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Learning from mistakes From Lisa Rodrigues CBE, Chief Executive 24 June 2013

Lisa_Rodrigues018_2Dear Friends

Five days ago, the new chair and chief executive of the CQC reported that they had found signs of a past internal cover-up about failure to spot unacceptable maternity care at Morecambe Bay Hospitals NHS Foundation Trust.

Since the announcement, there have been calls to name those who apparently authorised it, release of the names, denials from some of those named, and intense interviews with interested parties including parents of babies who died at the hospital.

There has been criticism of the last government, the previous Secretary of State for Health of this government, and others. There will no doubt be more. All this in the wake of the Mid Staffordshire enquiry report.

Right now, it is important to remind ourselves what matters most. We must support our people so they get care and treatment right. Together, we must use the best evidence, pay careful attention to safety and balance the risks of doing one thing versus another. And we must create a culture in which we truly listen to patients so they are partners in their own care.

In a human business such as ours, with so many risk factors, mistakes do get made. Some are obvious immediately, but others we only find out about with the benefit of hindsight.

More than anything else, we must tell the truth. To err is human. Finding out and admitting it can be frightening, and may result in sanctions. But to cover up is dishonest, dangerous and potentially unforgivable.

I have been in my job for a long time. There are no hiding places. I live with the consequences of my own past actions and those of my staff. My senior team are extremely experienced. And rightly we are also still learning.

We have below average levels of complaints and serious incidents at Sussex Partnership. But complacency is our enemy.

With hindsight, I believe in the past we gave an impression to our staff that we were intolerant of errors, rather than working with them to create an open learning culture. A learning culture is in fact proven to reduce errors. It is what we are working on right now. It lies at the heart of what we stand for.

When times are really hard, I return to first principles. We expect every person at Sussex Partnership to be part of our safety-first culture. That means taking responsibility for their own continued learning, working constructively with others, following agreed policies, raising concerns when they have them, reducing bureaucracy so there is more time to care, and being honest when errors are made so that we can truly learn from them.

It's a massive ask, I know, but it's worth it. The work we do changes lives. What could be more important?


Email: lisa.rodrigues@sussexpartnership.nhs.uk
Twitter: @LisaSaysThis