Thread by @markhughes1878

🧵#PatientSafety thread🧵

(1/12) Today @ptsafetylearn have shared a new analysis of the findings of the investigation into maternity & neonatal services at the East Kent Hospitals, published last month. This thread provides a brief summary of this⬇️
pslhub.org/learn/investig…

(2/12) The investigation covered serious safety failings, avoidable patient harm and deaths between 2009 and 2020. It makes a difficult read, finding that if nationally recognised standards had been followed, the outcome could have been different in 97 of the 202 cases reviewed.

(3/12) Initial responses have understandably focused on the implications for maternity care, explored in detail by organisations such as Sands, Tommy’s & Baby Lifeline. For example the below @birthrightsorg blog👇
birthrights.org.uk/2022/11/02/bir…

(4/12) In this analysis @ptsafetylearn looks at the report from a broad patient safety perspective, focusing on five key themes that are consistent with many other serious patient safety inquiries and reports in recent years.

(5/12) The key themes we focus on are as follows:

1⃣ Failing to listen to patients
2⃣ Still not learning from investigations
3⃣ Poor behaviour and a corrosive blame culture
4⃣ Lack of effective leadership for patient safety
5⃣ Absence of an effective regulatory framework

(6/12) Many of these issues can also be seen in other recent maternity inquiries, such as Morecambe Bay and Shrewsbury & Telford, but also in other serious patient safety failings, such as the Paterson Inquiry, the Cumberlege Review and the Mid-Staffs report, just to name a few.

(7/12) In some of these areas, such as improving investigations, work is underway to seek to do this (e.g. new Patient Safety Incident Response Framework). However in others, such as patient safety leadership, the evidence of meaningful changes being made is somewhat lacking...

(8/12) This is also another scandal which has relied on the persistence and determination of families/patients to bring these issues to light. The regulatory system did not identify these problems early enough and when they did action and improvements did not necessarily follow.

(9/12) This problem was also recently highlighted in a @prof_standards report - "more is needed to sharpen the linkages between the system’s constituent parts to deliver system wide responses to patient safety concerns that are adequate, robust and timely"
pslhub.org/learn/organisa…

(10/12) @ptsafetylearn argue that the Government and NHS response should not only respond to the reports direct recommendations, but also consider these system-wide issues and account for the broader trends from reports and inquiries from the last 20 years.

(11/12) We need to tackle the systemic causes of these issues. Central to this we argue is the need for a transformation in our approach to patient safety, ensuring that this is treated as a core purpose of health and social care.

(12/12) If we don't tackle the underlying causes of avoidable harm, we simply won't break from this chain of harrowing accounts of patient harm and deaths in future years. Read the full article below👇
pslhub.org/learn/investig…