When we don’t deliver the best possible care

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My world has been rocked recently by two very distressing Scottish Public Sector Ombudsman (SPSO) reports published at the end of last year about the care of patients in NHS Borders.  Regardless of how badly I felt it cannot be a patch on what the families of the patients felt when we didn’t deliver the best possible care and when they had to pursue answers to their concerns through the SPSO.

Both reports were distressing in that we did not deliver the standards of care both of the patients deserved. They are public reports and I will not go into the detail but I wanted to share that as the senior nurse in the organization they made me seriously think about what I needed to change.

Unfortunately, at times, healthcare is a difficult and challenging environment to be in as a patient and to work in as a member of staff. We don’t always get things right. Regardless of how hard you work or how your good intentions are. Sometimes things will go wrong. When it is evident that what you have been doing hasn’t been delivering the best quality of care it is important to take stock, look at the situation with humanity, be professional and do something different.

What did I learn? I learnt that I needed to own the problem; I needed to put some energy and focus around the problem; and I needed to direct staff to take action. I refer to it as my ‘three times a day of Evelyn’ and indeed I have been paying that level of attention to implementing solutions.

In relation to the SPSO findings I can say for certainty that now we have established clinical grip on three key indicators in relation to Adults with Incapacity, DNA CPR and nursing care planning. In order to improve communications for patients with dementia we have a plan to ensure every patient with a diagnosis of dementia is offered the opportunity to complete Getting to Know Me in the community. This is the beginning of a journey and hopefully, if the different way of working works, I’ll be able to report positive progress in future blogs. However, if it doesn’t I won’t rest on my laurels and will continue to look for solutions. 


Hello my name is Evelyn Rodger, Director of Nursing & Midwifery for NHS Border. I write my blog about topics related to nursing, midwifery, improvement, innovation and change. I work as Director of Nursing, Midwifery & Acute Services in NHS Borders. All views are my own. Follow me on Twitter @EvelynFleckDoNM or email me evelyn.rodger@borders.scot.nhs.uk