The story is based on the testimony of Dr Beatrix Futak-Campbell, Alexandra’s mother. It is a harrowing and tragic account which raises many issues for professionals involved in caring for parents in labour including use of the controversial Keilland’s forcep mode of instrumental delivery.

But the film’s major theme is that of “making amends” and raises the challenging and uncomfortable subject of what happens when different realities collide after harm has occurred.

We hope that by working with a broadcast media partner we will be able to stimulate a debate amongst professionals, patients and the wider public, about this crucial area of practice.

His work as a member of the Royal College of Surgeon’s / NHS England “Never Events” Task Force began in April. The public consultation is due to begin later this month. Murray is joined on the “Never Events” Task Force by Clare Bowen, mother of Bethany Bowen, with whom we collaborated to make our award-winning documentary “Beth’s Story” in 2010. Murray will also be joining an expert reference group to support the Care Quality Commission’s forthcoming consultation on the new inspection regime for acute hospitals and mental health trusts.

Murray commented “I’m delighted to have been invited to advise on these crucial initiatives. It is particularly encouraging to see that the experience and knowledge of those who have experienced harm is not only being heard but actively valued and used. For too long their stories have at best been unheard and at worst, ignored. Both processes have real potential to influence policy and practice to reduce harm but not if they are run like committees. So far, I am encouraged and our stories are helping to keep people grounded in the reality of what it means to people’s lives when things go wrong”

If you would like to participate in these consultations, simply follow us on twitter @patientstory or register on the website and we’ll let you know how you can join in the process.

He was a Special Advisor to Stephen Ramsden OBE in his role as National Director for Patient Safety First, the NHS campaign for patient safety improvement. Murray was then seconded part-time to work as Head of Strategy and Communications for the campaign. He led the delivery of the national campaign’s engagement strategies and produced a wide range of on-line resources and targeted campaigns including the first NHS National “Patient Safety First” week in 2009.

In addition to his role with PATIENTSTORIES, Murray is currently working with a wide range of networks and campaigns associated with quality improvement in healthcare including the Health Foundation, the Clinical Human Factors Group, AQuA, The Network, NHS Quest and NHS England.

He is a member of the Royal College of Surgeon’s “Never Event” Task Force and the Care Quality Commissions expert reference group for the new inspection regime for acute hospitals and mental health trusts.

His work has contributed to the Public Inquiry into the failings of care at Mid Staffordshire NHS Foundation Trust led by Robert Francis QC and the current review of the Francis report recommendations by Don Berwick.

Increasingly his research and writing is focussing on the cultural & ethical dimensions of quality and safety in healthcare and he is currently producing associated content for broadcast media partners including The Guardian and the BBC.

Murray is a member of the Medical Journalists Association and in 2011 was shortlisted as a finalist for the MJA Winter Awards (investigative/broadcast category) for “Beth’s Story”

There has been a great deal of talk about the need for “cultural change” in and around the health service in recent weeks. There has also been a great deal of publicity around the need for accountability. In the wake of the Francis Inquiry, Cure the NHS have called for the resignation of Sir David Nicholson, the NHS Chief Executive. Extensive media coverage has been fuelling the debate.

Professor Sidney Dekker, a cognitive psychologist and current Director of the Key Centre for Ethics, Law, Justice and Governance at Griffith University in Brisbane, Australia has a great deal to offer on the matter.

Dekker has focussed on the development of “Just Cultures”. He defines these are environments where learning and accountability are fairly and constructively balanced. The construct is based on a fundamental belief that when people make honest mistakes it is important to protect them from being seen as culpable.

Whilst this seems relatively simple and understandable, the concept forces us to consider the whole question of what constitutes an honest mistake, or rather, when is a mistake no longer honest?

Sidney Dekker argues that in complex human systems it is naïve to believe that there are absolute lines to be crossed or obeyed or that there can be pre-prescribed consequences for those who “cross the line”.

In his view those “lines” don’t just exist out there, but rather we – people – construct those lines; and that we draw them differently all the time, depending on the language we use to describe the error, on hindsight, history, tradition, and a host of other human, organisational and political factors.

What matters to Dekker is not where the line is drawn – but how it gets drawn and who gets to draw it. He argues that if we leave this to chance or to regulators, prosecutors or the media; or if we fail to be clear with those involved about who may end up drawing the line, then a just culture will be very difficult to achieve.

The absence of “just cultures” in an organisation, or indeed a whole industry or society he contends, will damage both justice and safety. If our responses to incidents, accidents, errors and mistakes are seen as unjust the effects will be significant.

Safety investigations will not produce deep learning but promote fear rather than mindfulness in people who do safety-critical work. Moreover they risk making organisations more bureaucratic rather than more careful, and cultivate professional secrecy, evasion, and self-protection.

A “just” approach is critical for thinking culturally about safety. Without ways of routinely talking about failures and problems, without openness and information sharing, a safety culture cannot flourish.

Key Points

• “Just Culture” is about creating a balance and between accountability & learning

• Changing the way we think about accountability and making it compatible with learning

• Clarity about WHO & HOW the line is drawn not necessarily WHERE it is drawn?

• Ensuring consistency between “story lived and the story told”

Things to consider

• Avoid the trap of the illusion that there are absolutely clear lines between acceptable and not acceptable

• Assess the way you deal with incidents and the tools that you use to determine not just what happened but how it happened (identifying the “error producing” conditions)

• Independent reporting & investigation is a crucial aspect of the creation of a “just culture”

• How data is shared and “protected” from undue probing is a crucial part of the process for determining who is involved in “drawing the line”

• Be clear about how the internal process works – to minimise anxiety about line-drawing.

Conclusion

A relational approach – a multi-disciplinary concept but with its roots within social psychology – recognises that every “solution” creates the context for a new problem. Thus approaches to change that are linear, politically motivated or expedient are unlikely to yield the long-term or sustainable gains needed to establish new cultures over time.

Thinking culturally about safety is complex and multi-factorial. There are no “silver bullets” and the “myth of leverage” (i.e. the notion that one critical move in the system will create cultural change) must be resisted. It requires thoughtful, creative and sophisticated responses and an intelligent system of regulation.

Safe care is fundamentally about morally sound professional practice within ethical organisational systems. It is about high quality clinical leadership, effective team working, respect, tolerance and professional humility. It is about curiosity, inquiry and excellence in communications both with patients and between professionals.

Sustainable systemic improvements in patient safety will only come about when organisational and professional attitudes and patterns of behavior start to shift to reflect these features.

We need to concentrate our efforts on creating the conditions for the difficult, sometimes uncomfortable but ultimately honest and hopeful conversations that will build those changes.

Related reading

Dekker, S. (2007) Just Culture – Balancing Safety & Accountability. Ashgate

Rowley, E. & Waring, J. (2011) A Socio-cultural Perspective on Patient Safety. Ashgate

Shale, S. (2011) Moral Leadership in Medicine. Cambridge University Press.

Far from sapping their time and energy, nurturing the healing relationship at the heart of medicine sustains clinicians’ vitality.

This article was originally published by the Health Service Journal

How do we learn from patients’ and families’ poor experiences? - PDF document

Gillian James, a former nurse, lived largely independently with progressive multiple sclerosis for more than 30 years. This film tells the story of the care she received in a number of settings during the last sixteen months of her life.

This film was first shown at the NHS England / NHS Institute for Innovation and Improvement National Patient Safety Conference on the 30th January 2013.

Murray Anderson-Wallace, PATIENTSTORIES Executive Producer who worked with the family to research and produce the film, introduced “Gillian’s Story” to the audience of 450 healthcare leaders by reflecting on the themes he felt the film raised.

“Firstly, I see a very real and complex story that provides us with vital insight about the hopes and expectations.  I see solid data about quality of care – how safe it felt, how effective care was and what the emotional and practical experience was like for Gillian and her family – all rolled up into an immediately accessible human ‘quality dashboard’.

“Gillian and her family placed trust in their caregivers to do the right things on their behalf.  They rightly expected that Gillian’s care would be co-ordinated and that communications between services and with them would be sensitive and careful.  And, when at their most vulnerable, they expected very special care to be taken to ensure that they came to no harm. They assumed that they would be treated compassionately in times of crisis and with dignity at the end of Gillian’s life.

“I believe that these fundemental expectations were breached. I think that the bond of trust was broken and mistrust and fragility dominated the relationships.  It coloured everything that happened thereafter and became the only lens through which action could be understood, by everyone involved.

“Secondly, I see a system that lacked resilience.  A system without the intrinsic ability to adjust its functioning before, during, or after changes and disturbances, so that it could sustain reliable operations under both expected and unexpected conditions. Without that resilience the system was bound to fail and the people who worked within it, and those who relied on their services, would inevitably suffer.

“But a focus on the resilience of the system does not mean that individuals should not be held to account for their actions – it is not good enough to just blame ‘the system’.  I believe that it is the social, moral and professional responsibility of all concerned – doctors, nurses, managers, policy makers – to speak up and say ‘This is unacceptable’ when they see such failings emerging.   In fact, I would go further and say it is their responsibility to actively seek it out.

“Finally, this care system lacked responsive, compassionate leaders and that was probably its biggest failing.”

A more detailed article exploring the issues raised by the film will be published shortly. If you would like to be notified when this becomes available, please register on this site for our e-bulletin and you will be the first to know (see bottom of this page).

We are collecting people’s responses to Gillian’s Story – Click here to take survey

This article is part of a series of pieces written to co-incide with the publication of the Francis Inquiry.

The attached PDF is an extended version of an article originally published by the Guardian Healthcare Network.

What kind of problem is NHS culture – Download PDF

“At 6.15pm on 27th July 2006 my family’s world as it was ended. We were a normal family of five; now we are three.”

Clare Bowen, mother of Bethany, Will & James and widow of Richard.

In this moving and challenging documentary we tell the story of the Bowen family following the tragic death of Bethany during ‘routine’ surgery. Following the trauma of his daughter’s death and the ‘torture’ of the inquest, Richard died suddenly of a massive heart attack aged 31 years.

Clare’s remarkable courage and humanity in the face of extreme tragedy is the hallmark of this powerful and provocative film. Through Clare’s testimony the film offers professionals the opportunity to explore the multiple ‘human factors’ that lead to Beth’s untimely death and to re-examine their own ideas and practice in relation to serious harm in the healthcare context.

Ultimately, this film is another step in Clare’s search for truth and reconciliation.

How to order and use Beth’s Story

The key purpose of Beth’s Story is to engender personal reflection and learning and to stimulate debate and discussion on key issues for improving patient safety.   A range of important themes and issues can be identified from Beth’s Story, including:

1. The nature of error and blame
2. Managing the aftermath of a tragic event
3. The challenges of developing a culture of openness

Beth’s Story can be used in education sessions and discussion groups to focus on some or all of these themes.

To  help facilitators get the most out of Beth’s Story, we’ve also put together a Facilitator’s Pack.  This includes:

• Beth’s Story DVD
• Beth’s Story – Comment & Analysis DVD
• Beth’s Story – a guide for facilitators. This is a comprehensive booklet which guides you through how to get the most from the film including:

1. Before you show the film – preparing the audience
2. Key themes
3. Suggested formats for facilitated sessions
4. Use of questions for discussion

Beth’s Story as both an individual film in DVD format and also as part of a Facilitator’s Pack is available to order online  - use our on-line order form here.

.

A play in 4 acts, with a prologue and epilogue

Set in this country and performed by a large cast.

Dramatis personae: members of the judiciary, police, NHS staff, teachers and examiners, journalists and broadcasters, social workers, bankers and politicians. All played by themselves (with some actors playing more than one part)

Synopsis of the Play:

Prologue
An individual or group of people is/are responsible for an error, mistake or intentional action which affects others adversely and then cover it up completely, distancing themselves from it, denying that it ever happened and if necessary, falsifying any evidence.

Act 1
A sharp-nosed journalist or ordinary member of the public suspects some wrong-doing and undertakes substantial, detailed research to uncover the truth. Those responsible vehemently deny any responsibility, often couching their response in impenetrable jargon appropriate to their particular institution.

Act 2
As public opinion grows, an internal review is launched, which completely exonerates the accused. Journalists/broadcasters/ public pressure groups refuse to accept the findings and seek an independent inquiry.

Act 3
A further inquiry chaired by an independent, eminent person is launched, costing many thousands and lasting several months. It reveals  most of the truth and makes a number of recommendations for improvement of the offending institution and/ or its staff.  It is greeted with the gravely uttered words “Lessons will be learned” by a spokesman for the institution. The tabloids and large sections of the public call for “heads to roll”and are told by supporters of the accused not to seek for “scapegoats”. They continue to press for a further inquiry.

Act 4 (Several months or years later)
Little or no action having been taken, to improve the offending institution or bring its personnel to account, a further enquiry is launched, chaired by an even more independent and eminent person. This costs several million pounds and can take several years to report. It reveals nearly all of the truth about the original situation and makes large numbers of additional recommendations for future improvement.

Amidst the ensuing chorus of calls for “heads to roll”, a spokesperson commends the excellent report and utters the immortal words, as the curtain falls, “Lessons will be learned”.

Epilogue
Another situation begins in which an error………

Jenny Wallace B.Ed MA is a retired teacher and was Director of Sixth Form Education for a large comprehensive school in York.  She is now an avid golfer, dedicated grandmother and wife, NHS patient and critic.

In 2007 when Paul Richards was diagnosed with non-Hodgkin lymphoma his family were stunned by the news.  Paul was fit, healthy and had a happy family and work life.  Paul began treatment which was progressing well and his family were slowly adjusting to Paul’s diagnosis.  Everyone was hopeful.

An admission to hospital however was to cost Paul his life and change his family forever.

On the 22nd July 2007,  Paul Richards and Baljit Singh (both inpatients on the same ward) died as a result of being given lethal accidental overdoses of Amphotericin, a highly toxic anti-fungal drug often used during chemotherapy.

This powerful film is based on the testimony of Lisa, Paul’s wife who gives a moving account of the events that led to Paul’s death and explores the effects on their family.

Paul’s Story is accompanied by a short film that explores and analyses the multiple organisational and human factors that contributed to this avoidable error and questions the systems we use to “alert” hospitals to such hazards.

Organisational subscribers to PATIENTSTORIES will automatically receive this film and the accompanying facilitators guide.   Non-subscribers can buy the DVD version of the film on our website.