Why Sh*t Happens

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

BBC Panorama on Doncaster

http://news.bbc.co.uk/panorama/hi/front_page/newsid_7976000/7976854.stm

Another gem from the Tameside report

Recommendation One arising from the investigation into the death of Child J includes the statement:

"Ensure that all staff are clear about the purpose of communication in respect of what action they expect to be taken as a result"

Does that mean that staff are to communicate their intentions clearly?

OK.  Cheap shot, maybe.  But many years ago I read a book by an ex-Chief Investigator of the UK's Air Accident Investigation Branch.  'Safety is No Accident' by William Tench.  In it he describes his attempt to communicate a serious flaw in the design of the the Boeing 747 to the Civil Aviation Authority.  Having had no response he collared the responsible individual at a cocktail party.  Soon after, a missive was sent around stating that it was the responsibility of the sender to ensure that mail got through to the intended recipient within the CAA.  So, it's not enough to put a letter in the post.  You then have a responsibility to check that it arrived.

Hmmm

But back to Baby J.  Communication across organizational boundaries is messy and prone to failure.  But recommendations like the one in the report are probably not going to achieve much.

Death of Baby Jack

Stacy Taylor and Mark Harrison were jailed last year after their 6 month old son, Jack, died from injuries and neglect.  The Serious Case Review was published on 31 Mar - narrowly missing April Fool's Day.  I say that because, in paragraph 1.7 of the Serious Case Review - entitled 'Good Practice' - it says that 'When the skeletal x-ray identified injuries to Child J after his death prompt action was taken by the agencies'.

The report comments on the catalogue of failures to take appropriate action before Jack's death but praises the prompt action taken afterwards.

Is that an example of tragedy or irony?

Go here to read the report

www.tameside.gov.uk/childprotection/reports

Child protection in Doncaster

The BBC Panorama programme has uncovered 2 internal reports that suggest that people in Doncaster's Child Protection  Services knew that things were not right.  In one report, the excessive demands being made on staff prompted concerns about their own mental well-being.

If you read one book this year, then make it 'Dignity at Work' by Randy Hodson.  It's a useful examination of toxicity in the workplace.  It explains what was happening in Doncaster.