“When things go wrong”

1. “When things go wrong” – Serious Incidents – what do we know about them and how can they help to improve practice? Friday December 5th 2014 Dr Colin Dale Chief Executive Caring Solutions (UK) ltd

12. Defining Serious Incidents sudden, unexpected death of a community patient in receipt of services or who has been involved with services within the last six months, inpatient suicides unexpected death of an inpatient suspected suicides of community patients serious safeguarding allegations any incident that is perceived to have possible media attention absconds from secure units serious self-harm

18. Consistent Failings Identified in Investigations • Inadequate application of CPA • Risk assessment and management • Inadequate discharge planning • Record keeping • Observation and engagement • Communication – transition points • Safeguarding • Inadequate response to non engagement or did not attend (DNA’s) 18

19. Consistent failings 2 • Poor liaison and engagement of families (ignoring families warnings) • Substance misuse / dual diagnosis • Confidentiality • Safety at night • Mobile phones/texts • Borderline personality disorder/ social difficulties • Lack or inappropriate use of the Mental Health Act

20. Concerns over Investigation Process • Excessive bureaucracy – reporting, investigation and review • How panels are established • How they are managed: • No terms of reference • No detailed RCA, or links with facts, conclusions and recommendations • Variable reports, structure, depth, quality, timeliness, documentation • Length of time and costs – including opportunity costs (clinicians)

21. Concerns over investigation Process (cont’d…) • Key individuals, agencies not interviewed – family, GP, police, victims • Dominant focus on practitioner actions or omissions rather than adequacy of systems, process, environment, skill mix, management or leadership • Inadequate analysis and identification of common themes, trends and patterns • Incorporating lessons back into organisation as a whole • Dissemination of lessons learnt • How action plans are tracked and monitored • Corporate responsibilities and Trust Board quality assurance • Blame orientation versus not acceptance of poor performance

22. Capacity & Capability of Investigators • Investigators qualities of assertiveness, objectivity, empathy, tenacity, and interviewing skills might not be present • May not understand legal process or safeguarding issues • May not possess report writing and communication skills • Significant workload demands – no back fill • Lack of awareness of National guidance

23. Implementing Action Plans The Action Plan arising from the recommendations is often at the lowest level of assurance. The NHSLA Framework allows for 3 levels of assurance: (1)Policy or Guidance; (2)Audit of implementation; (3)Action based on Audit findings

24. What is Going Well? Reassurance to the public Some standardisation of approach (RCA) Independent opinion Involvement of service users and carers Sharing of information 24

26. Dr Ian Clarke 2008 “Incorporating Lessons back into the organisation as a whole seems the most difficult objective to achieve”

27. A Learning Organisation / Culture ‘A learning organisation is one which relishes curiosity, questions and ideas, which allows space for experiment and for reflection which forgives mistakes, and promotes self confidence.’ (Hardy) 27

28. Characteristics of a Learning Organisation Leaders facilitating the formation of a clear vision for the organisation’s future An open culture of trust, with employees able to communicate, experiment and learn without fear of criticism or punishment A strong sense of community and caring in the organisation The structure of the organisation helps not hinders the employees in carrying out the organisation’s business 28

29. A Learning Organisation / Culture (cont’d…) Other perceived benefits include: Encourages innovation and adaptability Captures the knowledge of individuals and retains it when people leave Anticipates change Facilitates continuous learning and a proactive response to the changing environment 29

31. Ideas for Dissemination, Learning & Implementation Regular briefings / monthly newsletters: short and snappy sent to all clinical leaders and managers ‘Information not saturation’ Use patient stories / vignettes to heighten interest Develop a culture of openness, reflection and learning Accountability, expectation to discuss, share, engage, explain – not just passing on information Solution groups 31

32. Ideas for Dissemination, Learning & Implementation (cont’d…) Feedback to service user / carer meetings Formal feedback to universities and those responsible for internal programme development Establish a web site and promote local discussion groups on hot topics emerging from SUI’s Selective critical incident email measures – red for alerting to areas of concern, blue for lessons to learn Text messages to key senior clinical / managerial staff to alert to critical incident 32

33. Specific Issues Arising from SUI’s to be discussed at key meetings Trust Board Clinical governance Ward meetings – staff and patient / staff forums Professional groups Acute Care Forums Hand-overs Signing when read arrangements Including 33

34. Ideas for Dissemination, Learning & Implementation (cont’d…) Clinical supervision and reflective practice – group and individual Develop an approach to analysis and learning from near misses Organise positive practice events Peer review – structures, purposeful, single issue or bundle Benchmark with other Organisations Regular review of, and revision of, policy and practice guidance 34

35. Ideas for Dissemination, Learning & Implementation (cont’d…) Crucial job rotations for learning Cards, crib sheets, screen savers Appoint and develop safety champions / enthusiasts Intensive, comprehensive focus on a small number of issues Use video for analysis Use case studies, real or fictional, as training, and get a panel to undertake a review to see if their findings match those of the original panel 35

37. WHO Safer Surgery Checklist With the use of the checklist, surgery complications were reduced by more than one-third and deaths reduced by almost half (from 1.5% to 0.8%) in test hospitals compared to control hospitals.

38. A Safer Mental Health Checklist? What would we include? When would we complete it?