A medic’s experience of losing her voice

I met Kate in my postnatal clinic where she told me about her traumatic birth experience. She did not want to make a complaint but wanted the team to learn from her negative experience. As a doctor herself, she had a lot of clinical insight. 

‘I had a massive obstetric haemorrhage, and yet was not managed as such,’ Kate said. 

She was right. Looking through her clinical records and hearing her story, I was sure this was an opportunity for learning. Kate felt it would help her mental recovery to feed back directly to her clinical team. She wanted the team to learn from her experience.

The Helping Our Teams Transform (HOTT) programme at Imperial College Healthcare NHS Trust was set up as a safety and culture change programme. We inject kindness, empathy, and a culture of walking in each others’ shoes into our patient safety strategy.

There was some initial reluctance to bring the team into the same space as an unhappy patient. ​‘If this is a complaint, she needs to approach the complaints team,’ I was told by the Governance Lead.

Open culture. 

Transparency. 

Psychological safety. 

Learn not blame. 

I remembered these principles when I pushed to try a virtual team conversation with our experienced HOTT facilitators.

We invited all clinical team members who had contact with Kate when she was in labour, as well as the Governance team, a clinical psychologist and a lay partner to have a virtual User Experience Fishbowl.

The day came, but not without trepidation. Kate started by telling her story.

‘I used to work in the unit, so I felt safe when I arrived. I was admitted for an induction as my waters broke. It was around Christmas time and I had mentally prepared myself for some delays but the induction was not started until the next day, which was really disappointing as I developed an infection.’

All it takes is an individual having a bad day, or a personality clash, and everything changes.

‘I felt like I couldn’t speak. I had to just sit there and do what I was told. I could feel my contractions but the machine wasn’t picking them up so she delayed the pushing stage even more. She just wouldn’t listen. At one point she said, ​“this is the worst shift of my life”. I wanted to say, ​“well this is the worst experience of my life”. All the power had completely gone from me. I felt so weak.’

We opened the conversation to the outer fishbowl. This gave a member of the team the chance to apologise openly to Kate:  ​‘I am so sorry you experienced so much pain. If I could do things again, I would have made sure your pain relief was adequate.’

I asked Kate what her key message was to us.

There were some insightful and thoughtful reflections from the team on how we can create a culture where patients can be empowered to raise concerns or even ask for a different midwife, nurse or doctor. The reality is that this is hard to do. It is a lot to expect women giving birth, when they are at their most vulnerable, to escalate their concerns and to request a change of staff member.

We didn’t come away from this conversation with the warm fuzzies, but I was proud of Kate for finding her voice, of the HOTT Team for having faith in the process and in our values, and of the maternity team members who turned up with an open heart and mind.

I would love for us to use liberating structures and facilitated conversations with patients in a more systematic way to find learning through negative experiences and outcomes. A recent study showed that Muslim women, including those who do not speak English, often do not complain. So getting any learning from their experiences needs to be actively recruited.

Can we have a meaningful team conversation with families every time there is a clinical incident as part of the investigation process?  Lack of time and resource is often cited as a reason not to, but apart from the logistics of setting up the meeting time, the actual time spent was only 60 minutes.

If learn not blame is how we want to see the future of safety culture, I am treating this as round one of our PDSA. 

I am definitely not going to abandon this idea.