A presentation by Hans Rutberg at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All available content from SSAI2017: https://scanfoam.org/ssai2017/ Delivered in collaboration between scanFOAM, SSAI & SFAI.

1. What could we all learn from a
recent scandal in healthcare?
Hans Rutberg, former professor in patient safety,
Linköping University

2. Conflict of interest
None, re-imbursement of expenses in relation
to the congress has been provided.

4. Staffordshire
Between 2005 and 2008 conditions of appalling care were able
to flourish in the main hospital serving the people of Stafford
and its surrounding area.

5. • Patients were left in excrement in soiled bed clothes for
lengthy periods
• Assistance was not provided with feeding for patients
who could not eat without help. Water was left out of
reach
• In spite of persistent requests for help, patients were not
assisted in their toileting. Wards and toilet facilities were
left in a filthy condition
• Privacy and dignity, even in death, were denied
Mid Staffordshire scandal

6. Mid Staffordshire scandal
• Triage in A&E was undertaken by untrained staff
• Staff treated patients and those close to them with
what appeared to be callous indifference
• Hospital mortality was much higher than expected
• Patients, relatives and employees raised concerns
but no action was taken by the board

7. Then something happend…

8. Helen Donnelly Julie Bailey

12. Warning signs
• A culture focused on doing the system’s business –
not that of the patients
• An institutional culture which ascribed more weight
to positive information about the service than to
information capable of implying cause for concern
• Too great a degree of tolerance of poor standards
and of risk to patients

13. Recommendations
• Foster a common culture shared by all in the service of
putting the patient first
• Ensure openness, transparency and candour
throughout the system about matters of concern

14. • Openness – enabling concerns and complaints to be
raised freely without fear and questions asked to be
answered.
• Transparency – allowing information about the truth
about performance and outcomes to be shared with staff,
patients, the public and regulators.
• Candour – any patient harmed by the provision of a
healthcare service is informed of the fact and an
appropriate remedy offered, regardless of whether a
complaint has been made or a question asked about it.
Openness, transparency and candour

18. Helen Donnelly in 2013 became ”Ambassador for Cultural
Change at the Staffordshire and Stoke on Trent Partnership
NHS Trust
In 2014 she recieved ”Order of the British Empire” for
services to the NHS

19. Julie Bailey started the
campaign group
”Cure the NHS”
In 2014 she became
”Commander of the Most
Excellent Order of the British
Empire (CBE)”