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Case reviews

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In June 2017, the National Guardian’s Office launched a 12 month trial of its case review process. The trial reviewed the handling of concerns and the treatment of people who have spoken up, where there is evidence that good practice has not been followed.

Case reviews identify areas where the handling of NHS workers’ concerns do not meet the standards of accepted good practice in supporting speaking up and make recommendations to NHS organisations to take appropriate action where they have failed to follow good practice. Case reviews will also commend areas of good practice.

Case review referrals can be sent to the National Guardian’s Office by email to: casereviews@nationalguardianoffice.org.uk

When referring by email we recommend that you use the downloadable referral form below. Using this form will assist us in promptly processing your referral

Official documents

Published reports

Case review news

Monday 24 June 2019

Brighton and Sussex University Hospitals NHS Trust case review focuses on need to build on improvements

The National Guardian’s Office case review report published today (24 June) has commended good practice and outlined a number of recommendations necessary for Brighton and Sussex University Hospitals NHS Trust (BSUH) to continue to embed improvements in their speaking up processes, practices and culture.

Dr Henrietta Hughes, National Guardian for the NHS, said, “Our case review found evidence that the trust has made, and is continuing to make, improvements to its speaking up culture and that its leaders were focussed on the importance of positive working cultures in the delivery of high-quality patient care.

“We found evidence of actions to improve, such as the use of weekly ‘improvement huddles’, where all staff in a service were encouraged to speak up about issues. We also spoke to many workers who commented that there had been an improvement since a new leadership team started work in April 2017.”

The staff survey for 2018, published during the review, also reflected significant improvements from the previous year’s survey in how trust workers viewed the organisation’s working culture.

The review also reflected the fact some members of staff felt that there were historic issues relating to race inequality that were still not fully resolved and that there was also room for improvement when it came to the speaking up culture in respect of minority staffing groups.

In all, the review included meetings with 78 members of staff and saw a total of seven forums take place to encourage as many workers as possible to relay their experiences of speaking up. Specific forums were held for BME staff members, lesbian, gay, bisexual and transgender (LGBT) workers, and staff with disabilities.

The report makes six recommendations for the trust, including how they improve communication of the guardian role, revise their speaking up policy, and find ways to ensure their network of cultural ambassadors reflect the diversity of the workforce.

The report also makes a recommendation for the National Guardian’s Office in relation to its training and guidance. “The helpful feedback from undertaking this review has identified that we need to adapt our training for Freedom to Speak Up Guardians,” explained Dr Hughes.

“The Francis Report highlights the needs of ‘vulnerable groups’ of workers who may encounter particular barriers to speaking up. We recognised that we needed to amend our materials specifically to reference the needs of BME workers alongside wider considerations of other groups of workers.

“The fundamental purpose of our case reviews is to identify learning, and this applies to my office as much as any organisation. In the past we have also made recommendations to the CQC, Department of Health and Social Care and NHS Employers. Case review reports are used by Freedom to Speak Up Guardians in other organisations to make improvements. There are many examples of good practice in BSUH that others can learn from.

“We will continue to share learning and good practice in order to fulfil our remit to remove barriers and make speaking up business as usual.”

Marianne Griffiths, Chief Executive of Brighton and Sussex University Hospitals NHS Trust, said, “Since our arrival at BSUH, we have made it our absolute priority to work with colleagues and support them to help make further improvements to the culture of the organisation, particularly in relation to equality and diversity. It is extremely encouraging, therefore, to see our improvements recognised through such a comprehensive review.

“As with all areas of performance, we also know there are ongoing improvements to be made. We welcome the recommendations in the National Guardian’s Office report and I’m very happy to say we’re already well on the way to implementing all of them. I want to assure all colleagues, but especially those from minority groups, that we value every individual and hope anyone with a concern feels confident that they can speak up and that their feedback will be taken seriously and used to drive further positive change."

Friday 15 March 2019
 
National Guardian's Office publishes independent evaluation of its case review pilot
 
In line with its remit to review speaking up cases in NHS trusts and foundation trusts, the National Guardian’s Office (NGO) commenced a 12-month pilot of a process to review cases referred to it. This pilot was completed in June 2018.
 
Following the pilot, the office commissioned an independent evaluation to identify areas of learning and improvement. The evaluation began in August 2018 and took place over approximately three weeks.
 
The evaluation was not the only source of information the office used to help identify improvements to the process. It also sought comment and feedback from Freedom to Speak Up Guardians in NHS trusts, members of its Advisory Working Group and from its Accountability and Liaison Board.
 
The evaluation was an independent assessment of whether the NGO delivered the pilot as its management said it would be. Its purpose was to help the management of the office decide whether to extend the pilot, or to implement a more permanent process going forward. 
 
The evaluation assessed the delivery of the pilot process and made suggestions regarding its design and operation. 

Friday 21 December 2018

National Guardian review at Brighton and Sussex University Hospitals NHS Trust announced
 
The National Guardian’s Office (NGO) will be carrying out a review of speaking up at Brighton and Sussex University Hospitals NHS Trust, with visits to the trust planned for early in the New Year.
 
The purpose of the review is to support the trust to develop its speaking up culture, by identifying any areas for improvement and commending good practice, where it is found. On completion of the review the NGO will publish its findings and recommendations. At the request of the trust we are working to their timetable, so that the improvements that they are putting into place can be reflected in the report. 
 
Dr Henrietta Hughes, the National Guardian for the NHS said, “All of our reviews of speaking up focus on the learning that can be captured, so that not only can the trust in question improve, but all trusts in England can use the recommendations to look at their own practices, processes and policies.” 
 
Marianne Griffiths, Chief Executive of Brighton & Sussex University Hospitals NHS Trust added, “Helping our staff to find their voice and speak up effectively on issues which concern them is integral to our Patient First strategy, and to continually improving patient care and experience in our hospitals. It is vital that our staff feel supported in speaking out. I welcome this 2019 case review, which will be held at the height of our winter pressures, as an opportunity to identify what we are already doing well, and where we can make improvements.”

Thursday 20 December 2018

National Guardian’s Office makes recommendations for improving speaking up processes at RCHT

In its fifth case review report published today (20 December), the National Guardian’s Office has identified areas for improvement in speaking up processes, practices and culture at Royal Cornwall Hospitals NHS Trust.

Based on a review carried out at the trust in May and June this year, the report outlines evidence of the trust not always responding to instances of its workers speaking up in accordance with its policies and procedures, or with good practice. It found that as a result some workers felt that there was not a positive speaking up culture in the trust and that issues that they raised were either poorly handled, or ignored by management.

In relation to settlement agreements, the review identified several potential areas where they could be improved to remove obstacles to speaking up. The National Guardian’s Office has therefore made a recommendation for itself to complete, with its partners, the review of settlement agreement guidance in the NHS and it will publish its findings and any recommendations in due course.

Dr Henrietta Hughes, National Guardian for the NHS, said, “We identified 13 recommendations for the trust to improve their support for their workers to speak up. But we have also made one recommendation for ourselves around the content of speaking up training provided by NHS trusts for their workers, and another in regard to settlement agreements.

“We have committed to working with partners involved in reviewing settlement agreement guidance in the NHS, namely the Department of Health and Social Care, NHS Employers and NHS Improvement, to complete a review and take all appropriate steps to implement its findings.

“Our case reviews are focused on learning,” said Dr Hughes. “Learning for the trust, learning for others – including ourselves – and learning for all other trusts around England. We encourage all trusts to use case review recommendations to carry out their own gap analysis to ensure they have considered the issues outlined in relation to the speaking up arrangements in their own organisations.”

The case review also identified positive features. It was clear that the leadership of the trust understood well the need to improve the speaking up culture, and were beginning to take steps to do this. These included providing workers with a variety of means of raising issues through a network of speaking up champions across the trust, who supported the work of the trust Freedom to Speak Up Guardian.

Dr Mairi Mclean, Chairwoman for Royal Cornwall Hospitals Trust, said, “Supporting and encouraging colleagues to speak up when they have concerns is something we want to do well and is high on the agenda for our new leadership team. Over recent months we have seen more staff coming forward to raise concerns, using our new network of champions and other routes, and this is a positive sign we are starting to get things right. We all want RCHT to be a brilliant place to work and as we head into 2019 bringing about a fully open and supportive culture, in which the care and safety of patients and staff is always a number one priority, is absolutely our aim.”

Freedom to Speak Up Guardian and Deputy Chief Nurse at the Royal Cornwall Hospitals, Louise Dickinson added, “We welcome the report from the National Guardian’s Office which supports the actions we have been taking to encourage staff to feel confident to speak up. We will continue to work with them to improve our local processes and to bring examples of brilliant practice elsewhere into our hospitals.”

Thursday 8 November 2018

Conflicts of interest highlighted in latest case review report

A report published today (8 November 2018) by the National Guardian for the NHS in England, Dr Henrietta Hughes, makes 13 recommendations including one relating to conflicts of interest.

The National Guardian’s Office is an independent, non-statutory body with the remit to lead culture change in the NHS so that speaking up becomes business as usual. It also provides challenge, learning and support to the healthcare system as a whole by reviewing trusts’ speaking up culture and the handling of concerns where they have not followed good practice.

Today’s publication is the fourth case review report the office has produced and recommends Nottinghamshire Healthcare NHS Foundation Trust completes a number of actions relating to 13 recommendations within 12 months. These include the implementation of its conflict of interest policy, to ensure all staff are aware of its purpose and all relevant staff make appropriate declarations, including those relating to conflicting loyalty interests.

The recommendation also has relevance to both NHS England and NHS Improvement in regard to guidelines on conflicts of interest. The learning from the case review will be shared with them and other NHS trusts throughout England.

Ben Dyson, Executive Director of Strategy, at NHS Improvement said, “Publishing registers of interest is important in ensuring that the NHS is as transparent as possible in how it provides patient care and supports its staff. NHS Improvement wholly supports this initiative and plans to require Trust Boards to certify they are complying with these requirements.”

Dr Henrietta Hughes, National Guardian for the NHS, said, “Our focus with all case reviews we carry out is to identify learning and improvement to bring about a positive culture change in speaking up, and our report published today into Nottinghamshire Healthcare is no exception.

“I am delighted at the very positive response to our recommendations from the leadership at the trust and their commitment to create an Action Plan as soon as possible.”

Dr Julie Attfield, the Interim Chief Executive at Nottinghamshire Healthcare, said, “It is absolutely fundamental that staff are able to speak freely about concerns that arise during their work, that they are positively supported to do so and that we as individuals, and as an organisation, respond positively when this is the case. 

“I thank the National Guardian’s Office for examining the practice in the Trust and producing this report. I am clearly disappointed that there were areas of poor practice identified and that we didn’t respond in a timely or appropriate way. This does not reflect the values of this Trust and I am eager to make changes to ensure that these issues are considered across the organisation and improved. I am confident that we can build on those areas of good practice identified in the report and improve our staff’s experience of speaking up.

“We accept all of the recommendations contained within the report and I, along with colleagues, are committed to implementing changes to make sure that all of our staff, in whichever service they work, feel able to highlight concerns and speak up to improve patient experience.”

You can read the full report here.

Friday 27 April 2018

Case review announced to take place at Nottinghamshire Healthcare NHS Foundation Trust

In response to a referral regarding the handling of speaking up, the National Guardian’s Office (NGO) has announced it will be carrying out a case review of speaking up at Nottinghamshire Healthcare NHS Foundation Trust.

The purpose of the review is to look at how the trust has responded to its workers speaking up and to publish its findings. Where the NGO receives evidence that good practice has not been followed the review will make recommendations on how this can be improved.

“Importantly, the report will also commend areas of good practice and will be used by other NHS organisations as a means of identifying learning and assessing their own speaking up practices and processes,” said, Dr Henrietta Hughes, the National Guardian for the NHS.

Ruth Hawkins, Chief Executive for the Trust, added: “We welcome the scrutiny offered by this case review of speaking up. Whilst we are proud of what we have achieved so far with our Freedom to Speak up Guardian and other staff voice initiatives, we know we can do more. The Trust is keen to learn and improve and we hope this will be another tool to aid us with that.”

Friday 20 April 2018

Royal Cornwall Hospitals NHS Trust next in line for NGO case review

The National Guardian’s Office (NGO) will be carrying out its next case review at Royal Cornwall Hospitals NHS Trust (RCHT). This is in response to information that the trust needs to improve the support it provides to workers who speak up.

The NGO provides leadership, support and guidance on speaking up in the NHS. As part of its work, and reviews how NHS and foundation trusts have supported their workers to speak up.

RCHT is the main provider of acute and specialist care services in Cornwall and the Isles of Scilly. Its approximately 5,000 workers serve a population of around 430,000 people. In October 2017, the trust was rated as 'inadequate' overall by the Care Quality Commission. Following this inspection, the trust was put into 'special measures'.

RCHT will work with the NGO to review how it handles speaking up and issues raised by its workers.

The National Guardian for the NHS, Dr Henrietta Hughes, said: “I am pleased that Royal Cornwall Hospitals NHS Trust will be working with my office to identify areas for improvement in speaking up.

“The objective of this review will be identifying as much learning as possible about how speaking up arrangements and cultures can be improved. The review will also highlight examples of good practice, including any innovative steps that the trust has taken to support its workers to speak up.

“By working together we hope to continue to promote an open and transparent culture where speaking up is business as usual.”

RCHT Chief Executive, Kathy Byrne said: “It is vital every member of staff feels able and confident to challenge and to speak up if they have any concern about the safety of patients or staff. The case review is a positive opportunity for us to learn where we can improve and to make speaking up at RCHT an open and supportive process.”

In June 2017, the trust announced the appointment of Louise Dickinson as their new Freedom to Speak Up Guardian.

1 February 2018

National Guardian’s second case review identifies opportunities for trust to learn and improve speaking up processes

The second case review report to be published by the National Guardian’s Office has revealed significant opportunities for the culture of speaking up at Northern Lincolnshire and Goole NHS Foundation Trust to be improved.

Dr Henrietta Hughes, National Guardian for the NHS, said, “We received information that the trust’s support for its workers to speak up was not always in keeping with good practice, including instances where workers had spoken up anonymously to the Care Quality Commission (CQC).

“Our review found that the trust had failed to respond appropriately, including where staff had raised serious safety issues. We also found evidence of the existence of bullying in the trust and a bullying culture within specific teams that made workers fear the consequences of speaking up.”

The findings detailed in the report include reference to the fact there was no specific training for staff on how to speak up, or for managers to support people speaking up, or how to handle matters raised.

Some of the trust’s policies and processes were also highlighted in the report, with their speaking up policy not meeting national minimum standards as set out by NHS Improvement, and their bullying and harassment policy needing improvement to ensure it met the standards set out in guidance by NHS Employers.

The review found examples of good practice that was supportive of trust workers speaking up. This included a robust recruitment process to select staff to undertake guardian roles and the improvement of HR processes to ensure they are more supportive of workers who speak up.

“It’s good to see some activities are already being pursued by the trust and we hope the our report will help them to improve and draw together an action plan to address each of the 23 recommendations over the coming 12 month period,” said Dr Hughes.

“I encourage other trusts to reflect on the recommendations and to look at how they might improve and apply the learning to their own cultures and processes.”

Last week also saw the publication of new guidelines by the CQC in relation to the fit and proper person’s requirement (FPPR) for directors. The National Guardian’s first case review in relation to Southport and Ormskirk Hospitals NHS Trust made a recommendation for the CQC around FPPR for directors.

As well as making specific reference to speaking up, significantly the updated guidance also highlights bullying as an example of mismanagement, which can often be a serious and continuous obstacle to speaking.

Next week, the action plan to address the recommendations for Southport and Ormskirk Hospitals NHS Trust goes to their board, having been agreed by NHS Improvement (NHSI).

“Seeing our case review reports acted upon and driving real change is a key measure as we continue to roll out our case review pilot,” said Dr Hughes. “The reaction from the CQC shows a tangible development in relation to the issue our report highlighted, and it is excellent to have NHSI and the Southport and Ormskirk Hospitals NHS Trust board engaged in the process of implementing our recommendations.”

16 January 2018

Case review announced for Derbyshire Community Health Services NHS Foundation Trust

The National Guardian’s Office will be carrying out its third case review at Derbyshire Community Health Services NHS Foundation Trust. This is in response to a referral it has received regarding the handling of a case of speaking up in the trust.

This review will be taken forward as part of the 12 month pilot of the National Guardian’s Office case review process. This was launched in June 2017 to review the handling of concerns and the treatment of people who have spoken up, where there is evidence that good practice has not been followed.

As part of a case review the National Guardian’s Office makes recommendations to NHS organisations to take appropriate action, whilst also commending areas of good practice.

The National Guardian’s Office has already published one report for a case review carried out at Southport and Ormskirk Hospital NHS Trust and is due to publish a second relating to Northern Lincolnshire and Goole Hospitals NHS Foundation Trust shortly.

15 November 2017

National Guardian for the NHS calls for action on speaking up

The National Guardian for the NHS has published a set of recommendations following concerns raised by staff about the speaking up culture at Southport and Ormskirk Hospital NHS Trust.

The case was referred to the National Guardian’s Office as many people had spoken up at the trust but their concerns were not properly acted on. The report identified failures to act appropriately on multiple and serious allegations and a number of wide ranging issues that represented significant barriers to speaking up. These included a culture of bullying and alleged discriminatory behaviour.

As a result of the report, the National Guardian has made 22 recommendations for the trust and one for the Care Quality Commission, encouraging all organisations to reflect on these and apply the learning to their own cultures and processes.

Dr Hughes said:

“I would like to thank Southport and Ormskirk NHS Trust and all those who were involved in the review for their cooperation, willingness to work together, and appetite for learning. Many individuals at the trust said their views or concerns had not previously been taken seriously. The trust also failed to consider the needs of its black and minority ethnic staff.

“I have published a set of 22 recommendations for the trust, which are designed to improve workers’ ability to speak up and to tackle the barriers to speaking up that were present in the organisation. My review also highlights areas for improvement in the Fit and Proper Persons Test which I have recommended that the Care Quality Commission addresses in its revised guidance.

“I can, however, only act on cases that I am aware of. If any individual or organisation within the NHS feels that they have a speaking up case that has not been dealt with in accordance with best practice, I would encourage them to refer the matter to my office for consideration.”

Karen Jackson, interim Chief Executive, Southport & Ormskirk Hospital NHS Trust said:

“We were pleased to be able to work with the National Guardian’s Office to review how speaking up is, and has been, handled by the trust. We encouraged staff from across the trust to take part and they raised a range of concerns. Most of these concerns went back a good number of years.

“The trust now has a new senior management team in place. The learning from the review is a welcome and helpful addition to the robust action plan we have in place to ensure that speaking up is seen as a way to make improvements for our staff and for our patients.

Chris Hopson, Chief Executive of NHS Providers said:

“This is a constructive and valuable report. It provides welcome insight for all trusts into what makes speaking up work well and sets out the process and policies that support it.

“It highlights how openness and transparency from senior leaders are vital in ensuring staff are treated fairly at work. The focus on improving the culture for black and ethnic minority staff is particularly welcome given the concerns that exist right across the NHS.”

23 August 2017

Special measures trust to work with National Guardian's Office to pilot new review process

The National Guardian’s Office (NGO) was established in 2016 to support Freedom to Speak Up in NHS trusts. It also reviews instances where there is evidence a trust may need to improve its support for speaking up.

Northern Lincolnshire and Goole Hospitals NHS Foundation Trust is in ‘double special measures’ (for quality of care and finance).  There is evidence that the culture and processes for staff at the trust to ‘speak up’ or raise concerns do not always work well.

The NGO launched a pilot of its process for reviewing culture and processes for ‘speaking up’. Northern Lincolnshire and Goole NHS Foundation Trust has now volunteered to work with the NGO to use this pilot to review how it handles speaking up and concerns raised by its staff. It will do this with reference to the recommendations of Sir Robert Francis’ Freedom to Speak Up Review (February 2016).

The National Guardian, Dr Henrietta Hughes, said: “I am delighted that North Lincolnshire and Goole NHS Foundation Trust has volunteered to work with my team to identify areas for improvement in speaking up.  The purpose of this review will be to identify learning for the trust, as well as all NHS organisations and their staff. Working together is a positive step in embedding the open and transparent culture we all wish to see where speaking up is business as usual.”

North Lincolnshire and Goole NHS Foundation Trust Chief Executive, Dr Peter Reading said: “Our staff have recently raised a number of concerns about the trust. I am therefore pleased to have the opportunity to work with the National Guardian’s Office to review whether our processes and cultures have fully supported our staff to speak up and whether there are lessons to be learned about how we can do this more effectively. I intend to use learning from this review to make improvements for our staff and our patients”.

The Trust appointed Mr Makani Hemadri, consultant in general surgery, as its Freedom to Speak Up Guardian earlier this year to act in an independent and impartial capacity, working alongside the board and executive team to help support the organisation to become a more open, transparent place to work.

Last updated:
24 June 2019