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Jane Padmore Blog – August 2019

12 Aug 19 - 10 Aug 20

Four years ago this month my 29 year old nephew, Matt, died, leaving a young wife and son. He had moved to America and was far from home. He was the eldest of seven children and was incredibly funny! It was not expected. It was the result of a prescribing error, a mistake.

Recently I have been reading about and thinking about a ‘just culture’. Over the years the term ‘no blame culture’ has been used and this never sat well with me. It did not feel or seem as if the reality was one of a no blame culture as I still saw professionals struck off registers and disciplinary processes followed. I also saw that a disproportionate number of black and minority ethnic staff were disciplined and referred to professional bodies. At times, all of us do things wrong, how we respond to this individually and as an organisation says a lot about our values and culture.

As the calendar flicked over into August, my first thought was, as always, of Matt. My second was what would we do in HPFT if that had happened here and what could we do that would be right for Matt, the family and the staff involved in his care. No one intended for this to happen, no one wants it to happen to someone else.

A just culture promotes a system of improvement over individual punishment. It is about being fair and open and learning from the mistakes that have been made. It has kindness at its core, one of the HPFT values. Our new Quality Strategy, which is being launched in September, has fostering a learning and just culture as one of the priority areas.

This means that we will ensure timely investigations into serious incidents that enable learning to be embedded swiftly. It will incorporate innovative ways, such as SWARM, to be embedded across the Trust to ensure there is this swift learning from incidents. The Trust will have to develop a just culture that will support consistent, constructive and fair evaluation of the actions of staff involved in patient safety incidents. This will mean everyone supporting this aim and working towards this. It will not be successful if it is only seen as the responsibility of someone more senior. This will mean when something goes wrong, service users will be involved in the learning and action taken to prevent it happening to someone else and that the carers’ experience is valued in the learning and action taken to prevent it happening to someone else. Also that staff will be part of a just culture that ensures system learning is embedded to prevent it happening again.

Tragic incidents will always happen whilst humans are involved, we are all fallible and all capable of making a mistake. What is important is that we work together to support staff, service users and carers to learn and improve services. When someone makes a mistake they need an arm around their shoulder, a listening ear and not a pointing figure. We all have a role, if a colleague makes a mistake, stand by their side and share in the learning whilst supporting them through a very difficult time.


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