Bill Kirkup presents on the independent investigation into East Kent Maternity Services at #Anaesthesia2023 #OBAnes
Battled with how to put “In their own words…” together. 4 slides at a time doesn’t cut it. It was a very emotive experience. So I hope this works (Twitter Blue perk)
#Anaesthesia2023 #OBAnes (prelude to #OAA23ASM)
In their own words: FAMILIES.
Midwives, not nurses. They cut me open (@HofkampMichael @emilysharpe @ruthi_landau). He’s singing, then he died. We don’t talk about cesareans. Physician: I’m the doctor. Midwife: we won’t be doing that.
And that last one… apropos of @SQuashie’s… twitter.com/i/web/status/1…
In their own words: STAFF
Big egos, cliquey behaviour (OB, midwives). Made to look stupid. Dread going to work. A successful day: getting to car without tears. OB: hearsay & uncorroborated (until there are how many witnesses? How many errors?). Consultants refuse to come in.… twitter.com/i/web/status/1…
In their own words: AFTERMATH.
That first slide. I didn’t do my job, but I was handing over remember? That’s a PATIENT being asked if she could have done better. Discipline vs reflect. Cover ups. What caused suffering or extended suffering = lies. Grammar >>> #patientsafety. Why… twitter.com/i/web/status/1…
What happened:
Underlying failures - teaming (@AmyCEdmondson keynote from #SOAPAM2023 elsewhere on timeline); respectful workplaces; compassion and listening missing - replicated and repeated cycle of harm. (@SusannaStanford paraphrased in that quote)
Effects on care: most… twitter.com/i/web/status/1…
MISSED OPPORTUNITIES - EIGHT separate clear opportunities to change course, learn, improve between 2010 & 2018. However, reports met with 3 F’s (disbelief, denial and deflection). Arrogance. Any review met with hostility. All is well, good enough.
#Anaesthesia2023 #OBAnes… twitter.com/i/web/status/1…
Action now: a different approach required, after an endless cycle of failures. Can’t assume restricted to East Kent (@DOckendenLtd has demonstrated that, hopefully not worse in Nottingham). No detailed operational recommendations- FOUR areas for action: none easy, all… twitter.com/i/web/status/1…
Area 1: Maternity Signalling System. Plenty of data, no outcomes. Analyze poorly. Need 4 things. Accept natural variation, trends and outliers.
Area 2: Standards of Behaviour. Staff under strain ≠ excuse bad behaviour. Role models, not teaching. Can’t change vs won’t change?… twitter.com/i/web/status/1…
@threadreaderapp unroll please
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