim for collaborative decision
making
• Talk about patients being killed or maimed, not
nameless statistics
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What key things can you do?
...and remember that everything you say or do sets the
tone for the whole organisation.....
If a junior member of your Trust can’t deliver safety
AND good outcome AND positive patient experience
what would you want them to do....when no one is
around to help them?
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Clinical Human Factors Group
www.chfg.org
We are independent, impartial, and work
in a voluntary capacity…
Our vision is to engender human factors
thinking in the hearts and minds of all
healthcare staff and stakeholders.
From board to ward and beyond…
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What are we doing?
• Working with the NQB and bodies such as the NHS
CB, GMC, NMC, Leadership Academy, HEE, NICE, CQC
etc to embed human factors in the policies,
frameworks, education and regulatory processes that
affect you
• Representing HF in various other groups
• Promoting human factors widely and providing free
education materials/seminars/advocates
©2013 Robert Francis QC
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DH HF Reference Group
Recommendations inc:
• HF Advisory Body to coordinate action across system
• Thematic reviews of “Never Events”
• Embedding HF in education and training
• Trial of independent investigation using transport
model
• Support for NHS Boards around HF
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Consultant Anaesthetist
Consultant Anaesthetist
ENT Surgeon
Senior ODP
ODP
Recovery Nurse
Recovery Nurse
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Thank you…
……want to learn more about HF in healthcare?
• Have a look at www.chfg.org and register to stay in touch
• Have a look at our website for resources and links, inc HF How
to Guide
• In the coming weeks we’ll have the “HF How to Guide Vol 2”
and by June “Boards on Board”
• http://www.chfg.org/wp-content/uploads/Never-Eventsfinal2.pdf
• Watch out for our next free seminar due autumn 2013
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Lunch
(45 minutes)