Took yesterday to read the @DOckendenLtd report. The scale and extent of death & injury is appalling. The behaviours reported are unacceptable. That staff withdrew statements very recently is deeply disturbing. But this is not about one Trust 1/5
Nationally the NHS, professional bodies etc need to identify what behaviours are more likely to lead to optimum outcomes & which ones are commonly present in disasters. And how the better behaviours can be encouraged by the systems that influence the frontline. 2/5 #humanfactors
Training staff in teamworking/human factors/CRM/TRM/non-technical skills can’t work in a vacuum. Behaviours trained must be agreed, explicit, examined, expected, role-modelled, routinely assessed and performance managed across the whole system from day 1 to retirement 3/5
No system should ever change in the NHS without those accountable understanding “work as done” and how those changes will make it easier for the frontline to deliver safer, more efficient care with (not against) other staff groups 4/5
Finally @DOckendenLtd has done a remarkable job. But it’s the harmed families who have driven safety, who have helped make a difference, who have sacrificed much of their lives to try & help it not happen to others. When will healthcare drive safety & culture change? 5/5
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