Can Do Health & Care - NHS Uncomfortable Truths Report

26 | ICS System Learning: Uncomfortable Truths Uncomfortable Truth 11: Patient safety incidents are experienced disproportionately by marginalised patient groups exacerbating health inequalities and biases embedded in the healthcare system, its workforce, and practice. British Medical Journal Anthony: Child deaths are always tragic, and almost always very young children. The learning in the last ten years has been strong both on the causes of deaths and prevention. We have deaths, for example, where parents co-sleep when they are under the influence of alcohol or drugs. However, the work of public health messaging and evidence-led work with families is beginning to make a difference. Many of our cases show incredibly poor information sharing, even after 50 years of reviews and research evidence. This is so basic, and yet people are dying because the right information was not shared with the right person at the right time. One example is a woman in her late 80s who died of sepsis-related complications in a care home right in front of staff and visiting professionals. Even though the smell was strong no one smelled her, and no one saw her dying. Multiple professionals came and did their bit on a part of her, but nobody saw the whole person. Another two examples are a child and an elderly man who look their own lives and in both cases family members who had crucial information weren’t included. Since involving family members more in our partnership we have realised the limitations of professional assessment. What is often taken as fact is often well short of the reality of someone’s lived experience or even their clinical condition. Holding family meetings adds 20% to our understanding of the person. And bringing Martha’s Rule in will be an important step. “We have too much of a hierarchy still in the NHS… too much of a medical model, too much of a top down culture, social care too battered by everything and everyone.” To exercise professional curiosity and to share information when demand is rising, you are carrying out complex work and you are often covering for someone else, you have to be in a stable team. Yet we are probably at our weakest point in terms of the percentage of new staff, where the job is running away from their ability to do it. Our learning from research has been incredible in issues such as the impact of domestic abuse on children, and coercive control. But it is now very complex for the workforce and impossible with the resources available.

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