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Healthcare providers need to learn from mistakes rather than simply appointing blame

Incident investigators should also take into account the environment and pressures staff are working under.

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Finger Pointing Blame
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Providers need to focus on learning lessons from mistakes and preventing errors.

It is important for healthcare providers to focus on learning lessons from mistakes and preventing them in the future rather than simply looking to assign blame, says the Royal College of Nursing.

The comments come following the publication of a landmark review into gross negligence manslaughter and culpable homicide by the General Medical Council (GMC).

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The review was undertaken in response to the treatment of Dr Hadiza Bawa-Garba and Nurse Isabel Amaro who were convicted by the courts of gross negligence manslaughter following the death of Jack Adcock.

It calls for investigators to standardise their approach and take into account the environment and pressures staff are working under. Legal protection for reflective notes and the use of independent medical advisors to quickly determine if a criminal investigation is necessary are also recommended.

Echoing the findings of previous reports, the review highlights that black and ethnic minority backgrounds are more prone to complaints and investigation.

Impossible situations.

A spokesperson for the Royal College of Nursing said:  “Healthcare needs to be viewed as a safety-critical industry, with a focus on learning lessons from mistakes and preventing errors in the future rather than apportioning blame.

“Taking the approach we witnessed in the Dr Bawa-Garba case risks creating an environment in which clinical staff feel afraid to come forward for fear of censure.  In particular, we support the findings related to addressing the over-representation of black and ethnic minority staff in this type of criminal case.”

“There is nothing worse for a healthcare professional than knowing you’ve made a mistake or weren’t able to give the best possible care to a patient.  Focusing solely on individual blame ignores wider lessons, and risks repeating the mistakes of the past.

“Chronic nurse understaffing has left thousands of healthcare professionals doing the best they can in impossible situations, and simply blaming them when things go wrong, rather than addressing the wider issues, is not the answer.

Tragedy and unspeakable distress.

Dr Chaand Nagpaul, Council Chair for the British Medical Association, said: “When an error is made in a medical environment that is so serious that a patient loses their life, though incredibly rare, it is a tragedy, causing unspeakable distress to the person’s family and loved ones, as well as to the health professionals involved.

“This review’s recommendation for the appropriate authority to scrutinise the environments that doctors find themselves working in is a positive one. The BMA has repeatedly called for systemic pressures to be explored and recognised when errors occur.”

“That doctors from black and ethnic minority communities are more vulnerable to complaints and investigation, and are disproportionately represented in fitness-to-practise proceedings, is another concern that the BMA has long been raising, and we welcome this review’s work and recommendations in this area.”

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Professional Regulation

NMC apologises after misleading Morecambe Bay investigators

Up to 19 babies and mothers died between 2004 and 2012 as a result of mistakes by staff.

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The regulator has apologised over how it handled a Fitness to Practice investigation.

The Nursing and Midwifery Council (NMC) has apologised over how it handled a Fitness to Practice (FtP) investigation following the tragic death of newborn Joshua Titcombe at Morecambe Bay.

The independent review by Verita was commissioned by the NMC after the Professional Standards Authority (PSA) raised concerns over how the regulator handled the fitness to practice investigation.

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The report was initially commissioned by Jeremy Hunt, the then Secretary of State for Health and Social Care, after up to 19 babies and mothers died at the hospital between 2004 and 2012 as a result of mistakes by the staff of its maternity unit.

Jackie Smith, the former Chief Executive and Registrar of the NMC, resigned on the eve of the PSA report.

‘Incorrect and misleading statements’.

Investigators highlighted concerns over a chronology that was submitted as evidence by Joshua’s parents. They commented that they regulator failed to include the chronology in the evidence gathering process and also failed to “consider and understand the significance of this evidence and its relevance to a central issue in the case.”

The NMC then went on to make “incorrect and misleading statements” to Joshua’s parents, the PSA and the Secretary of State for Health about how it handled and reviewed the chronology.

Verita also commented that the regulator failed to treated witnesses “with the respect and sensitivity they deserved”.

Investigator on to recommend that the “NMC should make it a priority to ensure that it treats families and patients with respect and is honest and open with them” and “ensure that Panel Chairs are fully briefed about the importance of showing respect to bereaved relatives, perhaps by using this example as a case study.”

The total cost of Verita’s report was £151,742.22.

‘I am very sorry’.

Andrea Sutcliffe CBE, the current NMC Chief Executive and Registrar, said: “Throughout these fitness to practise cases the way we treated Mr Titcombe and his family was unacceptable. Our actions made an awful situation much worse and I am very sorry for that. I am also very sorry that our communications with Mr Titcombe, the PSA and the Secretary of State for Health and Social Care contained incorrect and misleading information about our handling of this evidence.”

“This investigation highlights a number of failings at the NMC at that time. We did not properly understand the significance of this important piece of evidence, in particular to Mr Titcombe and his family, and we did not put it before the panel when we should have done. This reflected a culture at the NMC at that time that prioritised process over people.”

“Since the events at Morecambe Bay we have made significant changes, including much improved record keeping, the introduction of a new public support service, and additional training for panel members to help them better understand the needs of witnesses.

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Hospital charity launches Christmas gift appeal for patients

Those wishing to help the campaign can buy a gift or donate online.

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Send a smile

The Send a Smile with Santa campaign delivers presents to patients who are unable to celebrate Christmas at home.

A campaign to deliver more than 1,000 gifts for inpatients at the Norfolk and Norwich University Hospital on Christmas Day has begun.

The N&N Hospitals Charity’s Send a Smile with Santa campaign delivers presents donated by the public to patients, both young and old, who are unable to celebrate Christmas at home with their families.

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Those wishing to help the campaign can choose an item from our Send a Smile with Santa list on Amazon or make a donation which will be used exclusively to purchase a gift.

Donations can also be dropped off by Sunday 8 December at the West Atrium Inpatient reception, Cromer Hospital, the Archant offices on Rouen Road, Norwich, and Greater Anglian Norwich Railway Station Customer Service.

The charity says that any donated presents should remain unwrapped so staff can ensure that presents are individually tailored for each patient, as well as protecting against potential infection.

‘Overwhelmed by kindness’.

Prof Nancy Fontaine, NNUH Chief Nurse, said: “We were overwhelmed by the kindness of people last year and we were able to deliver a lovely present to each of our patients.

“Nobody wants to spend time in hospital, and Christmas is so often a special time for people to be with family, and this is why we like to do something to make it a little nicer for our patients.

“We really hope that the people of Norfolk will once again support our appeal and help put a smile of the faces of our patients during the festive period.”

Louise Cook, Head of Fundraising at NNUH, added: “We know from our patients how lovely and unexpected it is to receive a gift on Christmas Day. They don’t need to be expensive gifts – toiletries, puzzle books, chocolates or socks are always greatly received.

“We have heard from people who would like to donate a gift but are unable to get out, so we this year we have an Amazon Wish List with small items which can be purchased and will be delivered directly to us, or a JustGiving page where a donation can be made and we will use that to purchase a gift for a patient.”

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