Jenny Vaughan | Just Culture for all in healthcare
@DrJennyVaughan
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Mother, #LearnNotBlame Co-Lead Doctors’ Association U.K. physician/neurologist 💙#DAUK #TedxNHS speaker #JustCulture #RCPCouncil #MWF #HPA #BMA #CancerKicker
London, U.K.
Joined March 2014
A privilege to give this talk for #TEDxNHS please visit the site & look at all the talks. They were brilliant. I reflected in mine on the importance of HOPE and being there for others when things go wrong in healthcare. We should all play our part in an honest & transparent way.
2 more #TEDxNHS Talks from August's #Reconnected are now live at @TEDx @YouTube! . @DrJennyVaughan's Reconnecting Hope: When things go wrong what part should we play? . @NakulGPatel's When art met science: a life-saving story .
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"The situation was absolutely appalling and this is a pandemic, this isn't an election," Dr Katie said, "How are we going to learn from this if we can't be honest about what happened?" @TheDA_UK @sbattrawden
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It is with a heavy heart to share that the amazing inspirational legend @DrJennyVaughan peacefully passed away yesterday, Easter Sunday, surrounded by family. (@matt_theknife)
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@yusuf_yousuf opens. How does a hospital porter help a family deal with the death of their child? By granting their last wish not to take their child away in a box but in his arms. Silence in the room at these words which go right to the heart of NHS human compassion
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No apology. No compensation. The humiliation of a criminal trial at the Old Bailey. A jail term. Seven years of hell. The loss of a son going into medicine and likely countless others. What was it all for ? #DavidSellu Never again.
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Been unfortunately vomiting after all my radiotherapy sessions this week. Not pleasant but found this note from kids - joint project from both of them to get me well again. It worked. Hope y’all see the funny side of this….!. Helping me cope with grim times. #StuffCancer
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The NHS frontline needs your support in the war against this virus. We keep hearing this from our members @TheDA_UK “ transferring ITU patients miles out of area. We are full. Staff doing extra shifts. Not going home “ #Covid is real #HandsFaceSpace #SaveLives #NHS.
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We @TheDA_UK have been calling for this ever since the pandemic began especially with our #ProtectTheFrontline campaign.With critically rising NHS staff sickness it’s crucially important that they have the right protection. Please like & RT if you agree
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Three years today cancer diagnosed. I thank God, my family & all my friends for their love and support that I’m still here & well. All of you suffering today because you have lost hope, lost love ones or just mentally finding all this so hard : Remain in Hope #thereisawaythrough.
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Am still having a tough time with this stupid cancer. But it’s been made better by my mate in #Melbourne who somehow gets flowers to my front door in London within one hour of my phone calls. #SoGrateful #StuffCancer #KindnessRocks
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Weather was here but that didn’t stop us ( Older Boy, Tall Boy, Naughty Boy and me the old lady ) having an amazing day at the castle. Thank you to the Princess Royal, Anne and to all the staff for a never to be forgotten day and to all of you for your support xxx
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Exceptional times, but so much more is required. Over 3000 healthcare workers are infected in Italy & tragically some have lost their lives in the line of duty.@TheDA_UK .#ProtectTheFrontlineNow.@MattHancock @doctor_oxford @DancingTheMind @bmj_latest .
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David Sellu FRCS all charges not proven @gmc. Free at last. Just why did he get sent to prison ? @cpsuk @gmcuk @doctor_oxford @doctorcaldwell @djnicholl @DacreJane @RCSnews @Jeremy_Hunt.
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Today I have #cancerandcovid Am not feeling lucky, Clint! Have retained a sense of humour & the cancer is getting better. So grateful for the support. Without our #NHS I would not be here. Am double vaccinated. It’s meant I will survive. #GetVaccinatedNow. RT if you agree!
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Help @TheDA_UK get the message out: there are young people (under 50) dying from Covid. Many ICUs are full & are having to transfer patients to wherever there is capacity. About 2/3rds of all hospital patients in London are Covid positive. Only way to stop this is #ObeyLockdown.
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Very important to know that GP actually said “folate if desired“ rather than “not necessary“ in the notes & is a very hard working and popular local GP who has served the area for > 20 years.@Bmj_latest @pulsetoday @DrNeenaJha @lizzie_toberty @wanderingwelch @mancunianmedic.
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“When we get through these horrific times, if I were to find myself or my colleagues round the country being dragged in front of the courts then this would be unbearable & a huge injustice to a group of people who have done nothing but the best they could.”@TheDA_UK @sbattrawden.
Dr Jenny Vaughan of the Doctors' Association demands emergency legislation to protect doctors who may have to prioritise some patients over others amid a rise in hospital admissions. @MaajidNawaz | @DrJennyVaughan
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Whatever has gone on here we absolutely must look at the whole system.
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As vice-chair of @TheDA_UK we do not ask for this lightly knowing the effects of it on so many. However, the NHS cannot be allowed to buckle & patient safety has to be top priority. Staff tell us of the hugely challenging & extreme conditions they are working under #SaveLives.
DAUK have written to Boris Johnson today with concerns over the current pressures on the NHS due to COVID-19 . We have called for a full national lockdown and extended closure of schools.
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Statement on the Chris Day case from The Learn Not Blame team @TheDA_UK . It has been almost 10 years since Dr Chris Day raised serious patient safety concerns over poor staffing and supervision on an Intensive Care Unit in South East London.
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To my mind we face the catastrophic loss of the NHS under another Tory government given their record so far. They’ve been in office 9 years and this is where we are at. I work in the service and this is all true. Please use your vote wisely.
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DAUK welcomes Dr Hadiza Bawa-Garba's fully restored licence to practice medicine - @TheDA_UK We say enough is enough when #CPS prosecute honest errors & the failing system gets away. #LearnNotBlame keeps patients safe. RT if you agree.
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Just enjoyed a lovely week on Monmouth and Brecon canal @CanalRiverTrust volunteers were extremely helpful in making our adventures safe on the #waterways
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Highly honoured to receive this from @BAPIOUK @RameshMehta15 tonight. I accepted it on behalf of all of those who fight daily to try & keep patients safe but who are equally human. To err is human. Only through the spirit of humility and learning can safety be improved.
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Doctors hold a vocation for everything they do & have an over-riding duty towards their patients. Their dedication in this pandemic knows no bounds. #HMG must recognise this & ensure doctors are adequately protected when putting themselves in harms way. #ProtectTheFrontline.
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@SkyNews This was systems failure. A tragedy Jack died but name, blame and Shame will never make any patient safer. We must get a more just culture which doesn’t scapegoat individuals in the future.
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Four years today my cancer diagnosed. I thank God, my family and all my friends for their love and support that I’m still here & well. All of you who may be suffering today because you have lost hope, lost love ones or just mentally finding all of this so hard : Remain in Hope.
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#Justice4DrArora If you’re #Boris drinking during a LD party you don’t even get a £50 fine from #MetPolice for this party. If you’re #DrArora #IMG #GP U get your medical license suspended for a month so you can’t work over #WordGate from a laptop request to do your job. PlseRT
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#Bawa-Garba. Appeal against erasure to be heard 25/7. Will be closely watched by an angry profession. Trying to blame your way to safety doesn’t work. We need honest reporting of ‘errors’ and all the learning and patient safety benefits that come with it
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I dedicate this paper to the memory of The Brave. They include, amongst so many, Dr Li Wenliang, a selfless WB, father & physician & Dr Hugh Gillies. Both laid down their lives for their patients & in doing so inspired future generations to keep caring.
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Although only small numbers of prosecutions for GNM in healthcare annually, it’s all been BAME last ten years. System-wide there are concerns though from med school onwards. We focus on the GMC in this article. Please RT widely. Good piece @AmaraSophia .
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Needing #OurNHS to sort me out again with some decent poisons to #KickCancer. It’s been a tough time. Have had such remarkable support & love though. Spoke to my mate in #Melbourne at 1300 GMT yesterday. By 1525 these were delivered to my door in London. #Speechless
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Privileged to speak at this today on #LearnNotBlame campaign @TheDA_UK & the power of #HopeBringers. Sharing the journey of @TEDxNHS with the team -so many extraordinary individuals. Please keep liking & RT the stories. This has been so #Healing for me after a difficult summer.
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Patient safety is paramount always and we wish Chris and the team well for next week so that these issues are properly considered and the whole case is heard -as it should have been from the start.
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Eilidh in her third year of a four-year medical degree #liveableNHSbursary , told Sky News she has no parental support to rely on and is forced to spend long hours on part-time jobs as well as studying and working in NHS placements.#OnlyRichShouldApply? .
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Success at the Modern Law Awards for The David Sellu Team. After the successful appeal no other health care worker has been charged with negligent manslaughter. Blame in healthcare threatens patient safety and promotes cover-ups #justculture
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What healthcare needs is a level playing field for all of its workers, with a fair system of regulation that acknowledges that a “rogue” manager is just as damaging as a “rogue” clinician." #LucyLetby.
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Listen up @gmcuk : it’s everyone’s job to make patients safer. #BawaGarba will never go away. Your decision to go to court in order to erase a trainee paediatrician in such working conditions is going to be your biggest REGREXIT.
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A privilege to be a speaker @TEDxNHS today to talk about the power of #HopeBringers in #Healthcare @drmattuk @wanderingwelch @pdbyrne @doctor_oxford @matt_theknife @MattFoot2 @DrMQureshi @drcmday @DrJ_Haddock @CNagpaul @jsbamrah @RameshMehta15 @BAPIOUK @bmj_latest @KamranAbbasi.
Hearing from @DrJennyVaughan - campaigning to reform the law on gross negligence manslaughter when applied to those working in healthcare. How do we create accountability + an open culture + a safer system without destroying individual lives?. #TEDxNHS #Reconnected #LearnNotBlame
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Ali, Hadiza and me outside courts of justice today. Having to listen to the #blamenotlearn show from the GMC. Here’s hoping doctors rise above a medical regulator which has clearly lost its way.
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Getting that #justculture is the only good thing which can come out of the tragedy of what happened to Jack Adcock and #BawaGarba. Please tweet, comment and share
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#DavidSellu [finding yourself in prison after an untoward patient death & the humiliation of a criminal trial] a significant number of people have taken their own lives.”Anger is an emotion that was going to finish me off. I tried very hard to control it.”
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Pleased to be recipient of BMJ editor “Speaking Truth To Power” award. All heard tour de force from @fgodlee of another exciting and important year @bmj_latest. Many thanks #DavidSellu &friends.@djnicholl you deserve this award too! Adrian Darbishire QC @QEBHW a treat to see you
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@TheDA_UK @Telegraph @DAUK_GP @IpsoNews @DrShanHussain @wanderingwelch @DrKaveri_J @Grumpybraindoc @lizzie_toberty I was pleased but profoundly disturbed to sign this complaint on behalf of my team @TheDA_UK about the appalling catalogue of insults from AP @Telegraph which are so factually inaccurate and demoralising for our GPs doing an extraordinary job in such difficult times.
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There are 50,000 nursing vacancies and nearly 9000 doctor vacancies in this country. As we approach winter this survey @TheDA_UK should ring loud alarm bells about how staff are feeling valued across the NHS. We can’t afford to lose any of them @MattHancock can we ?.
"If we're prepared to clap them we should be prepared to value them". Dr Jenny Vaughan spoke to Andrew Castle about the huge numbers of doctors planning to leave the NHS within just a few years. @LBC @DrJennyVaughan. #Covid19UK #ProtectTheFrontline
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One extraordinary day for this young man who I am privileged to call my son. Thanks to the whole team @NinianDoff @WKLondon @sainsburys @SainsburysNews @TarquinMD @ChrisDunckley
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Doctors have warned that a “culture of fear” in the NHS may prevent life-saving lessons being learned about COVID-19 after a leading hospital consultant emailed scores of staff saying those responsible for “leaks” would be found and fired.
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and attempts to silence him as a whistleblower. It is a travesty that an NHS trust has invested hundreds of thousands of pounds trying to shut down Days case and is again seeking to allow evidence from independent senior consultants revealing patient safety issues.
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Please tell me why we should trust #PritiPatel or #BorisJohnson when it was plainly announced that #ImmigrationHealthSurcharge is to be dropped for healthcare workers risking their lives and they are still being told to pay it? A total betrayal @Keir_Starmer please ask Boris why.
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@TheDA_UK have raised issue of second doses of #PfizerCovidVaccine for vulnerable clinical staff who could then save more lives on #TheFrontline. @IndependentSage agree especially @globalhlthtwit. @MattHancock @nadhimzahawi please take action ASAP. Hospitals need these staff now.
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Too many NHS staff have died - we need a public inquiry @TheDA_UK please RT we need the learn the lessons now.
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@BAPIOUK 2019SW @didoharding talking on the #NHSPeoplePlan “ so important we don’t forget our humanity in disciplinary processes. Things have to change. There is a burning crisis of not enough people working in NHS. Best NHS organisations treat their people well.'
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A #RoyalFree consultant emailed a report to colleagues at peak-pandemic claiming that the trust would “track any leaks to the media” & then “offer you the chance to post your P45 on Facebook for all to see.”@WB_UK @WhistleUK @NatGuardianFTSU @TheDA_UK.
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Chairman Dr Rinesh Parmar “ heartbreaking stories from across the country show the extent of bullying & harassment that frontline doctors face whilst working to care for patients. It is easy to see why the goodwill that the NHS relies upon has run dry.
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Old grey over the hill neurologist being trained as vaccinator tomorrow ! @pdbyrne @TheDA_UK @abnconf @doctorcaldwell @djnicholl @CatherineSellu @MirandaTraeger @helengrote @drkimholt @dr_shibley @JamesTitcombe @jsbamrah @RameshMehta15 #ProtectTheFrontline!.
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many thanks @CNagpaul for speaking Truth to Power. @MattHancock we met at the #LearnNotBlame launch. In a spirit of No Blame please reverse your decision to keep #NoDealBrexit on the table & put patients first. @djnicholl would agree #Yellowhammer.
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The double tap we all need in the NHS. How are you ? And ask them again a few days later. How are you ? Listen to the reply! @sbattrawden recounts how her son Joshua became her hero and his recovery helped her return to the NHS. Choose to be kind! #WeAreTheNHS #TEDxNHS @TEDxNHS
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"Matt Hancock must ensure all doctors receive death-in-service benefit. Doctors must continue fighting this pandemic without the added stress of worrying about leaving their families in financial difficulty should they die in the line of duty.”@sbattrawden #ProtectTheFrontline.
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@helengrote giving plenary on genetic testing for the general neurologist. An extraordinary clinician and neurogenetic specialist. Privileged to know her.
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His case makes its final appearance before a judge on 20 June, & witnesses include former Health Secretary The Rt Hon Jeremey Hunt & lawyer Sir Norman Lamb. The Doctors’ Association U.K. fully support Dr Day’s courageous mission to challenge these systemic failures.
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It’s clearly a case of global significance. Hadiza has been treated shamefully by a system desperate to trash her and save its own skin.
People around the world are following Dr Bawa Garba v GMC. Here is a map.showing the countries (green) from which people have visited our site to read.about it. #bawagarba #iamhadiza
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#LearnNotBlame #BawaGarba Proud to stand with these two & looking forward to the future. Hadiza always been keen to learn from this tragedy. Whatabout all the others including LRI? Let’s get that #justculture and move healthcare forward. Regain trust for Patients and trainees.
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So pleased that @BardocBdoc have offered support re employment for #DrArora in future. After all she’s been through. Here’s their statement please RT . "Healthcare professionals dedicate their lives to look after people, and are working in an ever-increasingly difficult climate.
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@MirrorTV Very important to know that the GP said “ folate if desired “ in the notes and is actually a very hard working local GP who has served the area for over 20 years.
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After #BawaGarba we need to move from blame not learn to #learnnotblame. Let’s fix the problem not the blame. Criminalising honest errors in healthcare kills more patients as it encourages the #coverupculture.
Dr Jenny Vaughan @DrJennyVaughan DAUK Law and Policy Lead telling the story of a trainee who wept in her office this week about a case where things had gone wrong, and was worried she was going to go prison post #BawaGarba at the #LearnNotBlame launch in Parliament
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Am pleased to hear that @gmcuk have APOLOGISED but this should NEVER have happened. We still have questions about the role of #Mastercall, & over why the provision of a work laptop, which is an essential piece of equipment, was not resolved locally.
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Exactly right prosecutions are simply not in the public interest unless the healthcare worker has been totally reckless or wilfully dishonest. They make no sense & simply allow institutions to hide behind individuals when they should be putting their own house in order.
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I have met Dr Manjula Arora personally. There is nothing about her which brings #UKMedicine into disrepute. This comment about her integrity from #CarlHargan @23essexstreet makes no sense to me. She should have an apology. Twitter, I am honoured to be part of the same profession.
Almost £40,000 spent by the GMC & the MPTS on the case of Dr Manjula Arora’s suspension, which was then overturned. DAUK’s Learn not Blame campaign lead @DrJennyVaughan says this case should never have happened. #justiceforDrArora.
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When we are so desperately short of GPs why is this happening ? What safety issues should now be looked at here which might provide the context to this case ? . Hard to know why it was referred when one word appears to have been at the heart of it. Why not local resolution?.
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Nobody wants to strike over this as we always put our patients first. We @TheDA_UK however can’t accept the exclusion which has gone on here for thousands when we know they have sacrificed so much. There is white-hot anger out there.
“Any improvement on the derisory 1 per cent previously offered to NHS workers is welcomed, but 3 per cent barely takes the edge off the erosion of doctors’ pay over two decades,” said DAUK chair @DrJennyVaughan @TheBMA #NHSPay #FairSayOnFairPay .
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@TheDA_UK recognises that the public health threat posed by #COVID-19 is unprecedented. However there have been multiple reports of problems getting #PPE in order to #protectthefrontline. We organised a letter signed now by over 8000 healthcare workers. Things are improving now.
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#Just Culture and the criminal law do not seek the same outcome. Criminal charges really the last resort. The wrong person is likely blamed the system does not change. Extraordinary hearing David talk again even after all this time and how he’s #KeptPositive despite his ordeal.
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Spent this afternoon with @rogerkline looking at the landscape of how @TheDA_UK can help disseminate better practice as in #Fairtorefer There is disproportionate referral of BAME doctors to @gmc by some employers. It needs to stop.
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“ Morally unforgivable that at this time where we ask them to put their lives on the line, those recently retired & returning to service, locum doctors and those forced out of the NHS pension scheme by a punitive tax are not eligible for death in service benefit.”@sbattrawden.
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Still means they are under the great stress of an investigation. Doctors should not be above the law but patient safety is not served by criminalising healthcare workers for honest errors when the system is broken. @MattHancock we look forward to review and reform of this area.
#WESAN2018 90% of doctors investigated for gross medical manslaughter are not prosecuted. Via @DrJennyVaughan.
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Telling the story of #DavidSellu and #bawagarba at medico-legal conference Peterhouse Cambridge. Very kind of organisers to invite me. Spreading the word that it’s Time Up For #grossnegligencemanslaughter in healthcare for honest errors in systems under pressure.
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We totally agree Stop the NHS GP Data Grab @TheDA_UK and others are taking the government to court over this. Please RT and donate this is wrong @sbattrawden @DoctorsDistress @doctor_oxford @PeterStefanovi2 @drcmday @doctorcaldwell @mancunianmedic .
Earlier today we wrote to @MattHancock calling for an immediate delay to the GP data for planning & research programme #GPDPR. @NHSDigital have failed to sufficiently communicate these plans to patients & there is not enough time for informed decisions to be made. (1/2).
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My talk will be all about the blame culture which is so pervasive not only in healthcare, but in our world generally. It’s so important to reconnect hope for those who have been affected. There are so many important stories to hear @TEDxNHS. Come & be prepared to be inspired!.
Dr Jenny Vaughan, co-lead for our ‘Learn not Blame’ campaign, is one of the speakers for @TEDxNHS 2022 event. 📅 Tuesday 23 August.📍 Wilton’s Music Hall. Tickets and further info: #NHS #MedTwitter
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Saurabh Jha says that what happened to Hadiza Garba in the UK would have been inconceivable in the US. So why do we criminally prosecute trainees? We should fix the system not the blame @cpsuk @gmcuk @doctor_oxford @BAPIOUK
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#RSMUrology @RSMUrology met @okarimurol excellent day tackling the challenges of the blame culture. We must improve patient and staff safety together. Organisations too often remain unaccountable and weaponise the GMC and courts against hard working staff doing their very best.
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@TheDA_UK and @BAPIOUK @jsbamrah @TheBMA called out #MPTS judgement. There must be a full investigation of what happened here. We @TheDA_UK are pleased that the GMC review will continue. This must not happen again. Utterly terrible treatment of Dr Arora, this whole ordeal.
Breaking: @gmcuk overturns the suspension of Dr Manjula Arora after it decided the dishonesty test was 'incorrectly' applied
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At BIDA with #DavidSellu, Dr Jonathan Leach@rcgp & Leslie Hamilton.Talking about gross negligence manslaughter. #DavidSellu sent to jail. Won his appeal, found innocent @MPTS. #notsafenotfair #justculture #learnnotblame #BawaGarba is no criminal. #jailisforcriminalsnotscapegoats.
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The unfolding human disaster India is utterly heart-wrenching but we can all do something ! Please donate here and RT this far and wide @RameshMehta15 @BAPIOUK we @TheDA_UK are pleased to help
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There needs to be a whole review of why this case came to the GMC and what lay behind the case and the allegations faced by #DrArora. @healthyopinion @BAPIOUK. All of the staff I have ever helped there have almost always been vital system failures as part of the context.
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@TheDA_UK “listed over 200 cases of staff being threatened, bullied, unsupported, silenced, or warned for speaking up over PPE use in their organisations.” Thanks also to Messly for their help with this work.
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Speaking @RCPLondon tomorrow ( my 50th birthday!) So important for all of us. @JamesTitcombe kind to give his views. Crucial we all work together. Where HONEST mistakes happen lets fix the problem not the blame? @gmcuk @cpsuk @DacreJane @fgodlee @drphilhammond @MartinBromiley
The Williams review is a significant step forward in tackling the blame culture and turning it into a learning culture, says @DrJennyVaughan
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@TheDA_UK @DAUK_GP welcomes the decision by @the_mdu to support the appeal of #DrArora. Appeals don’t always right wrongs unfortunately BUT we hope this will be successful and in the meantime there needs to be a full review of the circumstances of her referral @gmcuk.
@drguptagaurav @trentconsultant @deeleyc6 @OmgItsTania @gmcuk @okarimurol @_ShaziaKhan @DrShanHussain @DrSelvarajah @TheBMA @CNagpaul @drcolinm @tcgannon @gmenon1423 @NeenaModi1 @medicalwomenuk @AntonEmmanuel2 @NikkiKF @trentchambers4 @DrJennyVaughan @BAPIOUK @BIDAUK @drpshukla @VinodGadiyar @MaharukhSays @onyiokonkwogp @KalindiKrishna @johnghughes3 @alninety @BMARaceEquality @BMA_Consultants @DrMQureshi @ushkp @parthaskar @HealthRegLawyer @AmaraSophia @emilymorganitv @the_mdu Some good news. I have got a reply from MDU. They will be supporting #DrArora appeal! I am very hopeful that the High Court will quash the GMC/MPTS sanction of suspension. Further updates to follow.🙏🏼.
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@sbattrawden @TheDA_UK @TEDxNHS #TEDxNHS recounting her personal journey with her son Joshua born at 24 weeks. An NHS consultant and whole team showed #endlessempathy when Josh became critically sick which helped her cope. He survived his journey #TheBoyWhoLived. #WeAreTheNHS.
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Hadiza Bawa Garba on the road back Important day for #learnNotBlame.Thoughts also with the family of Jack Adcock #bawagarba #justculture.
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"Even in this inquiry, doctors, midwives nurses at Shrewsbury and Telford said they were silenced, they were told that there would be professional consequences if they co-operated with the inquiry," he [ Jeremy Hunt] said. @TheDA_UK
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It’s completely wrong that nearly 40% of doctors who trained abroad do not have legal representation, compared to 25% of doctors who qualified in UK and that as a result they are more likely to be suspended or struck off.
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Thank you #ASIT2020 for having us both @samanthatross talking about #diversity and @DrJennyVaughan talking on #bawagarba #DavidSellu #Learnnotblame @TheDA_UK @RCPLondon @TheBMA FMLM_UK @gmcuk @medicalwomenuk
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Folic acid doesn’t prevent 100% of cases, it was warned as a risk if not taken & a lack does not cause this type of spina bifida. Any doctor that has had a patient refuse investigation/treatment despite warning of risk (even 20 years ago), could be this dr. #IAmPhilipMitchell.
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One tragedy. Three victims. Patient, David Sellu, candour in healthcare. Just why did David Sellu go to prison ? Still no answers @BMIHealthcare @doctor_oxford @djnicholl @cpsuk
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“We risk a whole generation of those who want to care simply voting with their feet.” @MattHancock @TheBMA @TheDA_UK @RCPLondon @RCSnews @RCPCHtweets @rcgp @RCObsGyn @RCEMpresident
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