This week's exec message: If you knocked someone over in the street, would you say sorry?

Side of RRV with lozenge

For those of you who don’t know me, I’m Emma, and I’m the safety and risk lead for the Trust.

My team helps to look after the safety of our patients, and of our staff, and help to implement learning on the rare occasions that things go wrong, so that we try and prevent them from happening again. Trust security, Datix incidents, and the centralised team investigating serious incidents and HR cases also fall under us, and I’ll reflect on a bit of that later on in this article.

But first, a scenario for you; if you accidentally walked into someone in the street and knocked them over, would you say sorry? I think most of us would. But what about if you were on scene with a patient and you’d accidentally administrated them with the wrong drug? Would you feel confident in saying sorry then? In reality, it shouldn’t be any different.

As healthcare professionals we have a duty to be open and honest with patients, including when something goes wrong with their treatment or care that has, or had the potential to, cause harm or distress. That means saying sorry then and there – not as an acceptance of blame or admission of guilt, but because saying sorry is the right thing to do. In official terms this is called Duty of Candour, but in human terms it’s about showing compassion, trying to offer a remedy or support to put it right, and then explaining what’s happened and what you’re going to do next. I appreciate it can be really tough to say sorry if you’ve made a mistake, particularly when it comes to patient care. But we all make mistakes – the important thing to do is to try and put them right, and learn. Food for thought, but more information on Duty of Candour, and why it really does matter, is coming over the next month or so.

I have to say that when something does goes wrong, you really are some of the best in reporting it. Incident reporting has gone up, month on month, every month, for around the last two and a half years, and we now get roughly 1,000 reported incidents a month, with really low levels of patient harm. And that’s a great thing, because it shows that we have a very safety-aware culture. On the back of the reporting we can make improvements where we need to – it helps us to protect patients, and it helps us protect you.

But, our recent staff survey results showed that many of you have concerns about reporting clinical concerns involving a colleague. People don’t feel confident in challenging others on their clinical care, perhaps because they’re more senior or they’re a friend. But that ‘check and challenge’ is the fundamental basis of a really honest and safety focused culture. We all need to, hand on heart, feel confident in saying to someone ‘can you just talk me through what you’re doing, and why you’re doing it?’ Because their decision might be right, but it might be wrong, or you might have an idea for a better way of doing something. Even if after that conversation you both decide to continue with the original plan, that challenge helps us to sense-check decisions. Use your colleagues – they’re experts too.

We have to continue learning, and all keep an eye on each other and patients to make sure everything is as safe as possible. But sometimes, because we’re human, things slip through the net. In those times, it’s really important that we investigate what happened, why, and what steps we can take (as an organisation) to stop it from happening again. Investigations really are a non-punitive, non-blame process – it’s all about focusing on learning. We look at our training, our policies and procedures, and our systems to make sure that we haven't unintentionally set someone up to fail. We try to recognise gaps and fix them. We’ve got some patient and health and safety pages coming soon on East24, which will have a wealth of information about incidents, investigations, and the support we have in place for the rare occasion you might be involved in one. We’ll share on Need to Know once they’re up and running.

I also wanted to use this opportunity to reinforce some of the messaging Robert shared last week about security, on the back of the tragic events in Westminster. Security matters. I literally can’t stress that enough. The terror threat across the country is severe and yet we’re still in a position where, when we’ve done tests with plain-clothed colleagues, they have been able to make their way into the centre of a number of Trust buildings (including two control rooms) within five minutes of arrival. Simply by making up a story of why they should be there.

Please, please challenge people, as we’re not safe if we don’t take steps to make ourselves safe. Don’t let people tailgate you, and check everyone you don’t recognise – even if they’re wearing an ID badge. Ask them for the name of the person they’re there to see. This should happen even if they’re in uniform; our security management specialist has seen many cases where ambulance greens have been put up for sale and bought on eBay (which is fraud), but my point being that just because they’re in uniform it doesn’t mean they’re legitimate staff. I appreciate it’s severe, but it’s the sad reality we’re facing. Please feel free to come and speak to me, or our local security management specialist Anne Wright, if you need any support or advice. We’re here to help.

And finally, I’m going to do a shameless plug of our team’s new Twitter account - @EEAST_Safety. Please give us a follow, join in the conversations we’re having, and share ideas on how you think we can improve safety across the Trust.

Have a good week,


Emma De-Carteret, Safety and Risk Lead


Great work happens every day across our organisation, so our weekly leadership messages will highlight that from teams across the Trust.


Chief Executive Robert Morton shares his updates once a month, with the other three weeks showcasing the senior leadership team at EEAST. Know a leader who would be interested? Please get in touch, we’d love to hear from you.


Published 30th March, 2017

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