An Investigation At Winterbourne View Hospital

‘The providers had failed in its legal duty to notify the Care Quality Commission of serious incidents including injuries to patients or occasions when they had gone missing.’

He claimed that a new shift system had caused at least one death and one unnecessary operation taking place, and said that he and a small number of consultants were overworked and patient safety and continuity of care were compromised. The claimant had told the Manchester hearing he raised his concerns about the new ‘Consultant of the Day’ system with the trust clinical director Mr Watson and then the trust medical director Mrs Schram; however, he was reprimanded and told not to voice concerns again. The consultant said he was then investigated over a series of ‘malicious, vexatious and frivolous’ allegations and ‘imaginary deaths and complications had been conjured up’ to create a case against him. He believed that the investigation and the process from the beginning was about punishment for raising his clinical concerns, and he argued that the investigation did not examining the veracity’ of the allegations against

Concerns at Winterbourne View came to light after a charge nurse raised the issue with the hospital in October 2010 and his allegations were passed on to the local authority, South Gloucester shire Council, in its capacity as lead safeguarding agency, and then relayed to the CQC in December.

that between 400 and 1,200 patients died as a result of poor care between January 2005 and March 2009 at Stafford

All of the staff need to make sure that confidentiality is paramount. Staff have to read and understand the Data Protection Act of 1998. We have to make sure that we are clear about our standards of conduct, that we are expected to meet. We are encouraged to use the codes of conduct to maintain our own practice

The Data Protection Act (1998) requires that personal details and information must be kept secure and confidential. Confidentiality is necessary in any Health and Care Social setting because it maintains between the individuals and the organisation. An environment of trust encourages people to be open and honest with those who care for them. They provide all the details necessary so that they receive the best care possible. The employers are accountable to the regulators for protecting confidentiality .Preserving privacy and confidentiality is essential so that they do not risk the discipline of being struck off a professional register. Each member of the staff has a responsibility to ensure that the care record are accurate recorded. A clear information will aid patients to participate fully in decision making about their

The home shut down and many members of staff were suspended. The members of staff involved in the abuse were all punished and some receiving prison sentences after being found guilty of physical, emotional and verbal abuse. Ever since this case there has been many changes made to how care homes and residential services are regulated especially through CQC.

One of the most critical factors which contribute to the number of preventable cases of healthcare harm is the culture of silence surrounding these cases. The fear of medical providers to report incidences is related to the possibility of punishment and liability due to a medical error (Discovery, 2010). The criminalization of some acts of medical error has resulted in job dismissal, criminal charges and jail time for some healthcare workers. This is despite the fact that the system they are working in helped to create the situation which led to the error in the first place. Human error, due to fatigue and system errors can result in deadly consequences, but by criminalizing the error it effectively shuts down the ability to correct the root problem. Healthcare workers, working at all levels within the medical system, can provide valuable input on how to improve the processes and prevent harm from occurring (Discovery, 2010).

Every health professional has a legal obligation to patients. Nurses as part of the health care team share an important role in the quality and safe delivery of patient care. They have the major responsibility for the development, implementation and continuous practice of policies and procedures of an organisation. It is therefore essential that every organization offer unwavering encouragement and resources to support their staff to perform their duty of care in every patient. On the other hand, high incidences of risk in the health care settings have created great concerns for healthcare organizations. Not only they have effects on patients, but also they project threat to the socioeconomic status. For this reason, it is expected that all health care professionals will engage with all elements of risk management to ensure quality and safe patient delivery. This paper will critically discuss three (3) episodes of care from the case study Health Care Complaints Commission [HCCC] v Jarrett [2013] Nursing and Midwifery Professional Standards Committee of New South Wales [NSWNMPSC] 3 in relation to Registered Nurse’s [RN] role as a leader in the health care team, application of clinical risk management [CRM] in health care domains, accountability in relation to clinical governance [CG], quality improvement and change management practices and the importance of continuing professional development in preparation for transition to the role of RN.

Honesty is also one of ethical consideration, a very important value and must be followed within health and social care practice because honesty is a way also how people will treat you as a person, if you started dishonesty to that person they won’t believe you in the end and honesty also an expectation of individuals receiving health and social care service. That’s why in this organisation being trustworthy and truthful to others is a fact working in health and social care setting.

This importance of compassion is highlighted in numerous healthcare documentations which state that nurses should provide care that is compassionate (Francis 2013). An incident which occurred in a general hospital in Staffordshire over 50 months between January 2005 and March 2009 led to between 400 and 1200 patients dying due to poor care. Robert Francis published his report on the failings of Mid Staffordshire Foundation Trust which examined causes of the incidents. Since this incident the issue of patent safety and care quality has been in the public eye more than ever. The Francis report has made 290 recommendations which include; openness and transparency throughout the healthcare system, essential standards for healthcare providers, improving compassionate care and stronger healthcare leadership. It is also essential to focus and provide increased education and training on compassionate care (Francis

As known from recent issues in the media, lack of communication can prove fatal for example the case regarding Kane Gorny, 22, a keen sportsman who was so desperate for water he phoned police. “Kane was undoubtedly let down by incompetence of staff, poor communication, lack of leadership, both medical and nursing, and a culture of assumption” (Dr Shirley Radcliffe). If the nurses had communicated and listened to Mr Gorny they would have been able to prevent neglect thus preventing his death. Mr Gorny was not only failed by medical staff but also by police forces as we are made aware that he had phoned but as there was no assault found they left but if the police that were present had questioned medical staff once again Mr Gorny’s death would have been prevented. (The Guardian, 2012) Thus proving that without communication mortal incidents can happen because communication also involves listening, understanding and responding, which was not evident in this situation as Mr Gorny was not listened to and did not get a response to his plea. (Pease, 2000).

The late 1980s and early 1990s saw a major change of emphasis. Medical and later clinical audit became a requirement for hospital doctors working within the NHS. Clinical audit comprises: ‘the review of clinical performance’, ‘the refining of clinical practice’ and the measurement of performance against agreed standards or targets’ (QIS, 2005). Hospitals and community health

It was found that the nurses had insufficient recording of wound care and the staff were not monitoring the wounds consistently or keeping Mr Selir’s GP up to date on his condition. After this incident, the nursing home introduced new staff, systems and processes to improve the quality of care to residents. I felt frustrated and disturbed as coming from overseas, my family background has always taught us to respect and look after our elderly therefore back in our country we don’t believe in nursing homes. According to Nursing and Midwifery Board of Australia [NMBA] 2016, health professionals ought to provide safe, appropriate and responsive quality nursing practice.

In 2011, even before the Francis report was published, around 1000 frontline clinicians from strategic health authorities took part in a safety express pilot. The pilot was designed to test innovative way to achieve a reduction in patient harm. However, one of the programme’s successes was a simple audit tool, the ‘Patient Safety Thermometer’ (Buckley, 2014). The NHS Patient Safety Thermometer (PST) has been designed to be used by all frontline healthcare professionals. Power et al (2012), indicates that the PST can be used to take a ‘snapshot measure’ of pressure ulcers, harm from falls, urinary tract infection in patients with catheters and VTE. Through the use of minimal set data, the PST helps signal where individuals, teams and organisations might need to focus more on detailed measurement, training and improvement (Power et al, 2012). It should be noted that the NHS Patient Safety Thermometer measures prevalence, not incidence, therefore it is of benefit to understand the difference between these and how these harms are measured in the tool ( Table 4). The PST provides a ‘temperature check’ on harm that can be used alongside other measure of harm to measure local and system progress in providing a care environment that is free of harm (NHS, 2013). Power et al (2012) states that the NHS incentivized the use of the PST within the NHS operating framework of 2012/13. For the first time, the NHS used the