I wake around 3am. Turn to my ipad for a cheeky scroll of happenings and see a link to an article posted a day or so ago about the Health Safety Investigation Branch. (Four words that should knock insomnia out of the sleepless park.)
Ex Health Minister Jeremy Hunt launched the Branch in 2016. In a speech (no longer available) he talked about mistakes made by good people and the need for a ‘proper study of environment and systems in which mistakes happen’. This was a patient safety first.
HSIB. An elite, ‘independent’ swat team of human factor dominated safety investigators proudly wearing no blame badges. Led by Keith Conradi. A human factors geezer plucked out of the aviation industry. A name oozing shaken not stirred gravitas and Branch profile referencing ‘fast’ jets, skiing and triathlons.
I squint at the ipad glare. What’s happened?
A Kings Fund report has found widespread bullying, sexism and a culture of fear in the organisation.
Conradi has resigned.
And with no apparent hint of irony blames the NHS England CEO. And unexpected challenges of managing diverse cultures within the organisation.
I find a post I wrote about HSIB in 2016. The Moon on a Dick. And feel a fleeting sense of blog title pride.
HSIB. Hunt. Blinkered by a human factors fascination, coaxed and coached by an ever ready, uncritical and largely white male chum club.
Hey! Don’t you be harsh missy, I was admonished at the time. [By people who should have known better.] HSIB is a groundbreaking body led by a serious man doing serious work you don’t understand. Let’s wait and see what this shit hot group achieve. We waited.
I try to go back to sleep. An hour, maybe two before a day of research meetings. Growing older with a learning disability. Living a flourishing life. Experiencing loneliness. Giving evidence at fitness to practice hearings. Experiencing inquests… Work that tumble-fills life with overspilling layers of graft, fear, reflection, doing stuff wrong, making right wrongs, fun, stumblings, work. And constant concern. Of not generating anything that makes a difference to someone.
And then I feel familiar anger and rage. Empty words, white noise, environments, systems, ‘good people’ and ‘mistakes’. Made up people channelled into made up jobs. Encouraged by self serving cheerleaders who collude in the erasure of sense. Rights. Integrity. Honesty. Humanity. Hypocrisy always waiting in the wings.
Nearly six years has passed since Hunt launched HSIB. Bereaved families continue to be brutalised by inadequate and punitive investigatory processes. And the world leading patient safety investigation organisation has generated its own brand of harm and trauma.
How long does this wait and see lark last?
Lessons will be learned.
Much on record on how families have strive to know why mistakes that harmed a loved one – happened.
And they they know the long, costly, stony route to be taken before a Public organisation will admit fault.
And they earn that the penalty most usually imposed (for even serious damage done carelessly to another,) will be the serving of the mantra:- ‘ lesson has been learned’.
End of the matter.
Issue is now historic’, never to see light again.
A persistent family may be offered compensation in form of a slot in staff training session that never happens. The offer dies. When org reminded family may be offered slot at sleepy end of the day in staff induction session.
Or – if org really rattled, most consultants expensive consultants handed the lesson learning task. Well paid whipping boys.who salve org pain and generously take the learning away with them.
A good operational manager will insist on an action plan to evidence his/her ownership and t prevent recurrence; will also keep close contact with family.
Action plans are constructed and shared – objectives and team named.
But actions, objectives and actions fade away like the dawn after couple of meetings from lack of leadership or professional support. Embarrassing topic? Shared denial? Viewed by individuals as waste of their professional time/status etc. Or all etc.
The good ops manage/conscientious staff learn. They leave hoping to do better else where , or they stay, wounded.
Old news that huge amount of cash and energy are applied to defend the indefensible..And result in timely lessons not being learned. Self interest protects dodgy cultures and it compounds org apathy, ignorance and professional arrogance..
We persistent families ARE remembered. Filed in the org memory – filed under ‘ ‘awkward’ – ‘difficult’ -..exetera. This lesson is learned.
And we learn not to forget.
We learn never ever stop caring – we bank this learning up with our love.
……and we pass this baton is on.
….apologies for typos …am weary!
‘Defending the indefensible’ Weary Mother is standard. How can anybody excuse the blatant way NHS managers close ranks and ignore complaints against their staff even though they are aware that the complainant is telling the truth. Our NHS is wonderful but it also nurtures a rotten underbelly which shames it.