Libsyn Directory

Patient safety 3 - How do we improve how we learn from harm?

Release Date: 01/24/2024

Leading the Way 13: Leading change, with Dr Nadeem Moghal

RCPCH Podcasts

How can we build services that better understand population needs? In this episode, Dr Jonathan Darling speaks to Dr Nadeem Moghal, Director and Chief Medical and Innovation officer at Strasys. The discussion moves beyond traditional leadership theory and focuses on the practical realities of leading in complex environments, particularly where transformation and service improvement are required. The two explore the challenge of building better services in increasingly complex systems. Using the example of paediatric services, Nadeem discusses the fragility that can exist within healthcare...

Understanding the RCPCH Assessment Review - changes to workplace-based assessments

RCPCH Podcasts

Want to know more about the RCPCH’s Assessment Review particularly what, why, when and how it’s going to affect you? This podcast episode aims to do just that by bringing together some of the College faculty who have been involved through the planning, development and pilot stages. Dr Cathryn Chadwick, outgoing Vice President for Training and Assessment, Dr Josh Hodgson, Chair of the RCPCH Trainee Committee and Dr Sarah Hallett, Trainee Representative for Assessment at the RCPCH, discuss proposed changes to workplace-based assessments which are designed to better reflect real clinical...

Leading the Way 12: The quiet power of SAS doctor leadership, with Dr Kumar Swamy

RCPCH Podcasts

Representing around 30% of the medical workforce in the NHS, SAS doctors are essential to delivering high-quality care. Yet their role is still evolving in terms of recognition and development. In this episode, Dr Jonathan Darling, who has recently completed tenure as RCPCH Vice President for Education and Professional Development, speaks with Dr Kumar Swamy, neonatology specialist and RCPCH SAS Joint Chair about how the RCPCH SAS committee works to amplify the impact and recognition of SAS doctors through consistent and persuasive messaging. The two discuss how leadership rarely begins...

Child health research 1: Digital health technologies, with Professor Paul Dimitri

RCPCH Podcasts

How can we use digital technology to address children's physical and mental health needs and shift from reactive to anticipatory, personalised care? This episode is the first of a series on research and child health and discusses the role of technology in transforming child health. Professor Paul Dimitri, Director of Research and Innovation at Sheffield Children’s NHS Foundation Trust and paediatric endocrinology consultant talks with Nish Talawila Da Camara, Head of Research and Evidence. Paul outlines how digital tools, data and artificial...

Influencing the Children’s Wellbeing and Schools Act

RCPCH Podcasts

How does the College combine paediatric and policy expertise to influence legislation? Professor Andrew Rowland, Officer for Child Protection, talks about our work with colleagues from RCPCH and NSPCC. The UK Government introduced the Children’s Wellbeing and Schools Bill in 2024. This proposed measures to improve information sharing between services, strengthen safeguarding, reform children’s social care and raise standards and protections in schools. This received Royal Assent in early May 2026. Andrew invites Elizabeth Collin, RCPCH Public Affairs and Campaign Manager and Joanna...

Leading the Way 11: Trust, courage and diversity in medical leadership, with Dr Erum Jamall

RCPCH Podcasts

How can we overcome the transition from clinical practice to managerial roles? In this episode, Dr Jonathan Darling, RCPCH Vice President for Education and Professional Development, speaks with Dr Erum Jamall, a consultant paediatrician and currently the Divisional Medical Director for Women's, Children and Core Services at Dartford and Gravesham NHS Trust. The two discuss leadership within NHS trusts and the crucial role of medical management. A key theme was the importance of viewing medical management as an essential part of trust leadership, particularly by building networks and...

Leading the Way 10: Leading through advocacy and collaboration, with Dr Kay Tyerman

RCPCH Podcasts

How can we be firm, fair, and tenacious in standing up for our teams and those we serve? In this episode, Dr Jonathan Darling, RCPCH Vice President for Education and Professional Development, speaks with Dr Kay Tyerman, a paediatric nephrologist. Kay’s approach to leadership is rooted in advocacy and collaboration, qualities that are essential in shaping effective health systems. Kay and Jonathan talk about how hard knowledge has helped her build a valid argument to invest in child health, how she’s been encouraged by a simple thank you, and how she’s learned when to hand over a role to...

Leading the way 9: Compassionate leadership in challenging times, with Will Clement

RCPCH Podcasts

We are working in a period of sustained challenge. Many colleagues across the health system are stretched, fatigued and, in some cases, bordering on burnout. In this episode, Will Clement, a leadership consultant, executive coach and facilitator who has worked across the NHS and with RCPCH, tell us how compassionate leadership offers more than kindness; it delivers measurable improvements in wellbeing, team cohesion and outcomes. The views, thoughts and opinions expressed in this podcast relates only to the speaker and not necessarily to their employer, organisation, RCPCH or any other...

Leading the way 8: Strategic leadership in safeguarding, with Dr Vicki Walker

RCPCH Podcasts

All child health professionals, no matter their role, must have knowledge and skills in safeguarding. As a designated doctor in child protection, Vicki has particular leadership experience in this area and has recently led the redevelopment of intercollegiate competencies for safeguarding and children in care. Vicki speaks with host Dr Jonathan Darling about her career, which often took an unconventional path; she worked as a teaching fellow, got involved with the RCPCH trainees’ committee and became head of service of a growing community paediatrics team. Leadership often starts with saying...

Leading the way 7: Stepping up when opportunities arise, with Professor Steve Turner

RCPCH Podcasts

Failure, Steve tells us, is a good teacher, and when you get involved in leadership, expect to make mistakes (and learn from them). In this episode of our monthly series of leadership conversations, Dr Jonathan Darling, RCPCH VP for Education and Professional Development, speaks with Steve about how his academic and leadership roles evolved, starting with a thin CV and stepping up as opportunities arose. He became involved in child health research, first in small groups, and then collaborating with colleagues across the UK and globe. His route to RCPCH President began with other College roles,...

More Episodes

It is not enough just to collect data on harm occurring to children in healthcare settings. We need the data to be robust, comparable across the NHS and for it to be transformed into effective, meaningful changes in outcome.

In episode 3 of our series on paediatric patient safety, we speak with Dr Damian Roland, a paediatric emergency medicine clinician scientist and head of service for the Children's Emergency Department at Leicester Royal Infirmary.

As Damian discusses on the podcast, in order to learn from harm and prevent it occurring again we need to collect data and investigate what is occurring across the healthcare system rather than looking to individuals. Removing the individual, more punitive approach to harm investigations could improve the quality of how we record and report harm.

There is already a wealth of learning available from a range of sources including national reports, coroner’s findings described in regulation 28 reports to prevent future death and large-scale reviews like those of the Health Services Safety Investigations Body. We can investigate whether the causes of harm identified in these reports are occurring where we work and make proactive steps to avert it.

Damian also shares the progress of the SPOT programme (System-wide Paediatric Observation Tracking). This looks to reduce harm and improve how we learn from harm by creating a standardised common language to identify and discuss children whose health is deteriorating.

Thank you for listening.

Hosted by Dr Natalie Wyatt, RCPCH Clinical Fellow and Jonathan Bamber RCPCH Head of Quality Improvement | Produced by 18Sixty

Download transcript (PDF)

Please be advised that this series contains stories relating to child death and harm. All views, thoughts and opinions expressed in this podcast series belong to the guests and not necessarily to their employer, linked organisations or RCPCH.

About the Patient Safety series

As doctors we ‘first, do no harm’. However, the systems in which we work are rife with safety issues and resultant harm. In thinking about how to improve this, we have brought together leaders in the field to discuss challenging and thought-provoking issues around keeping our children safe in healthcare settings. We hope you will be entertained, educated and energised to make strides in improving the safety of the children that you care for.

The RCPCH Patient Safety Portal at https://safety.rcpch.ac.uk has lots of resources. It includes a wealth of information summarising reports and investigations that identify what puts children at risk of harm. It is imperative to turn this knowledge into action through improvement activities.

More about Dr Damian Roland

Damian is a paediatric emergency medicine clinician scientist and is head of service for the Children's Emergency Department at Leicester Royal Infirmary. Among his many achievements, Damian has been focused on addressing the challenges of identifying deterioration in health in children. He created the Paediatric Observation Priority Score for Children's Emergency Care and currently he is instrumental in the NHS England SPOT programme.

Topics/organisations/papers referenced in this episode

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