Why Sh*t Happens

If Heather Clark Was a Doctor ...

The coverage of the conduct hearing into the performance of Dr Stuart McNee makes interesting reading.  Having been found responsible for the death of Lisa Norris, Dr McNee will be allowed to continue to practise.  The panel found that:

'Dr McNee's actions fell at the "lower end of the scale" of lack of competence. They were "not deliberate, wilful or reckless" and did not amount to misconduct'.

Heather Clark, unlike Dr McNee, was judged not to have put any of her clients at risk.  Yet she has lost her livelihood, has been stigmatized as a threat to society and could not even serve as Brown Owl at her local Brownies.

But here is the interesting bit.  The Health Professions Council seem to have been using a 'Just Culture' algorithm to help them arrive at their judgement.  By saying that McNee's actions were not deliberate, willful or reckless they are saying that he made an honest mistake and should be treated accordingly.  Ironically, they point to staff shortages and lack of support from management as being contributing factors.

Heather was not acting in a deliberate, willful or reckless manner when she chose to deal with her clients in a way that seemed effective to her but did not necessarily meet the needs of the  social work bureaucracy.  She was overworked and lacked support from senior management.  How come the same rules are not being applied here?

Hmmmmm

So, Heather Clark does no harm, is suspended, stripped of her right to work and probably denied the chance to return to her former employment as a nurse.

A teacher in Wales traumatises children in her care, is suspended but will return to work after retraining.

Am I missing something here?

Quality of Care

There has been some heated debate in the media yesterday and today as patient groups complain about the quality of care in hospitals.

On 22 Apr 09 my father-in-law went to hospital with chest pains.  He had asked his wife to call for an ambulance.  He walked down the stairs to the vehicle.  It seems he was suffering a serious heart attack.  He was 82 years old.

His wife and immediate family made various visits to the hospital.  A doctor did take the time to explain the situation.  No clear picture emerged as to the seriousness of the attack nor the prognosis. Individuals came away with their own understandings of the information.

On Friday 1 May we went to see him and, as we entered the Ward, we were told that he was ready to come home.  My mother-in-law was stunned.  I was pleased for him and was more concerned that the family's reluctance to have him back could only make the old guy feel bad.  They simply didn't think he was fit enough.  We were given a rucksack of drugs and quite clearly told that, if he has any other problems, we were to call the GP and not to call the hospital.

It dawned on me later that this was the Friday afternoon of a Bank Holiday weekend.  Coincidence?  

Was the care bad?  Were the nurses more motivated to clear the wards?  We will never know.  But I wonder.

Heather Clark, Social work and Systems

What I find interesting about the case of Heather Clerk is that it shows how far Social Work is lagging behind in terms of understanding 'failure' as a property of complex systems.  At this point I need to stress that the tribunal clearly stated that no child was harmed because of Heather's supposed failings.  So why am I talking about 'failure'?

Heather seems to have been very good at dealing with her clients but very bad at keeping records up to date.  In an era of audit, social work is being forced to keep better track of who did what to whom and when. That, in itself, is not a bad thing.  However, and just as the Police are complaining about drowning in red tape, social workers are having to spend valuable time at their desks rather than providing a service to clients.  Researchers at Lancaster University have published a paper that looks at how social workers in England have found ways to 'fudge' the system because they are short of time.

However, my interest is in the response of Aberdeen City.  Rather than understand the circumstances that might prevent workers following procedures all the time, they have gone straight to taking disciplinary action.  In aviation you used to hear 'pilot error' given as the cause of an accident.  Now we understand that there are many factors that shape a pilots behaviour and simply to lay the blame at the feet of the pilot does not improve safety.  We need to understand the reasons why the pilot made the error.  So, first, we move from blame to comprehension.  Only once we understand the situation - and have identified the lessons - then do we consider if there is a charge to answer.  We talk of a 'Just Culture' in which error is recognised as being natural and commonplace.  Systems tolerate errors provided that they are unavoidable.  Systems take action to reduce the probability of errors.  Systems only take retribution when someone has been clearly culpable.  

Heather was deemed to have been negligent over a 2 year period.  So, what was her original supervisor doing?  Social workers meet with their supervisors periodically to review cases.  Why was nothing said. Aberdeen City gapped the supervisor post.  What action did senior management take to provide supervision during that period?  Why did the acting supervisor not take action.  Once a new supervisor was appointed ... still no action.  To understand events in Aberdeen you need to answer those questions. 

Heather Clark - Suspended Aberdeen Socialworker

It is hard not to think that, after 2 damning reports by Inspectors last year, Aberdeen City Council have found a scapegoat in Heather Clark.  For many years a nurse, Heather trained as a social worker in 2004.  Well-respected by her peers and her clients, she is good at walking the ground and dealing with people.  Unfortunately, she seems to be less good at leaving a paper trail behind her.

 Rather than counsel, train or even follow conventional personnel management practices, she has been hung out to dry.  Without even a formal warning she has not just been suspended but she has been stripped of her accreditation and looks to be barred from returning to nursing as well.  Branded by the Daily Record a a 'rogue social worker', Aberdeen City has acted shamefully,

Why did the Social Services Department not take action sooner is some of the charges go back to November 2006?  Why has no Significant Case Review been conducted to discover the root cause of the problem?

Meanwhile, other social workers in the City and the Shire have been warned not to speak to the Press but many are wondering who the next sacrificial lamb will be.

Deaths in the Construction Industry - Make the Workers Pay!

Today's Guardian newspaper carries a piece in the financial pages about the UK Health and Safety Executive being forced to name construction companies which had experienced a workplace fatality.  Of the 72 deaths last year, a quarter affected firms employing fewer than 5 people.  The bit that caught my eye was a quote by Garvis Snook, CEO of Rok, who said that 'construction workers should be licensed and you should only get a licence if you have done basic health and safety training'.

What Mr Snook is actually saying is that the cost of maintaining a safe workplace should, in part, be borne by the worker.  He doesn't say who will pay for the licence but if you need it before you get a job then it follows that the individual (or the previous employer) will carry the cost.

Back in the Victorian era it was argued that the risk attached to hazardous work was part of the deal and the worker was compensated by higher wages.  Workplace injury was considered hard luck.  After all, that's why you got the higher wages.  We have come a long way since those days although Mr Snook seems to want to turn the clock back.

Read article here:

http://www.guardian.co.uk/business/2009/apr/29/health-safety-executive-construction-industry

Vote for Margaret Haywood

The Royal College of Nursing has an online petition supporting Margaret Haywood, the nurse truck off for going public about conditions in her hospital.  Sign here:

http://www.gopetition.com/petitions/support-for-whistleblowing-nurse.html

Why should you sign?  Well, the UK has the Public Interest Disclosure Act - the 'Whistleblower Act'. Haywood is not the first healthcare worker to suffer because she raised issues people would rather keep quiet. 

The Quality Care Commission yesterday announced its intention to hold 'safety summits'.  Perhaps one of the indicators they could track is the number of staff in a hospital who would go public if it wasn't for the fact that they feared the consequences.

Joined-up thinking in the NHS?

2 bits of interest in the paper today.  The first is about the new safety watchdog planning to have 'safety summits' to check on standards of patient care in hospitals.  The second is about a proposed shortfall in funding for training healthcare professionals.  The cash shortage will result in reduced safety levels in hospitals because the training system will not be able to train as many people as are needed or that the training will compromised in some way.

Left and right hand?

Margaret Haywood - NHS whistleblower

Here are the reasons for Margaret Haywood being struck off after disclosing her concerns to the BBC Panorama programme.

Download Reasons CCCSH Haywood 20090416

Patient Safety in Mental Care

Todays Observer newspaper carries a particularly unhelpful piece about patient safety in NHS mental care.  The headline screams about '4 psychiatric patients dying each day in NHS care' and refers to data collected by the National Patient Safety Agency.  1282 people have died and 913 have suffered severe harm.

Unfortunately, the data doesn't distinguish between people who harmed themselves, people who were harmed by others or people who were themselves harmed by error on the part of the healthcare system. Furthermore, it doesn't distinguish between events that happened within an institutional setting and those that occurred when the patient was in the community.

There is a case study relating to a young woman, suffering from depression, who sought treatment but subsequently committed suicide.  The point of the story was that the suicide might have been prevented if the psychiatric nurse had told the victims family more about how bad the situation was.  Tragic, but no more than the benefit of hindsight.

Social workers have come in for criticism recently and it seems to me that child protection and mental health share many common problems.  First, both deal with the unpredictability of people.  Both work under conditions of extreme resource constraint.  Both have great difficulty in evaluating the risks present within a situation.  Failures in both often lead to tragedy.

I'm still trying to track down the substance of the Observer article.  In the meantime, I doubt if this is a good example of reporting a very real issue that needs more light and less heat in order to promote understanding.

Read it here:

www.guardian.co.uk/society/2009/apr/12/mental-health-patient-safety