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This page is part of the learning materials to support our Raising and acting on concerns decision tool

Back to the Raising and acting on concerns flowchart - Can you escalate your concerns to a higher level within your organisation or elsewhere locally?

Escalating concerns within your organisation

Background

Ms Donnell is a consultant surgeon working in a Northern Ireland hospital managed by the Health and Social Care Trust. 

The day-surgery cares for patients undergoing orthopaedic surgery and Ms Donnell is often the only surgeon operating during the day, due to difficulties filling rotas for medical and nursing staff.

She's worried about the low levels of staffing and the impact on standards of patient care and on staff morale. She raises the issue with Dr Lund, the Medical Director, who says that a staffing review will be done in a few weeks, and the issues will be addressed then.

Scenario 

A number of preventable incidents happen due to low level of staffing. This includes a post-operative bleed, suffered by Mr Byrne, not being picked up quickly by nursing staff.  This resulted in Mr Byrne not being rapidly assessed by the on call consultant.  

Ms Donnell fills out an incident report form to record what's happened.  However she remains very concerned as Mr Byrne is having a difficult recovery.  As the only surgeon on shift during the day, she worries she may have to deal with a post-operative emergency whilst still in theatre with another patient.

What the doctor did 

Ms Donnell emails Dr Lund about the low-staffing levels, and how these contributed to recent incidents. She gets a short acknowledgement saying the issues would be discussed at the next Trust management meeting. 

She tries to meet with Dr Lund, other staff and the risk governance team, to encourage an open conversation about the issues, but it's difficult to get everyone to agree a date.

A month later, Ms Donnell emails Dr Lund again to find out what happened in the management meeting. She finds out that other urgent business has delayed consideration of the issues by the management board. 

Ms Donnell concludes that take some time before a firm date is set to recruit additional staff. She's also clear that some urgent action is needed, at least to reduce the number of booked procedures, to reduce the risk of incidents happening during or after surgery.

Ms Donnell thinks the risks to patients is not being given an appropriate level of urgency and that further attempts to get Dr Lund to act quickly will be fruitless and create conflict. 

Ms Donnell asks her medical defence body for advice, and they suggest she raises her concerns in writing with the Chief Executive, who has statutory responsibility for maintaining patient safety.

They suggest that Ms Donnell details the reasons for her ongoing concerns, her earlier contact with Dr Lund, and her suggestions about short and longer term options to manage the situation. 

Although Ms Donnell is uncomfortable going over the head of her Medical Director, she feels she has no alternative, as patients are being put at risk. Ms Donnell makes clear in her letter that she is willing to meet with the Chief Executive and the Medical Director to help find a solution.

At the meeting, the Chief Executive shares Ms Donnell's concerns about standards of patient care and the demands being placed on staff. It's agreed the Centre manager would reschedule a number of admissions and the Trust would increase the use of locum staff.

Longer term, Ms Donnell and Dr Lund agree to work with the Trust managers on an action plan to increase staffing levels at the Centre, and develop better systems for forecasting and managing local demand for day-surgery.