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“Just culture” has become a buzz phrase in recent times, particularly in the aftermath of the Dr Bawa Garba / Jack Adcock case. However, what do people mean when they use this phrase?
One could be forgiven for thinking that for many people, just culture is only about treating staff fairly. For example NHS Improvement have developed what they call a ‘just culture toolkit’ which, although admirable, is simply about that. However, another way of looking at it is that a just culture is the same as what used to be called an “open and fair” culture. One where not only staff are treated fairly but patients and families are too in the aftermath of patient safety incidents.
Under the previous Secretary of State for Health, Jeremy Hunt, we were promised a ‘just culture taskforce’ to try to put some meat on the bone of what it is we all mean and want. However that attempt stalled before it got started and so AvMA has arranged a round-table discussion to move things forward, involving patients and families affected by avoidable harm, healthcare professionals and regulatory bodies. We will be reporting on progress in future issues of the newsletter.
We would like to hear from patients and families as well as staff working in the NHS about what they think and generate a healthy debate. Please send us in your thoughts and/or tweet to @AvMAuk using the hashtag #justculture. |
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It has been announced that the roll out of medical examiners across all English hospitals has been delayed. This was meant to happen by April 2019 but will not now be complete until at least April 2020.
Medical examiners will scrutinise deaths in hospitals that have not yet been referred to a coroner. They will be employed in the NHS system, with a separate professional line of accountability, allowing for access to information in the sensitive and urgent timescales surrounding death registration – but with the independence necessary for the credibility of the scrutiny process. This independence will be overseen by a National Medical Examiner, providing leadership to the system.
The establishment of a network of medical examiners was recommended as long ago as the Shipman Inquiry, and has been supported by the Mid Staffordshire, Gosport, and Morecambe Bay inquiries. The National Medical Examiner is in place and medical examiners are fully operational in a ‘handful’ of NHS trusts at the moment and results have been encouraging in terms of spotting patient safety issues that had not and probably would not be spotted otherwise, and in improving communication with families. |
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AvMA has provided evidence to two important inquiries which are due to report this year.
The Independent Inquiry into the issues raised by Paterson has spoken to over 150 patients affected by the rogue surgeon Ian Paterson as well as many relevant organisations. AvMA is hopeful that the inquiry will make recommendations about: - improving regulation of the private sector;
- the way that complaints are dealt with, including legal rights to access to an ombudsman or adjudication service and to independent advice for patients;
- mandatory full indemnity cover for providers of private healthcare; and
- full transparency requirements for private providers concerning clinical audits, patient safety incidents and surgeons’ performance.
The Independent Medicines and Medical Devices Safety Review is also expected to make recommendations for improving regulation of medicines and devices and for more transparency of data.
The Civil Justice Council working party on fixed costs in clinical negligence should be concluding its work this month, whilst NHS Improvement’s patient safety strategy including revisions to the Serious Incident Framework may not now emerge until the summer following consultations last year and earlier this year, to which AvMA contributed. |
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You can help make healthcare safer and fairer for all
AvMA wants to build on the support we enjoy from people all round the country who share our passion for making healthcare safer and fairer for those who do suffer harm. By signing up to be a Friend of AvMA you will belong to a growing movement for change. Join injured patients and their families, healthcare professionals, lawyers and many more who share our goals.
Becoming a Friend of AvMA costs from as little as £5 a month. - £5/month could provide vital advice to patients and families via our helpline
- £10/month could help train a volunteer helpline advisor
- £50/month could help support a family through an inquest hearing
Benefits of membership - Regular newsletter keeping you up-to-date with our work
- Invitations to special events
- Share your thoughts on our work and policy issues
Your help could make a real difference to patient safety in the UK |
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A caller rang our helpline concerning the death of her partner in 2016. Her partner had been prescribed medication by his GP before his death and our caller believed the GP had overlooked known side effects of the medication, and this had directly contributed to the death. She had complained to the GP practice but the GP denied any link. Our caller wanted answers to explain how this could have happened and reassurances that it wouldn’t happen again to another patient.
Our volunteer helpline advisor explained how to complain to the Ombudsman if she feels her initial complaint has not be handled correctly, and to the General Medical Council about the GP’s fitness to practise. Our advisor also warned her that, as the time limit for legal action is three years from the date of death (or from the date the personal representatives had knowledge whichever is later), she will need to move quickly if she is considering making a claim for negligence.
Our caller was pleased with the advice she received. “[Your advisor] was brilliant and helped me a lot,” she said. “It’s nice to talk to somebody in relation to my partner’s case and give me a bit of hope, to hopefully get somebody to help me and fight for change. Thank you.” |
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"I just want to say thank you very much for taking the time out to really listen to me, to be thoughtful and considerate. I sensed empathy and that was the reason I felt that I could calm down and talk to him more. He was definitely knowledgeable in giving me the information to follow up my case. I am really grateful to the opportunity to have spoken to him today and I feel much better about my day because of it. Thank you." |
"It was very productive speaking to [your advisor], who was very sensitive and understanding and an excellent listener to all the details that I gave her. Thank you very much for your help." |
"Very very helpful advice and information, and helpful navigation through your website. We really appreciate your help. Thank you." |
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Action against Medical Accidents Freedman House, Christopher Wren Yard, 117 High Street, Croydon, CR0 1QG Helpline: 0845 123 2352 (Mon-Fri 10am-3.30pm) Registered charity in England & Wales (number 299123) and Scotland (SCO39683) If you no longer wish to receive marketing emails from AvMA please unsubscribe here |
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