I said to the staff that were there, ‘When do you hold your debrief to decide what worked well, what didn’t, what problems you have and what you need to do?’ They said they didn’t have debriefs. I said, ‘But surely you must get together and discuss things?’ ‘Only if the patient dies.’ Only when someone has died do you discuss, when it’s too late. And at that time it’s emotionally charged, because you are all worried about the consequences. ‘Why don’t you have a normal session when everything’s been okay and you can see all the things you’d like to improve?’ They said they don’t have time. That
...more
