Patient Safety
How we look after you
Listen – Learn – Communicate – Collaborate
Patient Safety Team
We do everything we can to make sure people who use our services receive high quality care. We actively encourage our staff to report incidents so that we can review our processes to ensure patient and staff safety is top of our priorities. We thoroughly examine these cases under our Patient Safety processes.
Patient safety is where we all work to protect everyone and avoid harm.
We need staff, patients, and families to share their experiences and ask questions so we can continually learn and improve.
Patient and Family engagement
We listen carefully to what our patients say. Please question anything you feel may affect your safety or wellbeing.
The Family Liaison team and SWASFT Engagement Officers ensure that Duty of Candour procedures (see below) are followed when an incident is identified.
- Should you wish to contact the Family Liaison Team, please email: patientsafety.flo@swast.nhs.uk
- If you have any queries for the Patient Safety Team, please email: patientsafety@swast.nhs.uk
What is Duty of Candour?
Duty of Candour is a statutory (legal) duty to have conversation with patients, their families, or nominated person when something goes wrong.
When a Patient Safety incident is identified as having caused the death of a patient, Severe or Moderate Harm, or prolonged psychological harm to the patient, Section 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Duty of Candour (DOC) process must be followed. Contractual and National standards require that contact be established with the patient/family/nominated person, and that this engagement should be “open and honest” and reasonable support should be provided.
What to expect
There are times when something goes wrong with the care, support and treatment provided to patients.
On those occasions, we should provide patients, families, and carers with the following :
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Information about what has happened and offer an apology .
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Provide a full and true account of all known facts to date .
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Information about the learning response being completed .
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Information about support agencies .
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At the outset written information will be provided .
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Answers to any questions and address any concerns raised .
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At the conclusion of any review, information about the findings should be shared with the patient, family, or carers in writing .
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The organisation should act on all actions that come out of the review and ensure these are completed with in an agreed time frame .
Should you wish to read more about Duty of Candour and Patient engagement please click here
Patient Safety Incident Response Framework (PSIRF)
PSIRF is a completely new way of looking at patient safety and empowers people to speak up when things go wrong.
PSIRF has four key aims with regards to patient safety incidents:
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compassionate engagement and involvement of those affected.
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a system-based approach to learning.
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considered and proportionate responses.
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supportive oversight focused on strengthening response systems and improvement.
The Patient Safety Incident Response Plan (PSIRP)
Sometimes we identify areas of care that we can learn lessons from; that may be where things have not gone so well, where care has been recognised as excellent, or we identify significant learning for the Trust. It is vitally important that we capture that learning to improve the standard of care we provide.
PSIRP sets out how SWASFT will seek to learn from patient safety incidents reported by staff and patients, their families, and carers so we continually improve the quality and safety of the care we provide.
Learning responses
Patient Safety Incident Investigation (PSII)
A PSII is a thorough investigation into the care we provided. It is not to apportion blame, but to undertake an investigation that looks beyond the individuals concerned and seeks to understand the underlying causes and environmental context in which the incident happened.
These findings are then used to identify effective, measurable actions that will lead to improvements. Recommendations and action plans are then developed to effectively address those system factors and deliver safer care for people who use our services.
After Action Review (AAR)
An After-Action Review is a structured review of a patient safety incident which involves an in-depth analysis and exchange of ideas, in a safe and non-blame environment.
Discussions are held with all involved to identify what actually happened, versus what should have happened, to help identify learning, set actions, and make improvements.
Equality, Diversity, and Inclusion - Easy read and translation
Promoting equality, embracing diversity, and ensuring full inclusion for people who use our services is central to the vision and values of SWASFT.
We use Easy read and language-line to ensure we provide all the detail you need, in a format that suits you, whatever age, preferred language, learning ability or even if you need a quick read option.
We can help, when required or preferred and provide information clearly in the manner which suits you. Please let us know if there are any changes that we can make that could help.
Introduction to our Patient Safety Partners
Achieving quality driven, high performing, patient centred care is at the heart of SWASFT’s strategy.
Pivotal to delivering an outstanding patient experience is the need to listen to, learn from, communicate, and collaborat e with our patients in this way helping us to both build upon positive experiences, as well as learn from situations where things may not have gone as well as we would have liked.
The NHS Patient Safety Strategy of 2019 recognised the importance of involving patients, families, and carers in improving the safety of NHS care . As well as encouraging patients to be more proactively in their own safety, the strategy also proposed the creation of a voluntary Patient Safety Partner (PSP) role within all Healthcare Trusts , to ensure members of the community could play a more proactive part in contributing towards patient safety.
Working in support of the Patient Safety and Clinical Governance teams, our Patient Safety Partners provide input to our patient safety processes and initiatives and provide assistance by acting as the ‘voice for the patient.’ PSPs are drawn from a wide variety of backgrounds and experiences, ensuring a diverse representation of views.
SWASFT ( South Western Ambulance Service Foundation Trust) currently has 2 Patient Safety Partners, Nigel Jones, and Geraldine Ashton, who help us to continuously improve patient safety through a combination of both collaboration and challenge.
What if I do not agree or am unhappy with the learning response?
If you are dissatisfied at the end of our review, you can put your concerns to:
Complaints – Speak to your contact within the Patient Safety team who will raise with Patient Safety managers.
Still not happy – Your contact will escalate your concerns to SWASFT Senior Management Team
What if I still do not agree or am unhappy with how my concerns have been managed?
The Ombudsman can carry out independent investigations into complaints about poor treatment or service provided through the NHS in England.
The Ombudsman’s services are free.
If you have any questions about whether the Ombudsman may be able to help you, or about how to make a complaint, please contact their helpline on 0345 015 4033, or email phso.enquiries@ombudsman.org.uk. Further information about the Ombudsman is available at: www.ombudsman.org.uk. You can write to the Ombudsman at:
The Parliamentary and Health Service Ombudsman, Millbank Tower, Millbank, London SW1P 4QP
If you are struggling or need support
Being bereaved, seriously injured, or involved in a traumatic event can leave you with a wide range of emotions. You may feel distressed, upset, angry or frightened. Everyone’s reaction is different and there is no one way to feel or deal with those feelings.
You may wish to deal with these feelings alone or with close friends or family. However, you may feel more able to speak to someone outside of this circle. There are many agencies whose trained staff or volunteers can help you.
Often these are people who have been through similar experiences . We have developed a useful guide of charities and organisations that may be able to provide support to you and your family. This can be accessed here.
Your voice
We always welcome any suggestion on how we can improve our contact with patients and families .
If you have any recommendations as to how this might be made better , please do let us know or if you wish to become involved and make changes from within the organisation, please follow the links below: