Susanna Stanford: Patient safety – understanding good intent should be the starting point for conversation

Matthew Taylor

Hello. This edition of Health on the Line will, I think, illustrate a number of themes: the impact a determined individual can make; how we can and should try to learn from adversity; the importance of the experience and voice of the patient. The focus of our conversation today is patient safety. It's part of a series we at the Confed are delivering in collaboration with NHS Supply Chain, and there's more detail on our website. But now it's time to hear from a pretty remarkable campaigner and reformer.

I'm joined by patient advocate Susanna Stanford. Following a traumatic personal experience in 2010, Susanna became interested in patient safety. She’s spoken about her experience, contributed to patient safety research, campaigned to engage medical students and clinicians in how to manage adverse events. And how patients and clinicians need support in the aftermath of things going wrong.

Amongst other things, Susanna is an ambassador for the Clinical Human Factors Group, on the Harmed Patient Alliance Advisory Group, and she's also in the steering group for the UK Obstetric Surveillance System and the National Safety Standards for Invasive Procedures.

So, Susanna, welcome to Health on the Line.

Susanna Stanford

Thank you very much. Thank you for inviting me.

Matthew Taylor

How are you this morning?

Susanna Stanford

I'm very well. The dogs are all quiet, so I'm hopeful that we'll have a good chat.

Matthew Taylor

I've got dogs here as well, so let's hope your dogs don't set off mine and vice versa.

So, take us back to 2010 and the incident that changed your life, I guess, if you don't mind describing it to us.

Susanna Stanford

Yes, it did. So, I already had one son. I'd had a straightforward pregnancy and delivery that time. Second time around, I needed a C-section for my second son because I had an anterior placenta previa. And it was explained to me that that was higher risk. And it's really important to emphasise that was life-saving surgery.

However, unfortunately, I experienced spinal block failure. So, I was able to feel major abdominal surgery, which is every bit as horrific as it sounds. It was very traumatic. My fear was focused on my child whilst I was experiencing pain that I perceived as life threatening. The operation was stopped three times and eventually I had a general anaesthetic. Now, afterwards it wasn't handled well by the anaesthetist in the trust, and I left hospital with a standard discharge note which stated I'd had a routine C-section on regional anaesthetic.

That meant that when I tried to mention it to my community midwife, she saw nothing on my notes and thought I was making a fuss about nothing. And said, ‘oh never mind, the baby's all right. That's all that matters’.

So, it was ten months later that I went to my GP because I was really struggling to engage with life. I had of course developed post-traumatic stress, and it was only when I told her, that she knew I'd had a general, and just knowing I'd had a general would have been a clue to her that something hadn't been straightforward.

Now, she wrote to the hospital asking for access to my notes and received a response back that stated I had been conscious and comfortable at the time of my son's birth. Now, of course, had I been comfortable, there would have been no need for a general anaesthetic. So, it was a really difficult situation to be in and she emphasised to me that the adversarial route was very stressful and I didn't want to go that way. I already said I didn't want to complain. I just wanted there to be learning and I wanted to understand myself.

But the defensive response from the trust made that difficult. However, I became aware that other women had similar experiences. So, I created a survey and I had 150 women respond. In their own words, highlighting the same issues I had identified, and they were all over the country.

And that made it very interesting because it then meant I no longer had one trust to contact. So, I did the only thing I could think of which was to write to the President of the Royal College of Anaesthetists, and to his immense credit, he responded in under two hours the Sunday before Christmas and invited me to go meet with him.

He put me in contact with Obstetric Anaesthetists Association, and long story short, we've now got guidelines for testing and managing regional anaesthesia for C-sections.

Matthew Taylor

Oh, that's amazing.

In that period after what happened to you, were there moments when you just thought I want to try and put this behind me. I'm not going to do anything about it. And what were the factors that gave you the determination to carry on and to create, in the end, the kind of movement and the momentum which has led to change?

Susanna Stanford

It's a really interesting one because I have had so many people say to me, why don't you just put it behind you? You're never going to get anywhere. And I simply refused to take that answer. Yes, in part there was a really clear sense of injustice at it. But the really big thing was that I appreciated that I was in a privileged position.

I felt that I was able to approach medics at a sort of an equal level, I suppose. And I was really, really concerned about what would happen to someone who was more vulnerable than I was. So, girls who are too young, women not in their first language, women who have been raped or abused. If it had already broken me, then what for them?

And that has always been the motivation. Because at the end of the day, it was never going to change my outcome. It was about everyone else.

Matthew Taylor

And how did the experience and what's happened since shaped the kind of principles that you bring to the idea of patient safety?

Susanna Stanford

I think it's really important to say that I always believed that harm had not been intended. And I think understanding good intent should be the starting point for any conversation on patient safety. So, keeping that in mind, I've always been very driven by trying to understand why things happen. I found that if you really work to understand what's going on and why, from the clinician perspective, and then you connect it to the patient experience and explain that to clinicians, it's really powerful.

And so, you're basically working with two different groups, frames of reference, and explaining them one to another.

The two things that have really stood out for me in the process of talking about it to clinicians - the first time I spoke, it was the biggest obstetric anaesthetists conference, there were 600 or so anaesthetists and me, and it felt somewhat gladiatorial going in. But I learnt that I was speaking in front of people who included mothers, who'd had their own traumatic deliveries, and fathers who felt they'd let their partners down. And it was very, very humbling to be reminded of our shared humanity and that's really stayed with me.

And the second thing that stood out for me is just how willing people are to learn. So, if I go back to the 18 months after the first couple of times I spoke, I asked the Obstetric Anaesthetists Association if we could survey the people who'd been present to see what impact they gained from me talking. And a little over the half the consultants had refined their own practise and 70 per cent had changed what they taught their trainees.

So, on the one hand, I had made them reflect about their practise and there was a tremendous willingness to learn. But on the other hand, I could see that clinicians cared deeply about providing good, safe care. And that understanding has driven much of the work I've done in patient safety since, because it's been as much about keeping clinicians safe as it has been about keeping patients safe.

Matthew Taylor

So, I'd like to put out a couple of themes of that, very kind of eloquent account that you've given Susanna. So, the first is it seems natural, that a mistake, an adverse experience is an enormous opportunity for learning and that's how we're encouraged to think about our lives. But as Matthew Syed has said, he wrote a whole book about it, different cultures, different industries treat this differently. And one of the reasons, for example, that aviation is so safe is because of the black box system, which says we have to design things so that we can learn when something goes wrong. And that we will share it with everybody in the world so everybody can learn. And I think, Matthew says that's unfortunately not the case in health, for example.

So, given how obvious it is that we should learn from adverse experiences, from mistakes, from tragedies, why is it not always the case? What stands in the way of turning these things into learning experiences?

Susanna Stanford

Fear. It's about what have you got to lose? And when people feel they have something to lose, they cannot be honest. The contrast is that when you're talking about patients who've experienced harm or they've lost a child, they have nothing to lose. Those fearless campaigners, we see maternity investigations, for example, they had nothing to lose.

So, it's about fear. And that really leads into what people are talking about now in terms of trying to achieve a just culture and in terms of describing a culture where trust enables reporting to occur with the focus of facilitating learning to drive safety improvement. Just culture is a good start, but I think it's the minimum of what we need to transform the culture and people's experience of working in healthcare.

Because for me, the crux is in people feeling safe, not only to report error but also to ask questions, to get feedback, to raise concerns. Psychological safety is becoming a bit of a buzz phrase, but it's really key. Both at a team level, and within organisations too. There's a lot of concern in the NHS about staffing and workforce with concern about burnout, with people already being at their limits and people leaving.

And personally, I think things like yoga classes and resilience training are all pretty meaningless if an organisation isn't really committed to getting the basics right in terms of creating an environment where people feel supported if things go wrong. Because no amount of yoga is going to make you feel better if the pressures you face at work mean that you see one of your colleagues hung out to dry for a mistake that could have been made by anyone else in the same circumstances.

And I think that's why cases like Hadiza Bawa-Garba case get so much support because it speaks to the fear that everybody feels.

Matthew Taylor

The other thing about your approach which stands out, and which I think has sometimes led to criticism, is this idea that we should understand that both patients and clinicians can feel upset, traumatised when things go wrong. Wanting to try to avoid blame being the first instinct. But, for some people, that doesn't feel right. For them, what has happened is something blameworthy.

It does reflect arrogance, it does reflect a power imbalance. In those debates, Susanna, that you've had when you've encouraged us to understand how this feels from the clinician perspective, and to recognise that blame probably doesn't help us to learn, you must understand presumably the perspective of those who say, well, that's all very well, but I am just enraged and I think that I have been mistreated.

Susanna Stanford

Of course, yeah. I think first of all, it's very important to say that the idea of a just culture is not without accountability. Reckless and negligence behaviour should always be called out, full stop.

I'm very lucky I think, because I stayed away from the adversarial route, and I've been able to get to know so many brilliant, conscientious, kind, compassionate clinicians. So, it’s had a big impact on me.

But I completely understand how people can become so cynical. As I did. You receive a letter which gives a version of events which is just not true. You get strong, visceral response to it. There's a very strong sense of injustice, of hurt, anger. Because you've experienced harm and you're being wronged. And there are people who haven't had my subsequent experience, but instead have been trapped in a cycle of endlessly being stonewalled, and even being blamed for what happened to them.

So, I know mothers who have been blamed for their babies dying, people who've been to fitness to practise hearings, who've been cross-examined by a criminal barrister for two hours without support. And they're in an endless process of investigations, going on for years with multiple different organisations. And when people are put through that particular mill, and it is about being ground down, they can end up bitter and angry because they lose trust in everyone.

Matthew Taylor

I'm interested in the questions of organisational culture because when we talk about events like the event that you experienced, we can often see it as a one off. But yet, I think it's important isn't it, to connect it to the broader organisational culture. I'm making a programme for Radio 4, at the moment, about bullying, and actually the NHS is a case study, partly because actually NHS is one of the few organisations that really has the data on it.

Nearly one in five people in the NHS say they experience bullying in any given year, most of it from managers but actually almost as much from colleagues. And when you see that level, I think what it reflects is a culture which has got two very strong characteristics. One is it's very hierarchical and the other is that people are almost always working under pressure. And these two characteristics create the kind of culture which people feel bullied, which is the kind of culture where people can’t ask difficult questions, can't say, if they're a junior member of staff to a more senior member staff, are you sure we're doing the right thing?

So how deep do you think the cultural change has to go? And in answering that, Susanna, tell us more about this concept of ‘just culture’.

Susanna Stanford

It does have to go deep because it's both at a micro level within teams and at a macro level within organisations, as you've just indicated. Undoubtedly authority plays a role, and we need both managers and senior clinicians modelling the behaviour we want to see. The hierarchy can be exploited and that's when really unpleasant behaviours follow. So, for example, bullying, but also sexual harassment as well, which has really come to the fore recently.

And those negative behaviours might be the minority, but they have a chilling effect on whole teams and even units. And I think the key point is that if any colleague doesn't feel psychologically safe and feels that others will undermine them or humiliate them, you immediately have a situation which is bad news for patient safety because there's no way that people will speak up.

I think the good news is that people are much more aware of the impacts of hierarchy now and there is this awareness that we need to move towards a fairer way of handling things. I always tell trainees, no matter how senior they become, they have to be behaving in ways that enable others to speak up.

So, yes, there's the idea of what do you do after something's gone wrong? But, we've got to be further upstream from that and to be trying to get the behaviours which stop things going wrong in the first place. And I think that's where the concept of psychological safety then becomes really, really important.

And it takes humility. I know an orthopaedic surgeon who had some time off for health reasons and when she went back into surgery, she simply said, ‘right, if you see me going to do anything stupid, please tell me’. Because she's really inviting and giving other people voice and saying, look, I'm going to value your feedback.

Matthew Taylor

I want to run past you a theory that I've developed over the years. It goes back actually to a personal experience I had. So, many, many years ago, I went to a rather weird group cognitive and behavioural therapy session run by an organisation that was a bit cultish, to be honest, I wouldn't recommend it.

But we were all there together, there was about a hundred of us in this room in central London, being shouted out by a charismatic Frenchman, and we were all there because we were either doing something we didn't ought to have been doing, people were taking drugs or drinking too much or cheating on their partners, or we weren't doing things that we should have been doing. We weren't fulfilling ourselves, we weren't succeeding at work.

Anyway, we spent the weekend hardly eating and being shouted at, and it was all very intense. At the end we were asked to come up on stage and share our story. And what was fascinating was that almost everybody came up and said the same thing.

They all said a version of the reason I do this or the reason I don't do this is because it's hard being me. And I derive from that an insight into cultures, which is that actually most organisations - this is why it's the cover up that is often the problem, not the initial mistake - because when something goes wrong, people often mobilise this story of how hard it is to be them.

There's a kind of sense of I ought to recognise this, learn from it, admit to it, but it's so difficult being a police officer or a member of parliament or working in the NHS under this pressure, that I shouldn't have to do that and that's why I'm going to try to cover up or push it away.

So, I've come to the view that one of the things cultures need to do is to recognise that story, the story that gets mobilised when you have to choose between whether or not to face up to something and be honest about it and learn from it, or instead try to kind of cover it up. Does that have any resonance with you, Susanna?

Susanna Stanford

Yes, yes it does. Now there's two angles on this. One is the fact that people are often asked to write down what happened. And in doing so, I think you probably get the strongest demonstration of that pattern. And I think if you were, for example, to get people in the room, without the charismatic Frenchman, to talk through what happened, and then suddenly you get that… but that happened… and so and so said that… and then such and such was happening over here… you get a build-up of a narrative which is being corrected within itself by the people who were there, as long as everyone there is motivated to be honest about it, of course.

The other thing I would observe, and this comes from my experience of working in schools and particularly at the time that I was starting out with The Obstetric Anaesthetists Association, I was working at a very high performing school where a lot of the students went on to read medicine.

And I was actually working in the university's application team and responsible for their references and hearing what they were wanting to do. And I was meeting these really wonderful young people wanting to go into medicine. Brilliant, bright, highly motivated. And I kind of started wondering what happens to them when things go wrong because you’ve got really bright young people who have come through the sciences usually. Some people sort of breeze through the sciences and they find it all very easy. Some people have to work a bit harder. But the great thing is that if you do your work, you can get 100 per cent. And it kind of breeds perfectionism. And you get people who will really be aiming for that because they don't want to be found lacking.

And then they go into medicine, which is just the cruellest environment for perfectionism because they are working under time pressure, they are responding to five calls on their attention at once. They may be without a full set of results. They may not have all of the information. They can be making a decision for the least worst option, rather than there being a best option.

And that's really, really tough on them. And so, one of the things I feel really strongly about is actually getting in with medical students and trainees young and pointing it out to them and sort of highlighting all of our imperfection and being able to say, look, it is going to happen, things will go wrong. So now what we want to do is to start thinking about how you're going to respond when it does.

And a lot of that is about reflection in not writing it down but to be able to just within themselves have the kind of intellectual and emotional curiosity to try and figure out what made something good. What could have been better. So that they're just better equipped to manage these situations.

Matthew Taylor

And Susanna, how successful do you think you've been? How far have we got in changing the way in which we think about the way we educate medical students or indeed anybody in the health service… leaders, clinicians. And how we do training and development in the future. Do you think that there is now a shift away from that kind of assumption of perfectionism, the assumption that there's always a simple distinction between the right and the wrong way to do things? Do you think that is changing?

Susanna Stanford

I think we're only just beginning. Because don’t forget you've always got a new intake. So, there is an element of always having to educate the next lot coming through. And because of the way medicine works with almost as soon as they’re through training, they become educators. And you've got people right the way up through 40 years, further down their career.

So, it takes quite a long time I think for knowledge to change sometimes.

Matthew Taylor

And do you think that the burnout that we see in the health service and obviously that is to do with two years of covid and the fact that we went into covid with 100,000 vacancies, etc. But do you think that burnout is also partly to do with what you're describing, which is that people have been led to a set of expectations and then when things do go wrong, they don't see this as just part of the role and part of how you learn, but they somehow see this as a failing.

And do you think that contributes to the number of people who now don't seem to want to stay in healthcare?

Susanna Stanford

So yes, on the point on personal failure, one of the things that I say to obstetric anaesthetists is that when they're testing the block that it is the block, it's not their block. So, there is a really instinctive sort of personalisation of what they're doing. And so that can come back to haunt them.

I think it also can mean that they’re functioning with one hand tied behind their back in some senses, because it makes it harder to see when something isn't going right. If you're personally invested in it, as opposed to being able to objectively say, this is what's going on right, now I need to move on to plan B because that plan A wasn't working. If you're really kind of invested because it's a personal thing, then you're more likely to fall into the traps of things like confirmation bias and fixation error, where people sort of continue going down the wrong track.

In terms of burnout, I think what you're saying is right. I think we do have to understand the unrelenting pressure the people are under. I think one of my frustrations is that politically, discussions on workforce tend to be about recruitment rather than retention, which is problematic when highly-skilled people aren't readily available and training takes years.

So, to be sustainable, we've got to look after the people we've got and that very much comes down to the basics in my mind. So that is about creating an environment where people feel able to report, to feedback in. It means having an environment where they've got space to support one another. So, for example, in a lot of places there’s nowhere to have a coffee just away from the patients to be able to debrief one another.

That's a massive impact on people's ability to support one another. And also, you have to appreciate the changes that have happened to rotas mean that you don't have the same sort of social cohesion that you used to have. I think that's had quite a big impact. And when you add into that, the trainee experience of being moved around again and again at frequent intervals. You and I would know that moving jobs is very tough and it takes a little while to settle in.

But actually, you're asking these young people to do that again and again. And they may be a long way from home. They may have very little social support around them. Their hours always mean that they can't maybe have the dog or join up with the local hockey club because their off duty when other people are working and they're working when other people aren’t… so that social isolation that people experience is really key in that bigger picture.

Matthew Taylor

And then final question, Susanna, is part of this also about the fact that still in the way in which the media represents, particularly kind of fictional health situations, we still at core have this notion that it's all about the kind of heroic cure, the heroic act, which leads somebody to eventually be able to walk out of hospital better again.

And in fact, what that means is that on the one hand, people who have long-term complex conditions for whom health is part of the story, but actually it's much more also around the wider quality of life that people with exactly the same level of acuity can have very different qualities of life to do with a whole range of other factors.

And that if you're a doctor, you can only influence some of those things. You have to work with other people if you're going to influence a wider quality of life, or on the other hand, palliative care, where there is not going to be a heroic cure. But yet a lot can be done to enable people to die with dignity.

So, is this part of the story as well about clinicians recognising that notion that they can do something which will mean that everything is okay, often that just isn't the case?

Susanna Stanford

I think interestingly most clinicians are quite uncomfortable with the hero label. There was a lot of it early on in covid, and the public putting them up on a pedestal from which they can only fall. And I think that isn't helpful to people because they don't feel like heroes. They're constantly afraid of things going wrong.

It probably doesn't help in terms of expectations on them. And maybe that feeds round into what patients themselves can do towards their involvement in their health. And so, if you do have this kind of portrayal then it means that to some extent to patients, it's another way in which patients can be sort of disengaged from their own health because it becomes perceived as kind of handing themselves over to be fixed.

So that then leads into a much longer-term thing of wanting to get patients more involved and engaged. I was speaking to a consultant recently who works in epilepsy and particularly with regard to teenagers who were transitioning from paediatric to adult care. And she always asks them to bring her three questions every time they come to see her.

And I thought it was the most lovely thing, because what she's doing is that she's training them up to become active participants in their care because when you're talking about long-term complex healthcare needs, each healthcare interaction is not a one off because it's part of a continuous thing. And within that, every contact that they make with healthcare leaves a trace, which is why trust is incredibly important.

But of course, people will be most engaged in their healthcare if they feel involved in it.

Matthew Taylor

I absolutely agree. And I think there's enormous scope in the years ahead to engage patients more actively. And we saw during covid, didn't we, how we all got used to diagnosing ourselves at home, for example, and the challenges that process where we personalise healthcare, we empower people more and healthcare has got to be one, and this goes back to a point you made earlier, Susanna, that doesn't exacerbate inequalities by empowering those who already have the confidence but empowering those who may need the most support to become partners in their healthcare.

Susanna, it's been absolutely fantastic talking to you. Thank you for all the work that you've done and all that you're doing. And thank you for joining me on Health on the Line.

Susanna Stanford

Thank you.

Matthew Taylor

As a reminder, this episode of Health on the Line is part of a series of activities the NHS Confederation is undertaking in collaboration with NHS Supply Chain, focusing on the subject of patient safety. And there's an accompanying briefing and webinar available on the Confed’s website.