Robert Tomlinson

 East Lancashire hospitals Trust patients endured 5 never events in 6 months. Instead of punishing staff East Lancashire demonstrated that by treating staff with respect they will be repaid by patient centred intelligent approaches to improve patient safety. This presentation looks at a systems-based approach to a never event which created a learning environment and a perfect climate for change. Listen to the story of a Hospital Trust who took an aviation concept and parked it straight in the heart of a busy theatre complex.

I have been a scrub nurse since 2008 with an ‘unblemished’ CV until November 2017 when I was involved in a Never Event. Witnessing how staff react when serious incidents happen that was not improving staff morale or patient safety; I wanted to do something about that. My intention after the Never Event was to demonstrate to my colleagues and anyone who would listen, the best patient centred approach productive to patient safety post serious incident. With incredible support from East Lancashire, we launched the noise reduction / behavioural improvement concept Below Ten Thousand. I still work in the vascular theatres at East Lancashire but still enjoy sharing our experiences of one of the simplest patient centred concepts to appear in the NHS, Below Ten Thousand.