Patrick Keady

Patient Safety Congress, ExCeL, London, 22-23 May 2008


Josephine Ocloo Josephine Ocloo


Krista Ocloo, was born in 1979. Her congenital cardiac abnormality was successfully repaired at an NHS Hospital, shortly before Krista’s second birthday. She went on to enjoy a happy and normal childhood and early teen years. But in 1995, Krista started to complain of chest pain. In January 1996, she was admitted to the same NHS Trust for an exploratory catheterisation.

Krista’s mum, Josephine, was assured by the NHS, that Krista was perfectly all right and that an appointment would be booked for another check-up. Krista was discharged but the appointment was not scheduled until January 1997.


On 5th December 1996, Josephine found Krista at home in bed …….. Krista was dead. The post-mortem revealed death from acute heart failure.


Josephine Ocloo, relayed her story to the 600 delegates at today’s Patient Safety Congress. The Nursing Director next to me, stopped taking notes. She placed her notebook on the floor and gave her undivided attention to Josephine Ocloo. Josephine then described how she tried to get answers from the NHS Trust. Josephine wanted to know why Krista had died. SheJosephine described an NHS that was at best, unhelpful. Around me, I saw some tears, I heard lots of sniffles …… and there was very little note-taking.


Krista died before the introduction of Clinical Governance, the Turnbull Report, Choice and Competition as we know it today. But what can today’s NHS do to ensure that all of today’s patients get a better service than Krista received 12 years ago? Professor Bernard Crump (Chief Executive of the NHS Institute for Innovation and Improvement) asked delegates for their thoughts. He asked them to identify which one of the following can best improve patient safety


1. Regulation and Standards
2. Commissioning, Competition and Choice
3. the personal motivation of NHS professionals, leadership



David Nicholson, Chief Executive of NHS England, told us that delegates and the NHS in general, needs to be clear about the services that we want to deliver for patients. He added that techniques such as PDSA, Lean etc, together with new behaviours, will help.


Don Berwick


Don Berwick, President and CEO of the Institution for Healthcare Improvement, added that improving healthcare needs to be embraced in every hospital, by every GP practice and by all healthcare professionals. Professor Cecil Helman alerted us that the definition of health, continues to change. Since the NHS was established in 1948, the definition of health has fragmented into physical, psychological, social and spiritual. David Dalton Chief Executive at the Salford Royal NHS Foundation Trust, joked that his organisation was ‘crap at implementation’. He then added that his Trust reduced Clostridium Difficile infection rates by 70% in 10 months. The Trust achieved this by empowering staff to identify the problems that they wanted to deal with, and giving them the necessary support. Sir Liam Donaldson, Chief Medical Officer, suggested that in 2018, infection prevention might be achieved with the help of sensors, that there might be voice operated electronic prescribing, checklists in surgery and an aviation-style ‘black-box’ in operating theatres. Peter Walsh, Chief Executive of Action against Medical Accidents, pointed out that NPSA Being Open, is only guidance. He urged for a major uptake of training in NPSA Being Open. Rashmi Shukla highlighted the characteristics of a safe system. Eamonn Kelly identified how World-Class Commissioning, the Assurance Framework and the Standard Contract for Acute Services can improve services. Katherine Fenton challenged the role of Strategic Health Authorities, adding that it needs to shift towards motivating their PCTs and Trust improve. Sarah Andrews added that while NHS targets can be useful, the NHS will benefit from celebrating it’s achievements. Gerry Marr from NHS Tayside highlighted how data owned by Clinicians is being used to show decreases in Hospital Acquired Infections. Data from Clinicians in Tayside, will be used to confirm a 15% reduction in mortality and a 30% reduction in adverse events. Martin Fletcher, Chief Executive of the National Patient Safety Agency highlighted Royal Gwent where there is a 95% compliance with hand hygiene, more than twice the average compliance of 40% in England and Wales. This high level of compliance was achieved because of strong leadership, the use of an effective implementation tool, the measurement of outcomes and providing feedback to staff. To be a Regulator or not to be a Regulator, that was the question! Paul Philip (General Medical Council), Sarah Thewlis (Nursing and Midwifery Council), Gary Needle (Healthcare Commission) and Simon Gregor (Medicines and Healthcare products Regulatory Agency) were all proud of their roles as Regulators. But Professor Bruce Campbell (National Institute for Health and Clinical Excellence) and Professor Dame Joan Higgins (NHS Litigation Authority) emphasised that their Organisations were not Regulators.


And what responses did delegates give to Professor Bernard Crump’s poll? 3% of Delegates voted regulation and standards as the most effective approach to improving Patient Safety. 2% went for Commissioning, competition and choice. The other 95% opted for the personal motivation of NHS professionals and effective leadership.


Is it a coincidence that in the 12 years since Krista’s death, we have seen a plethora of activity in the areas that received the fewest votes? – regulation, standards, commissioning, competition and choice.


It is refreshing that based on the messages from these speakers, that effective leadership and the motivation of staff is leading to dramatic improvements in parts of the NHS.



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