A member of the community midwifery team came to Susan Clennett, Freedom to Speak Up Guardian at Kettering General Hospital NHS trust, with a concern about her father-in-law’s care in the hospital.

Kerry’s father-in-law, Tom, was admitted as an emergency. Due to his sudden illness, Tom was unable to communicate. When he was admitted onto one of the wards, he was assessed as needing bed rails in place to address the risk of falling, but these were not put in place. During the night, Tom fell from his bed and was injured. His condition deteriorated while he was undergoing various tests and assessments.

The family became concerned because, at times, staff failed to keep them updated on results and plan of care. Because of the fall, Tom’s injuries and the lack of communication, the family lost confidence in his care; they were worried about Tom’s safety when they were unable to be by his side.

Kerry brought her concerns to Susan as the Freedom to Speak Up Guardian because she thought there was scope for organisational learning. Kerry wanted Tom’s experience to be used positively to improve safety and quality of care because she believed the safety issues she’d witnessed affected not just Tom, but other patients as well.

Following an investigation and meetings with Susan, together with the Head of Patient Experience and Chief Executive Officer, the trust launched a learning tool and short film called ‘Tom’s Story’.

The film is shown in facilitated workshops so that every clinician can consider how they will take the learning and experiences of Tom and his family back to their area to identify where they can make improvements. Tom’s Story is also available via a link on the intranet page for all staff to
access so that they can understand the impact of potentially avoidable patient safety incidents and failure to communicate effectively with relatives.

Kerry’s main message to the trust was, “If you say you are going to do something, do it or let the patient and family know why not.”

Susan said, “Effective communication is often a theme on feedback to NHS organisations. Kerry’s case highlights the need to listen to the views of relatives (who knew Tom the best) and to feed back when promised.

“Tom’s story has had a major trust-wide learning impact on both patient safety and how we communicate effectively  with patients and their relatives and we’re grateful to Kerry and her family for their continued support in sharing Tom’s Story as a learning too.

This case study was part of our 100 Voices publication which accompanied the 2019 Annual Report.

Case studies are vital to illustrate the good work of Freedom to Speak Up Guardians. We encourage all organisations to share the learning from their speaking up stories.

If you have a Freedom to Speak Up story to share, please send an email to [email protected]