Articles for tag: change, change management, education, inquiry, investment, lessons, patients, people, risk, safety, standards, waste

The Great Training Robbery: Why Lessons Are Not Learnt

Every NHS trust maintains a mandatory training matrix. Staff are tracked, chased, and occasionally threatened until compliance rates hit the target — typically 85% or above. The annual study day is booked. The e-learning is clicked through. The tick goes in the box. And then, overwhelmingly, nothing changes. This pattern is not unique to the NHS. In 2016, Beer, Finnström and Schrader published a landmark Harvard Business School paper they titled The Great Training Robbery. Their argument was blunt: billions ...

The Ockenden Report – a tale of pathogenic system failures

The Ockenden Report, published on 24 June 2026, lays bare the human cost of systemic failure. It examines maternity services at Nottingham University Hospitals NHS Trust (NUH) over more than a decade, making it the largest inquiry of its kind in NHS history. More than 2,500 families came forward to share their experiences [Acknowledgements, p. iii]. The findings are shattering. For years, warning signs were ignored. Staff shortages were chronic. A culture of bullying silenced those who tried to speak ...

Safe Prescribing Review: The Five Gates

This work contains a downloadable PDF document below. It is a working instrument, not a policy paper; a single-page crib sheet with explanatory guidance, for structured individual or team review of prescribing. Every gate serves one closing question — what justifies continuing the medication(s) for this person today? That question is the point of the whole exercise. In everyday practice, continuation is the default. Optimising, changing or stopping medications is what requires sound clinical and legal justification. Study of Good ...

Why the Oliver McGowan Case Still Matters

On 11 November 2016, Thomas Oliver McGowan, an 18-year-old man with epilepsy, mild autism, a mild learning disability, and cerebral palsy, died at Southmead Hospital in Bristol. He had been admitted on 22 October 2016 with uncontrolled seizures. During that admission, he was sedated, intubated, and given olanzapine, an atypical antipsychotic, despite explicit warnings from his family and documented evidence of prior adverse reactions to antipsychotic medication. He developed neuroleptic malignant syndrome (NMS), suffered a catastrophic brain injury, and died. ...

The Southport Inquiry: Analysis (of Phase 1)

On 29 July 2024, Axel Rudakubana carried out a fatal knife attack at a Taylor Swift-themed dance and yoga class in Southport. Three young girls were murdered, and many other children and adults suffered grave physical and psychological harm. The event shocked the country not only because of its brutality, but because it involved a young perpetrator whose history, as later examined by the Inquiry, contained repeated signs of serious and escalating risk. The Southport Inquiry was established because the ...

Riding the AI Donkey straight to the Regulatory Gallows

1. Introduction: The False Promise of the “Auto-Expert” The current discourse around AI in professional services—especially in high-stakes fields like Law, Social Work, and Psychiatry (LSP)—suffers from a significant lack of depth. A common fallacy suggests that all AI tools are interchangeable, as if a budget transcription service is equivalent to a high-end analytical engine. This reliance on “brute force” automated assessment creates a situation where human clinical judgement is traded for machine-generated simulations of understanding. This exploration traces the ...

Reflective Notebook Entry: Moral Injury in the Architecture of Accountability

I have been thinking about documentation of capacity assessments in overview spanning the last 5 years – and how that connects to prescribing of medications. There can absolutely be no debate that capacity and consent are the bedrock of therapeutic relationships and prescribing practices. This exploration excludes considerations that fall under the Mental Health Act 1983 (to become the MHA 2025). But some of the basic issues will become relevant when prescribing under the MHA 1983. I focus almost exclusively ...

Applying Bayesian Thinking Models in Suicide Risk Assessments

Daniel was 34 years old and on remand, awaiting trial for a serious offence. He had been in custody for six weeks. His history included two previous suicide attempts by hanging in the community three years earlier, a diagnosis of emotionally unstable personality disorder, and a longstanding pattern of alcohol and polysubtstance misuse. He was lost to contact with his mental health team in the community. The prison where he is housed is notorious for ‘drugs’ being readily available. His ...

Bayesian reasoning in forensic psychiatry

Bayesian reasoning is not, in this context, a demand for spurious mathematics. It is a disciplined way of thinking under uncertainty. Its value in forensic psychiatry lies in requiring the assessor to distinguish between the baseline picture, the new evidence, the weight of that evidence, and the updated judgement that follows. In ordinary professional language, the question is simple: what was already known, what has now emerged, how much should it change the view, and why? [See also: Applying Bayesian ...

Contractual Matters for Locums: Legal and Professional Frameworks

The locum “Assignment Schedule” is often treated by agencies and NHS HR departments as a trivial bit of admin—a template filled with blanks and vague placeholders. It is a lazy habit. For a consultant, an ambiguous contract threatens clinical safety and professional standing. The defence that “I am not a lawyer” is an admission of incompetence in a high-stakes environment. In specialist medical practice, fuzzy arrangements lead to systemic failures. When a contract fails to define start times, shift durations, ...