Patient safety

Random stuff

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After many years, things are being taken out of cup-boards and off shelves, turned inside out and properly looked at. Dusty books, clothes, folders, boxes and sachets. Some familiar fragrances are escaping and some old scenes are playing out on the screen of the mind. Bits of stuff slipping out of other stuff and falling to the ground with a clink. Some stuff that was believed to be misplaced is being placed. Some that was believed to be forgotten is being revisited.

Sample 1

A nappy pin. Special feature – A white safety cap to prevent accidental opening up while the baby has his cloth nappy on. Commonly used in India and other developing countries. Original owner: Baby Saagar.

Sample 2

A business card. Special feature – Simplicity. An invitation to music and joy. Original owner: Saagar.

Sample 3

A Crisis Plan. Special features – Not worth two pennies. Highly ineffective. Not accompanied by a conversation. No detail. Not individualised. Not created in partnership with the patient. Not an alive document. Does not mention anything more than ‘self-harm’. Doesn’t tell us what ‘Crisis’ looks like. Doesn’t identify any helpful distractions, activities, friends or family. Doesn’t appear to know the patient, for example, a key fact – does this person have a key worker? Does not express any understanding or compassion.

Commonly used in developed countries.

Oops! The name of the GP surgery is visible. It doesn’t matter. It closed down years ago. We were it’s last few unlucky patients. Owner: Saagar Naresh (1994-2014).

(Resource: Safety Planning is essential to safety: https://stayingsafe.net/home)

Home

CHIME

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132 billion pounds = money saved for the UK by unpaid carers.

6.5 million = number of carers in the UK.

6000 = number of people who become carers every day.

1 in 8 adults are unpaid carers for a family member or friend.

Carers UK call them ‘The Second NHS’.

Yet, do we or the Health Service truly value them? Listen to them? Include them? Give them a voice? Understand their concerns? Treat them as an ally? Respect their abilities and contributions? Answer their questions? Educate them? Empower them? Support them? Partner with them as well as we could? Sadly not.

In my experience and that of many other families of individuals with a mental illness, the power imbalance between the health care providers and the service users does not allow for an equitable relationship. Hence, denying the patient the best chances of recovery. There is national and local evidence that proves that carer engagement saves lives.

Triangulation of services is essential for best outcomes for patients and professionals. Risk averse practices may help reduce risk in the short term but may increase risk in the long term. A recovery approach to risk and development of a “life worth living” may have longer lasting benefits through rebuilding relationships, increasing service-users skills and confidence in collaboration with carers.

Norfolk and Suffolk Foundation Trust (NSFT) have developed a program called “Stepping Back Safely” up-skilling staff, carers and service-users. It is based on five main drivers of Recovery: CHIME

  • Connection
  • Hope
  • Identity
  • Meaning
  • Empowerment

NSFT are offering free training in Stepping back Safely in July 2021 on-line. Having heard many stories where a life could have been saved only if there was a meaningful and effective communication between the three parts of the Triangle of Care, I think this training is most relevant and essential. I shall be taking it as I am sure it will deepen my understanding of the subject. If you or anyone you know might like a point of contact, here it is: catherine.phillips@nsft.nhs.uk

Bad doctor!!!

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Despite check-lists, protocols and guidelines, mistakes happen. As long as human beings carry out jobs, mistakes will happen. To err is human. Safety is an outcome of a person’s attitudes and actions within a given environment. Both, the person and the environment have a strong impact on each other and the outcomes. The bad mood of one person affects the whole team. Similarly, a stressful milieu for any reason such as lack of time and resources has a direct impact on the performance of each person in it.

In my 19 years in the NHS, the working conditions and morale amongst the staff have gradually worsened.  When things go wrong, clinicians, being visible on the frontline are expected and often willing to take responsibility. Holes in the system and staff morale are hidden. Only on a closer look are they clearly seen.

I sit in a unique position where I work for the same organisation that is at least partly, if not fully responsible for the fact that my son is not in this world any more. Yet, I know and see many doctors and nurses work way beyond their call of duty. However, our very own GMC took the case of a paediatric registrar, Dr Bawa-Garba to the High Court, supposedly in the best interest of the public. She had looked after 6 year old Jack Adcock before he tragically died of severe sepsis under her care. Her Counsel summerised:

“The events leading to [Dr Barwa-Garba’s] conviction did not take place in isolation, but rather in combination with failings of other staff, including the nurses and consultants working in the CAU that day, and in the context of multiple systemic failures which were identified in a Trust investigation.”

Yet, the high court convicted her of ‘manslaughter by gross negligence’.

A blog by concerned UK paediatric consultants stated that:

“On this day: Dr Bawa-Garba did the work or three doctors including her own duties all day and in the afternoon the work of four doctors.
On this day: Neither Dr Bawa-Garba (due to crash bleep) nor the consultant (due to rosta) were able to attend morning handover, familiarise themselves with departmental patient load and plan the day’s work.
On this day: Dr Bawa-Garba, a trainee paediatrician, who had not undergone Trust induction, was looking after six wards, spanning  4 floors, undertaking paediatric input to surgical wards 10 and 11, giving advice to midwives and taking GP calls.
On this day: Even when the computer system was back on line, the results alerting system did not flag up abnormal results.
On this day: A patient who had shown a degree of clinical and metabolic recovery due to Dr Bawa-Garba’s entirely appropriate treatment of oxygen, fluids and antibiotics was given a dangerous blood pressure lowering medication (enalapril) which may have  precipitated an arrest.”

The case has now been put to the Court of Appeal.

So, whose fault is it? No handover, no induction, no senior support, temporary nursing staff, poor IT services, shortage of doctors … whose fault is it? Obviously the doctor’s. Why this huge disparity in the way in which hospital doctors are treated as opposed to the others? It’s not ok for the sickest of patients to die in a hospital whereas fit and healthy young men and women are allowed to die in the community with not an eye-brow raised.

Parity of esteem? Bollocks!

 

Day 864

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This is a well-known story within medical circles. A few years ago, a patient was in the operating theatre to have his diseased kidney taken out. Everyone believed it to be the left kidney, except a medical student who said in a hesitant, soft and muffled voice that he thought it was the right kidney. No one paid him any attention and went right ahead to take the left kidney out. It turned out, that was the wrong kidney. The only person who was correct was the medical student. The person who suffered the damage was the patient.

Large organisations are hierarchical by nature. Decisions taken by those on top are rarely questioned by juniors. But true leadership means, the ability to challenge the status quo. The culture of an organization is shaped by the worst behavior the leader is willing to tolerate.

During their selection process, Google particularly look out for ‘courage’ in candidates. They prefer to hire people who ask the right questions and are not afraid to be open if they disagree with what is being said, irrespective of who says it.

The only way to improve is to be open. That is how we learn.

When was the last time I kept quiet when in fact I had something to say? When was the last time I didn’t have the patience to listen? What are the dynamics at my work place? Who pays the price for my silence or my inability to listen? Will I have the courage to speak-up the next time? Will I have the courage to listen?

“It is not because things are difficult that we do not dare, it is because we do not dare that they are difficult.” – Seneca

Ref: Just a Routine Operation (A short film about the importance of Human factors , one of them being assertiveness) : https://www.youtube.com/watch?v=JzlvgtPIof4

Day 816

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Health and social care, care of the elderly, care homes, care in the community, child care, nursing care, residential care, respite care … The word ‘care’ is used everywhere but what does it mean?

The Cambridge Dictionary defines it as ‘the process of protecting someone or something and providing what that person or thing needs’ and ‘serious attention, especially to the details of a situation or thing’.

Synonyms: caution, attentiveness, alertness, vigilance, observance, responsibility, forethought, mindfulness, regard.

Medicine and nursing are caring vocations. Yet, they are jobs like any other. They pay a salary for a service rendered. The care element can potentially become optional as long as all the boxes are ticked.

‘Continuity of care’ is particularly tricky in mental health as relationships are based on trust and every time a new person takes over a caring role, all the facts need to be repeated and trust re-established, starting from scratch.

Now that I belong to a network of mothers and fathers who have lost their children to suicide, one common theme emerges: “It seems that our sons and daughters didn’t need more resources, more GP’s or more psychiatrists or more nurses. They just needed more care…”

Let’s not use the word carelessly. 

Day 725

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Another story.
Another young man.
Another family.
Another mother.
Same themes. Same gaps. Same cover-ups.

“Y went to University, experiencing life away from home for the first time. Although only a 40-minute train journey away, he lived in halls of residence, sharing a flat with four other students. I saw him at least once every fortnight and although I knew he was upset at the break up of his first serious relationship, there were no signs that he was struggling to cope with his studies or not enjoying university life. He appeared to be the same quirky teenager who made friends easily and faced challenges full on.

One Sunday he failed to come home for lunch with the family. Frantic, I drove to his halls where an ambulance and police car were parked and I was given the news that our beloved son was gone. It was another 24 hours before we discovered he had completed suicide. Nothing could have prepared me or our family.

Five months later we attended an inquest into his death where an open verdict was recorded, and the Coroner claimed that everything possible had been done by health care professionals to support Y following a university doctor diagnosing him with depression and prescribing anti-depressants. He had been referred for counselling and his university tutor was informed.

At the inquest, the GP had legal representation. A representative of the university’s counselling service gave evidence on behalf of the counsellor; a statement was read out from a doctor who had admitted Y to hospital following two incidents of self-harm, and another statement was read from the university tutor in whom Y had confided.

As a family, we sat completely dumbfounded that all of these people knew that our child was suffering from mental health issues. Not one of them had contacted any of us, or identified us as a ‘safety contact’, yet felt the need to be legally and professionally protected in court.

Just one month after starting university and following the break-up with his girlfriend, Y made his first suicide attempt. We were not informed. The reason we were given was that he was an adult and all of the professionals involved had a duty to respect his confidentiality. The counsellor’s representative commented that it was ‘possible’ that it ‘may have been suggested’ that Y talk to me about his situation, but she could not confirm that this was the case.

Had Lawrence been involved in any sort of accident then I would have been contacted immediately, but because his admission was a mental health issue the veil of confidentiality came down and prioritised clinical staff welfare rather than that of my son.

Did we as a family – or me, specifically, as his mother – fail him? We failed to see his suffering, but when he was around us he was the usual Y we all knew and loved.

Did the university fail him? Yes, they should have informed his emergency contact/next of kin that he had expressed suicidal thoughts.

Did the clinicians fail him? Yes, by averting culpability and absolving themselves within a care system culture that protects its own and isolates the patient from their family – the people closest to them and those who would have provided the love, care and protection that could have saved a young life.

As a family we felt that the ‘professionals’ closed ranks to protect themselves. In the weeks leading up to that awful day, and the months before the inquest, their self-protective instincts mattered more than the duty of care they had towards protecting our son Y, a caring, funny, intelligent young man with a whole lifetime of adventures in front of him.”

NO CONFIDENTIALITY WHEN IT COMES TO SUICIDE.

In Jan 2014, an official document was published – “Consensus statement on information sharing” (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/271792/Consensus_statement_on_information_sharing.pdf)

“The statement applies to adults in England. Information can be shared where it is in the public interest to do so. In practice, this means that practitioners should disclose information to an appropriate person or authority if this is necessary to protect the child or young person from risk of death or serious harm. A decision can be made to share such information with the family and friends, and normally would be.”

Who’s left to deal with the loss for the rest of their lives? The people who never knew it was happening. The people who would have gone to any lengths to avert the tragedy. The people who had a right to be informed.

10th of october 2014 was a friday, the beginning of my last weekend with my darling son, the last italian meal we shared. All that is left now is a broken heart holding many beautiful memories on one hand and reliving the nightmare over and over again on the other.

 

 

Day 707

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While the government in England aims to reduce the rate of suicide by 10% in 5 years, an independent charity ‘Contact’ (http://www.contactni.com/) in Northern Ireland (NI) holds the vision of creating a society free of suicide. Its mission statement is – ‘Getting you through the most difficult times.’

Here are the salient features of its manifesto for this year:

  1. Zero Suicide is the only target to aim for, the ultimate expression of our commitment to patient safety. Driving suicide to zero must commence with health and justice care systems, affirming the conviction that, ‘no one should die alone, in despair, by suicide’.
  2. All learning achieved from saving lives in our care must be urgently applied to community and family settings. Continuity of care at crisis point must ensure critical real-time information sharing agreed by memorandum of understanding, investing in robust multi-agency relationships, applying 24/7 ‘air traffic control’, gold standard patient safety quality assurance for everyone in our care.
  3. No wrong door – every patient at risk of suicide must receive comprehensive clinical assessment and safety plan at first point of contact (including family/ loved ones, GP and crisis clinical support), testing safety plan relevance on every subsequent contact.
  4. No wrong door at times of crisis. Perfect crisis care requires 100% commitment to a ‘no blame’ culture, championed by accessible, visible and competent corporate leadership accountability – with immediate learning from honest mistakes celebrated as opportunities to achieve continuous service improvement excellence.
  5. Civic leadership must invest in competent, courageous suicide prevention championship, encouraging compassionate understanding while promoting courageous lived experience voices of hope and recovery.
  6. A regional Suicide Prevention Standing Conference to celebrate what works and drive the zero suicide challenge. If suicide is preventable, then NI health and justice systems have a unique opportunity and compelling obligation to provide world-class suicide prevention integrated care, from crisis-point, to stabilisation and recovery, with a renewed, ambitious, relentless resolve to drive the NI suicide death rate down, establishing NI as the safest-from-suicide region in the UK and Ireland within the next five years. Every suicide is preventable until the last moment of life.

Belfast was home for 7 years. Saagar was there from the ages of 5 to 12. He did a fantastic ‘norn-irish’ accent! I never thought I would be going back there to participate in a Suicide Prevention Conference but in November I am.

Day 700

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When our GP heard of Saagar’s death, the first phone call he made was to the Medical Defence Union and they advised him not to call us. Despite having known us for more than 7 years and seeing Saagar every 2 weeks with us for the last few months of his life, he did not call us on his death.

A qualitative study of GPs’ experiences of dealing with parents bereaved by suicide by Emily Foggin et al was published last month in the British Journal of General Practise.

It acknowledged that bereavement by suicide is a risk factor for suicide but the needs of those bereaved by suicide have not been addressed and little is known about how GPs support these patients, and how they deal with this aspect of their work. 13 GPs in the UK were interviewed in a semi-structured format. It explored experiences of dealing with suicide and bereavement.

GPs disclosed low confidence in dealing with suicide and an unpreparedness to face parents bereaved by suicide. Some GPs described guilt surrounding the suicide, and a reluctance to initiate contact with the bereaved parents. GPs talked of their duty to care for the bereaved patients, but admitted difficulties in knowing what to do, particularly in the perceived absence of other services. GPs reflected on the impact of the suicide on themselves and described a lack of support or supervision.

It concluded that GPs need to feel confident and competent to support parents bereaved by suicide. Although this may be facilitated through training initiatives, and accessible services to refer parents to, GPs also require formal support and supervision, particularly around significant events such as suicide. Results from this qualitative study have informed the development of evidence-based suicide bereavement training for health professionals.

Ref : http://bjgp.org/content/early/2016/08/15/bjgp16X686605

This evening a vigil was held by SOBS (Survivors Of Bereavement by Suicide) at Hyde Park to remember those lost through suicide. Some of the people there had lost a brother 25 years ago or a sister 5 years ago or a friend 1 year ago and so on. Some of the families had not been able to speak about it for many years. Others had kept quiet as they were not sure if anyone would understand. But in that space, we sat together on the brownish-green grass with the pictures of our loved ones and lit candles in their memory and we opened our hearts. For about 2 hours we claimed that space and made it our own knowing full well that we are being listened to and perfectly well understood. What a rare gift that is!

When it comes to suicide, post-vention is pre-vention.

 

Day 690

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“Everything starts and ends in your Brain-Soul connection.
How your brain and soul work together determines how happy you feel, how successful you become, and how well you connect with others. The brain-soul connection is vastly more powerful than your conscious will. Will power falters when the physical functioning of the brain and the health of your soul fail to support your desires, as seen by illogical behaviours like overeating, smoking, drug and alcohol abuse, and compulsive spending.

It is the aim of The Amen Clinics to provide instructional programs and materials, evaluations and medical treatment where necessary to help you to understand and direct your mind to enhance your relationships, your work, and your health!”

Dr Daniel Amen is a psychiatrist in America who is a strong proponent of SPECT (Single Photon Emission Computerised Tomography) imaging of the brain. It bothers him that psychiatrists are the only medical specialists that never look at the organ they treat. Cardiologists, orthopaedic surgeons, neurologists look, whereas psychiatrists guess. As a result of which diagnoses are still made in the same way they were in the 1840s, based on symptom clusters. It’s like shooting in the dark especially when most psychiatric medications come with black box warnings that they might make the situation worse.

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Simply put, the images tell us 3 things about the brain – areas of good activity, too much and too little activity. In his TED talk he shows some very convincing pictures of brains ‘before’ and ‘after’ interventions. He also shows scans of 2 patients with clinical depression but very different scans, one showing gross under-activity and the other significant over-activity.

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He expresses great concern about the homeless people, criminals and soldiers returning from war zones who are not getting appropriate care as no one is looking at their brains and tailoring the care of their mental state.

He claims to have helped many people over the years using this technology but his work has been much criticised, firstly for not having enough evidence in its favour and secondly for the potentially harmful effect of the radio-nucleotide dye that needs to be injected in every patient. He has also amassed a great amount of wealth doing this work that insurers will not pay for. This  fact further discredits him within the medical community.

Would I have paid 3500 dollars for Saagar’s first assessment and scans at one of ‘The Amen Clinics’? Probably not. But it would have been good to have a more scientific approach to the diagnosis and management of his illness. It was like throwing darts in the dark. 

 

 

Day 681

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About 5 months after Saagar’s passing, one of my close friends sent me a subtle message suggesting that I should be careful about what I write in my blog as a few of my work colleagues read it regularly and if I appear to be too fragile or vulnerable, it might have a negative impact on my professional life. I understood her concern. The medical profession is not known for its understanding and compassion for mental frailty in colleagues.

Dr Wendy Potts was a GP in Derbyshire who blogged about living with Bipolar Disorder on a regular basis. One of her patients read the blog and complained to her Practise. The doctor was suspended. A few weeks later she ended her own life.

Firstly, I don’t understand the basis of the complaint. Would patients complain if their GP had diabetes or cancer?

Secondly, I don’t understand the basis for suspension from work. If the doctor’s performance was not questionable, then there is no ground for that.

Ref : https://www.theguardian.com/uk-news/2016/aug/26/gp-found-dead-after-being-suspended-over-bipolar-disorder-blog?cmp=oth_b-aplnews_d-2

This is one of many examples of poor treatment of medical colleagues with mental health issues. I think we are a long way from seeing parity between physical and mental illnesses as the ones who are supposed to put that into practise are themselves caught in the stigma associated with mental illness.

(PS: apologies for not being able to insert the link to the article in a better way. The ‘link’ icon on my page doesn’t seem to work anymore. Any ideas? )