The practitioner joined their clinical team in 2013. From the outset, the team environment was characterised by poor behaviours, intimidation, and a lack of psychological safety. Despite this, the practitioner remained in post, motivated by professional values, a strong ethical framework, and a commitment to patient-centred care. Patients trusted the practitioner and felt safe under their care, and their practice was consistently guided by professional codes of conduct and national clinical standards.
For many years, they informally raised concerns about culture, behaviours, and governance while safe care continued to be delivered. However, over time, these issues were not addressed effectively. By 2023, team functioning and decision‑making had deteriorated to a point where the practitioner believed that patient safety was at real and increasing risk.
The Patient Safety concern
The practitioner identified that changes to prescribing practice were being introduced without appropriate governance. These included deviations from national patient safety alerts and professional guidance, the absence of agreed and ratified Standard Operating Procedures (SOPs), and inconsistent decision‑making outside of full multidisciplinary team (MDT) discussion. Documentation standards were slipping, attendance at ward rounds became unpredictable, and there was a growing lack of shared understanding within the team.
As an accountable non‑medical prescriber, the practitioner repeatedly highlighted that any departure from national guidance required an evidence‑based SOP, formally approved through governance processes. While this was verbally agreed during MDT meetings, the necessary work was not completed, and changes to practice continued regardless.
When clarification and supporting evidence were requested, the practitioner was told, “This is safe, you’re just going to have to trust me,” and “I know this is safe, I just can’t explain it to you.” These responses were incompatible with safe, accountable prescribing practice. Senior prescribing and nursing leaders later confirmed that continuing under these circumstances would breach organisational policy and professional codes of conduct.
At this point, the practitioner faced a critical dilemma: continue within unsafe and non‑compliant practice, or escalate concerns to protect patients. They chose to raise a protected disclosure via the organisation’s Freedom to Speak Up process.
What happened after Speaking Up
Following the protected disclosure, a rapid sequence of events unfolded within hours that had profound personal and professional consequences for the practitioner. Datix incident reports were submitted alleging patient harm. A 24‑hour incident review meeting was convened, during which the practitioner experienced verbal abuse that went unchallenged. Attempts were made to exclude them from discussions, and shortly afterwards they were signed off work due to deteriorating mental health.
Despite their express wish to contribute, investigations proceeded without their input. While off sick, the practitioner was suspended from clinical duties for an extended period, initially without clear timelines or updates. The focus of organisational activity shifted away from the original patient safety concerns toward allegations about the practitioner’s competence and conduct. They were referred to their professional regulator for alleged gross misconduct, despite later findings indicating no case to answer.
Over time, the cumulative impact of these events led to significant psychological harm. The practitioner was diagnosed with Post‑Traumatic Stress Disorder (PTSD) and required long‑term trauma‑focused therapy.
Investigation and outcomes
An external investigation into the clinical team was eventually commissioned. Its findings validated the practitioner’s original protected disclosure, confirming serious concerns regarding team culture, governance, and ways of working.
Despite this validation, the practitioner experienced ongoing detriment. They were described as difficult to work with, subjected to differential treatment compared with colleagues, and told that their ongoing role within the team was considered untenable. Redeployment options offered were largely unsuitable, including roles at lower bandings or in environments that were not physically or psychologically appropriate.
The practitioner submitted a formal grievance, followed by an appeal. At grievance appeal, the organisation upheld findings of bullying, harassment, discrimination, and detriment arising from a protected disclosure.
Organisational learning and response
This case became a catalyst for significant organisational reflection and change. Senior leaders, the Freedom to Speak Up Guardians, and the practitioner worked together to identify where different actions could have altered the trajectory and prevented harm.
As a result, the organisation developed a Detriment Guidance and Action Plan, informed directly by lived experience, national guidance from the National Guardian’s Office, and best practice from across FTSU networks.
Key improvements include:
Clear recognition of detriment
The organisation is strengthening and embedding a shared understanding of detriment as any disadvantageous, demeaning, or harmful treatment that may arise following Speaking Up. This includes deliberate actions, passive failures to act, and subtle behaviours such as exclusion, excessive scrutiny, withholding of information, and cumulative psychological harm. Guidance and leadership messaging are being developed and reinforced to ensure that the impact on the individual, rather than intent, is consistently recognised and considered in decision‑making.
‘Break‑glass’ safeguards
The organisation is introducing and testing formal ‘break‑glass’ safeguards to ensure that any protected disclosure is identified and fully considered before disciplinary, investigatory, or HR processes proceed. A Detriment Risk Assessment and Response Checklist is being implemented to support early identification of risk, alongside developing practice to pause, review, or reconsider other formal processes where there is concern that detriment may be occurring or escalating.
Independent oversight and governance
A dedicated Detriment Subgroup has been established and embedded to provide independent oversight. With Non‑Executive Director involvement, executive accountability for Freedom to Speak Up, and representation from HR, Equality, Diversity and Inclusion, and the FTSU Guardian team, the subgroup reviews all formally reported cases of detriment following speaking up to ensure that all instances are fully addressed, emerging themes are identified, and learning to prevent future cases is reported through Board governance structures.
Trauma‑informed and compassionate processes
The organisation is actively developing more trauma‑informed approaches following Speaking Up and throughout HR processes. Expectations around respectful and compassionate communication, consideration of wellbeing and family impact, time‑bound review of suspensions or restrictions, and access to appropriate psychological and peer support are being strengthened and embedded into practice, with ongoing refinement based on learning.
Training, awareness, and cultural change
Work is underway to embed detriment prevention and psychological safety within training and leadership development. Detriment awareness training is being rolled out, detriment prevention is being incorporated into manager induction, and leadership development continues to focus on behaviours that support speaking up, listening well, and learning from concerns. Awareness activity will continue to evolve as learning emerges.
Accountability and continuous improvement
The organisation is developing its approach to monitoring, reporting, and learning from detriment through Freedom to Speak Up governance structures. Detriment‑related themes are now routinely tracked and reviewed, with senior oversight and Board assurance evolving over time. Learning from cases is being progressively embedded into policy, training, and improvement planning to ensure protections for staff who speak up remain visible, responsive, and effective.
Closing reflection
This case was deeply challenging for the individual involved and highlighted serious system and cultural failures. However, it is leading to meaningful organisational change. By grounding policy, governance, and training in lived experience, the organisation reaffirmed its commitment that speaking up must never result in harm.
Protecting those who raise concerns is essential not only to staff wellbeing and psychological safety, but to organisational integrity and, ultimately, patient safety. This case demonstrates the importance of listening early, acting proportionately, and ensuring that Freedom to Speak Up is supported by robust, compassionate, and accountable systems.