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

Release Date: 01/24/2024

Building Capacity 2: Alternative research pathways

RCPCH Podcasts

In the second episode of our Building Capacity: Past, Present and Future series, recorded at the RCPCH Trainee Research Network National Conference in Stafford, we explore stepping outside of standard training routes. Dr Leila Ellis of the Trainee Research Network speaks with Dr Sharna Shanmugavadivel and Dr Priyen Shah about how their careers have developed beyond the conventional clinical academic route.  They discuss finding opportunities, mentors and how research experience can open doors into areas such as policy, artificial intelligence and health technology. Sharna and...

Building Capacity 1: Routes to get involved in research

RCPCH Podcasts

In the first episode of our Building Capacity: Past, Present and Future series, recorded at the RCPCH Trainee Research Network National Conference in Stafford, we explore some of the different ways paediatricians can become involved in research.  Dr Leila Ellis of the Trainee Research Network speaks with Professor Will Carroll, Professor Damian Roland and Dr Jon Elliot about the current child health research landscape and why research should be part of everyday paediatric practice. They discuss the importance of building research capacity beyond traditional academic centres, how...

Leading the Way 15: Giving leadership a go, with Dr Chakrapani Vasudevan

RCPCH Podcasts

How can we manage major career transitions? How do we ensure colleagues get the support needed to succeed? In this final episode of our series on leadership conversations, Dr Jonathan Darling speaks with Dr Chakra Vasudevan about his work in medical education, patient care and supporting others. From training in India to his move to the UK, to his current role as Head of School in Yorkshire and new RCPCH Officer for Recruitment, Chakra shares the experiences and lessons that have influenced his approach to leadership and professional development. ...

Leading the Way 14: Leading through improvement, with Dr Yincent Tse

RCPCH Podcasts

How can you use your voice to enact impact? In the penultimate episode of our Leading the Way series, Dr Jonathan Darling, our recently departed Vice President for Education and Workforce, speaks with his successor, Dr Yincent Tse, a paediatric nephrologist. The two share valuable insights into leadership, quality improvement and the positive mindset needed to create lasting change. Jonathan and Yincent discuss the importance of saying ‘yes’ to opportunities, but also knowing when it is time to move on. Yincent encourages leaders to talk to as many people as possible and to...

Child health research 2: Getting started and finding support with, Professor Will Carroll

RCPCH Podcasts

How can paediatricians get started in research alongside clinical work? This RCPCH podcast is the second in of our series on Research and Child Health. In this episode Davide, a College staff member from the Research and Evidence Team, is joined by Professor Will Carroll, respiratory paediatrician and previous Officer of Research at the College. The two discuss how paediatricians at any level can get started in research alongside a clinical role. Will shares his experience in building research infrastructure for issues regarding children and young people in district general hospitals....

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...

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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