1. Dr Rumina Mirza

2. DISCLAIMER Many of the things that follow are opinions of individuals and personal views of friends and colleagues, and in no way reflect the opinion or position of any particular Trust/ Hospital

3. Introduction Case scenario Effects on the individual Effects on trainers Support available Reporting SUIs/ Near Misses Improvements

4. Situation Patient with COPD presented with SOB and noted to have a pneumothorax Colleague performed pleural aspiration Needle inserted into the wrong side Result: patient decompensated  cardiac arrest Consequence: death

5. Effects Personally: ‘It could have been me’ Frightening  paranoia Not mentioned to other colleagues

6. Effects Trainee: ‘Will my seniors perceive me differently?’ ‘Shall I take time off?’ ‘Am I no longer trusted?’ Solicitor states to not trust your Trust Cannot talk openly to people at work - Does it help to talk about it? Loss of self confidence Risk to career

7. Effects Trainer: Instinct to protect Not always possible - if CPS are involved Feedback  limited

8. Support Difficult and lonely time Support available? More complicated if CPS involved What next?

9. Learning Points Incident reporting is about Risk Management Should affected person be involved in implementing a strategy to ensure this doesn’t happen again? There is a ‘gossip’ culture Inform doctors for the sake of Awareness – not intended to scare/ spread rumours Medical staff coming under increased scrutiny Realise how easily things can go wrong