Patient Safety Protected

At Norfolk and Suffolk NHS Trust, a case came to light of a clinician who spoke to a colleague regarding a senior member of staff working in an inpatient unit. Their colleague recommended that they raise this with the trust’s Freedom to Speak Up Guardian.

The issue involved a senior ward nurse who gathered staff together to discuss a patient with dementia who had been displaying challenging behaviours such as banging on doors, kicking furniture and assaulting staff.

During the staff briefing, the senior nurse suggested that staff use an unauthorised prevention and management of aggression (PMA) technique to control the patient. Many team members thought this was extreme and unnecessary, but felt unable to voice their concerns as they feared reprisals.

Liz Keay, the trust’s guardian, immediately passed this information to the senior manager in charge of the area. They raised this as an incident on Datix, reported it to the police and began an internal investigation, suspending the senior nurse from duties for the duration. The NMC also conducted a ‘Fitness to Practise’ investigation.

The individual who reported the incident was kept informed by Liz via their colleague, and remained anonymous to all those involved in reporting and investigating the incident.

After the issue was brought to the guardian, the following changes were made:

  • All workers were directed not to undertake the PMA technique in future
  • Managers checked that all staff understood current methods for managing challenging behaviours
  • Improvements were made to investigate incidents faster to speed up this process.

Liz said, “The individual who spoke up found it particularly stressful initially. It was important that I reassured them
that it was the right thing to do and thanked them for speaking up, even though this was through a third party. It is vital that workers know they will be listened to when they speak up.

“As time went on, other staff on the ward were able to see actions being taken and improvements being made following their colleague speaking up. I hope this will empower and embolden them to speak up in the future.”

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]