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Good evening, Yvonne. So we might just get started. Now, thank you so much for your patience. Just wanted to see if we had any other viewers wanting to join us before we started this evening. My name is Elizabeth. I'm one of the Moynihan Academy and currently hold the role as our locally employed doctor representative. But here today, I'm just moderator for our fantastic guest speakers. First of which I will introduce in a moment and thank you again for joining us for our learning from our mistakes webinar, which is what we're planning to talk about this evening. So our first speaker is Mr Par Sains. He's a general surgeon based in Sussex in London and has a special interest in Call of Proctology. He's here today more because of his interest in patient safety, medical law and clinical governance. He also has a master's in medical law as well as being a general surgeon and his current roles, aside from his surgical practice is actually the governance lead for the Department of Surgery and he's currently the AGB medical legal lead. He also has a keen interest in teaching and training new surgeons and medical students and holds an honorary title at the Brighton and Sussex Medical School, which leads me on nicely as to why he's here with us this evening, which is to teach us his audience a little bit more about keeping ourselves out of trouble in our surgical practice and how to best prepare ourselves. Should we need to appear in court at any point? So MRSS thank you so much for joining us and I'll pass over on, on you. Hi, Elizabeth. Thanks very much. And um thanks for the invitation uh to, to, to give this webinar or certainly part uh partake in the, in the webinar. Um And thanks very much everyone for, for uh logging in and listening. So, um thanks and again, thanks for the introduction. Um Just a couple of things I actually work independently now uh after 30 years in the NHS. Um And certainly do have uh lots of interest in patient safety and medical law. So as Elizabeth um said, it's, it's about learning from mistakes and this is, this is an aspect of learning from mistakes on the medical legal front whenever anyone uh I think in the early days, especially when, when me medical legal issues were brought up. Um uh found out that I was sort of interested in medical law and I was doing a masters in medical law. The first question to ask was why are you doing it? Try and keep yourself out of trouble? Well, there is part of that. There is a self preservation aspect to it and, and everyone has that, that's human nature. But actually the reason why II looked at medical law was to possibly turn it round, turn it slightly round on its head and look at it from the viewpoint of risk reduction. So if we know what medical framework, sorry, Medico legal or legal frameworks we work in, uh then um you are more likely to adhere to those safety frameworks and possibly improve patient safety. That's the way I would like to look at it. So it's not all about just keeping yourself out of court, although that's, that's a, a great thing to do. Um So I'll move on. Um This is a very indulgent slide but um uh we're not very good doing it medical um uh presentations and uh and meetings uh is to give uh a summary of your um qualifications as to as to why you're qualified to give a certain presentation or take part in a webinar. Um uh And this is my resume um as well as uh the kind words from uh Elizabeth regarding my governance uh roles and um uh medical examiner roles. So, uh the aims here to discuss the concept of concepts of negligence and its application in surgery also to outline good practice. Um A and to, I can't profess to say we're gonna understand the legal mind. Um But it's to sorry about that, but it's to um gain an understanding of how lawyers may look uh at um uh a series of events, um a series of practices that you may be involved in or certainly goes on uh quite commonly uh in uh medical negligence cases. So just a little bit of housekeeping 1st. 1st, it is to say that this, this isn't a forum for discussing specific cases or advice on specific cases. I mean, we, we can sort of look at it in the round. If anyone's got uh uh uh sort of points they want to make about things they've been involved with but not specifics, please. Uh And there's not the forum to discuss issues about specific departments or hospitals. Um And I'm sure you'll take that on board. I'm just gonna stop talking which unusual for about um 20 seconds to just for you to look at that word bubble and read what's on it. OK. So that word bubble encompasses everything to do with patient safety. Uh I'll go back to what I said about how this talk about medical legal aspects fits in or dovetails in uh not just with law but how it, it trails back to safety and learning from mistakes because there's nothing more um uh nothing more that gives more leverage than actually finding yourself in a very tight position medical legally to hopefully make you learn that there is uh you could have done something differently. That's as an individual and also dare I say it now as a corporate, um, or, uh, a bigger, um, uh, a bigger workforce. And also, uh, again, dare I say it now at corporate level with the, um, uh, the, the, the, the top end of hospitals and trusts and we'll talk a little bit about that as we go on through the talk. Now, um, things will go wrong no matter how much we try. Um, uh, and there's some admirable things that people have done uh to try and reduce risk, er, throughout the, er, health care industry and we continue to do it, but things will always go wrong and this is in any industry. I'm just gonna point to um a, uh, a quote that, er, sir Liam Donaldson, former Chief medical officer in the nineties um uh put down his or actually quoted in his um uh white paper is to, er, is human to cover up, is unforgivable and to fail to learn is inexcusable. Now, I have to say that was put set out in a white paper um in the 19 nineties and I'm sorry to say, I'm not sure whether actually those words have been heeded in the health care industry. Unfortunately, we seem to have a very short memory um but we can come back to that in the Q and A one thing to remember the medical negligence when it comes to litigation. There are no winners. There's been a patient who's harmed or died. There's a family who's been affected and there are financial payouts where, uh, it's from the taxpayer's purse, there's a clinician, uh, normally an individual, uh, and then an organization which has had reputational damage and, uh, the psyche effects that come with patient harm. Um, there's supposed to be a no blame, culture, transparency and learning. Um, I'd be interested to hear your thoughts when it comes to the Q and A's as what, whether that's actually the case and your experiences. Um just to put it in context and this is slightly probably more. Now, there's an estimated 12,000 avoidable deaths in the UK every year and over 24,000 serious incidents seems quite a lot, but that is according to the King's Fund. So how do things go wrong? Well, individual clinician action or in action. So it's not something you'd do. You could in surgery, for example, you could er performer AAA maneuver that ends up in disaster. Um or you may not er, perform a maneuver that would avert disaster. So, very simply speaking, um let's say uh a big vascular injury may have been caused by a slip of the knife as it were with the scissors or uh inaction, maybe not to control that by putting the clamps on or doing it in time systems errors. Now, systems, errors are still the majority of errors. It's the old Swiss Cheese model, which I'm sure you all know uh non learning organizations. So have organizations really got it embedded in their culture that mistakes that are made are looked at in morbidity mortality meetings. Are they discussed at higher levels? And is um the feedback that comes from all these sort of uh assessments and uh um uh e error reviews and uh feedback that comes back from the coroners, for example, is it all fed back to the, the ground floor, the people who are actually doing the, doing the job. And more importantly, these days, I think this is something you've got to think about. And II, I'll, I'll be possibly touching on this in the A S GBI conference in Belfast this year is the feedback, er, to the executive boards where, uh, we start looking at system errors in terms of litigation. It's rarely a malicious or calculated event. Although, er, recently we've had the, let me case, which has opened up a real can of worms quite rightly, er, er, and that heads that points directly towards systems, er, as well. We'll move on rapidly. I've got a frightening amount of slides. I won't apologize but I will go through them quickly. So, first thing I'm gonna talk about is, um, uh, as a sort of meat of things, er, in negligence is the law of tort, tort is injury. And there's three components, there's the existence of the duty of care. There's a breach of that duty of care ie that the standards of care that are expected in that particular scenario have dropped, they haven't met what is required, uh, to perform safe and effective surgery or a treatment. Uh, and there's also causation, causation is literally what it says is if an event has occurred or if something's been omitted, has that then caused harm or the, has the harm that has been caused is a result of that particular action or an action. The standard of care is um er judged by the tests of uh of, of the standard of care and the longstanding test of career has been blu we'll talk about that in more depth in a second. Um Beho and Montgomery. Now, Montgomery is specifically related to consent. I'm not gonna talk too much about consent today because of the subject in itself. And I have offered uh to Elizabeth that uh I'd be happy to come back if you'd ever want me to uh to talk about consent in a separate uh session. So, the duty of care it, it spans back to a case called Donohue versus Stevenson where Mary mcallister, er or Donohue at the time uh bought an action against a chap called David Stevenson, who uh owned an Aerated water manufactur manufacturing factory in Paisley in Scotland. She claimed 500 lbs damages as she bought a bottle of ginger pop. And um uh when she drank it at the bottom of this er, bottle of ginger pot, there was a snail. Um, and you can imagine, I mean, if I found a, uh, a snail bottom of my ginger pop or beer or something, I wouldn't be very happy. She wasn't and therefore, uh, she went to court with it and the duty of care, er, was thus defined. And, um, it's a legal obligation and it basically says it's always to act in the best interests of individuals and others not to act or fail to act, which is very important. I'm gonna, I'm gonna keep on repeating this in a way that results in harm and act within your competence and not take on anything. You do not believe that you can safely do. So that's in, er, really strong in medical terms. So we come to Bolm, which is the main test and bum uh was a patient who had er, effectively depression and he was undergoing treatment for his mental illness again. Er, strangely, this was up in Scotland in 1957. Um, er, he underwent um electroconvulsive therapy. Uh the, the anesthesin, the um, procedure or part of the procedure didn't give any relaxant drugs and the claimant Ie Bolland suffered serious er, fracture and there was divided opinion amongst professionals as to whether relaxant drugs should be given or not. Um, there is a small risk, obviously, as we know with the relaxant drugs or sedation of death and uh if they're not given, there's only a small risk of fractures. So there was, there was this divided opinion, the claimant or Bowdle argued that the doctor was in the breach of duty by not giving the relaxant drug ie, um, the standard of care was not as expected. So this went to court and, um, at, er, courter it was held that the doctor was not, sorry, it wasn't held. So the doctor wasn't in, er, in breach of duty. Um, and mcnair, er, was the judge in the first instance. Uh and the House of Lords then formulated the blu test, which I'll read Ver Batam because it's quite important is that a medical profession is not guilty of negligence. If he and I say, or she has acted in accordance with the practice accepted as proper by a responsible body of medical men or women skilled in that particular art. So putting it in other way round, a man or woman is not negligent if he or she is acting in accordance with such a practice merely because there is a body of opinion who would take a contrary view. So if you could, if you can find as far as bowling goes in very simple terms, a group of professionals who are of your specialty, who do the same procedures, um who are trained in the same way and they have uh an opinion um uh which is similar or the same as the opinion that you acted upon. Then uh there is a defense that can be put forward. Now, you can see from this why B has been battered, left, right and center by the legal fraternity. Um And quite understandably is because the, the, the sort of the cozying up of, you know, a group of professionals, especially surgeons or doctors protecting their own um uh is, you know, this is really open to that. Um And we'll talk a bit more about it. Uh Hopefully in the discussion now this in the 19 eighties um, was a change to the tests. Uh Bolitho was sort of deemed as the, the change in, in thinking. Um, and unfortunately, it was based around a two year old child who was admitted to hospital suffering from breathing difficulties. And the registrar, the pediatric registrar was summoned but couldn't, er, attend as the bleep wasn't working and she was attending another emergency. The child unfortunately died. Uh The parents brought an action against the claim doctor uh, and claimed that um, er, the child would have been intubated, had the registrar attended the evidence that the doctor gave was that had she attended, she wouldn't have intubated anyway. Um And uh there was logic that was um given as regards that rationale, this was held and there was no negligence. Now, befo um in uh a paragraph is that, er, from the courts as the defense could not be considered reasonable if a body of doctors or supporting witnesses were not capable of withstanding logical analysis. This is the important bit in this is where it's not only about a group of people saying, well, we agree that we would have done the same thing. Now with Belia, in the, in the eighties, there was this additional, the logical analysis where if that decision could not withstand logical analysis, then negligence would be proven. Um a case which is dependent on a practice which is not reasonable or logical, thus cannot be defended. You would imagine that bolitho makes sense and it's logical as it says. Uh however, um bum still um uh has stood the test of time, especially in these very testing times where COVID has occurred and, and we've been in some very unprecedented er, situations where experts really, um uh as a group can possibly be the only way of giving their, er, or coming to a conclusion as to what the best, er, guidelines or practice is. So we'll move on uh understanding the legal mind, like I said, I don't profess to, to say we, we, we, we're here to dissect what lawyers think about. It's pretty difficult. My wife's a barrister but, er, er, um, yeah, we don't wanna go into that. Um, but it's to understand what the legal professionals approach to facts and evidence are. Um, in order to improve your, your, your actions and reasoning, it's very straightforward stuff. This and you may think, well, he's teaching us to suck eggs but I make no apologies because these are the kind of things are forgotten that are forgotten on an everyday basis. And I'd like you to think of it in terms of improving patient safety. So, you know, if you're, if you're standing there writing a set of notes and you say, oh, that webinar we listened to with MRSS banging on about something or I'll write it this way this time. Hopefully that's a move to improving patient safety. Uh and not just keeping yourself out of trouble or us trying to, um predict what lawyers are going to do. First of all, the use of words, I'd, I'd just encourage you to think about it. Possibly happened, probably happened. Very ambiguous. Could or would or should or may or might ambiguous. Sometimes you have to write these things but you have to qualify them as to why you've written them. The third one long is quite an important one. So, y you know, we've all been in the situation. Uh I been as a junior, as a trainee as a consultant even now is when you go in and Missus Smith, the patient was better. Uh Missus Smith's symptoms had improved. Now, what you're gonna be is quite articulate is to say how they've improved ie observations wise, you know, the parameters you're looking at pain. Are you looking at the blood test results? You're gonna be quite specific as to why uh the patient's um, uh condition was better or indeed worse or still the same. So it's been very, very articulate about why uh your assessment um uh has concluded um a a certain thing. So um effectively words must be used clearly and avoid ambiguity. Now, I don't expect you to read all this. Um but this is uh a case um uh that was judged on by a chap called Lord Hoffmann. And it's really to say that the inherent probability or improbability of an event remains a matter to be taken into account when weighing the probabilities and deciding whether on balance the event occurred. So this is introducing the concept to you of the balance of probabilities, which is how uh a case is judged by the court by the judge. So it's a binary system, I've highlighted the binary system. It's a 49 51% situation. So the judge based on the evidence from a claimant, um and the re the respondent uh basically has to judge whether an event occurred and did it lead to, was it a breach of duty? Did, did it lead to causation? And it's a binary system either happened or didn't happen and that's up to the court to make that decision based on the evidence. So now it really becomes important as to how that evidence is gathered and what evidence there is. So go back to what I was talking about about the lack of ambiguity as far as the words go. So logic lawyers don't have an implicit medical knowledge and nor do judges in fact. Um, or basically assume they don't, you'll get the odd one who's very rarely who's got, um, uh, some, uh, medical background as well. Um, lawyers need clinicians to explain in simple concise and logical terms. What's happening. This brings in the concept of medical expert witnesses. I do a lot of expert witness work and at the, er, Congress in May I'll be talking about, uh, um what it means to be an independent medical, um surgical witness or expert witness. Um I can't emphasize this enough, demonstrate a logical approach and reasoning process based on material facts and the weighing of alternatives. Now, it's really important that last bit is the weighing of alternatives. Uh It's not just good enough now to say, well, you know, yes, I'm the doctor very important. I'll tell you how it's gonna happen. Uh You have to have weighed the alternative, discuss them with the patient. Uh This is not only about the, the, the consent aspect, this is about, um you know, their management and treatment and um and documenting the fact that you have done this reasoning. So when a lawyer or a judge, well, certainly when a judge listens to evidence or reads evidence or a lawyer looks at the, a set of notes, um what they'll be looking for is really how a clinician's conclusion is reached. Its identification of facts, evidence, which are material to the issue being addressed and a description of the reasoning process which results in how the conclusion has been reached. So it, it doesn't take as long as one might think to explain your decision making. You know, your, your, your decision making is an algorithm that comes from experiences about pattern recognition. You can actually, even if it's a flow chart in the notes, you can show your reasoning as to why you've come to a conclusion at the end, why someone has acute appendicitis, why, um uh it may be diverticulitis instead of appendicitis and then your differentials and how you're gonna treat e even in a flow chart will mean you have explained your, your reasoning and you are telling the story. So what's the importance of keeping good records? Well, one is vital for patient safety and clinical decision making. Uh It's amazing how when you go through a set of notes and believe you may have been through quite a few in this, uh, with the medical legal interest, er, and you're writing a report that the reporter and it won't be news to you. But you know, there's a lot that a lot of notes which are absolutely inadequate in terms of handwriting and I'm guilty myself occasionally with that, I'll put my hand up in terms of chronology in terms of accuracy of um, uh, of events and occasionally, which is I think pretty unforgivable. It moves off factual evidence and moves on to, er, er, conjecture which is something you really should keep away from, especially commenting about, um, uh, patients affects and so on unless it's directly related to the, uh, the medical, er, situation. Um, the discussions with patients can be convincingly recalled and, and described. So a lot of complaints that are made, um, uh, that come to the door are as you will know, again, uh, are about communication. So any discussion you have with the patient again, it can be done in bullet form. It doesn't have to be an essay. Um, and the points that you've discussed with the patient, patient views uh should be, uh, should be documented, a subsequent inquiry into records will be better informed. So I end up, I've ended up looking at as an expert witness, um, er, notes from about seven or eight years ago. Uh, it's taken that amount of time for something to come to court and, uh, it's only the good ones, the, the good set of notes that actually, you know, will send the case one way or another towards the, the, the, the, the, the claimants side or the respondents side and there's no excuse for ambiguity or uncertainty. I mean, that's the way the legal system will look, uh, look at it because, um, that's the way they function. Um, what should be in the notes. Well, uh it's the accepted normal uh observations, new scores, blood test results, any absences I've said it before, but why something was omitted, for example. So you, you know, let's say someone says, ok, um, uh, uh, so analgesia was omitted. Uh, why was it omitted, er, antibiotics? Why were antibiotics not, not given you? You may well have a absolutely bona fide case for doing that. But it needs to be documented as to why, uh, no abnormalities and observations, um, examinations and investigations. I did a case, er review on, um, a patient who, um, who was deemed to be, uh, ended up having peritonitis. But, um, the coroner really quizzed us about why had it not been written down that the patient was not peritonitic, specifically, not peritonitic when it came to, er, examination. Um, so, uh, it's not just by, by saying it's tender, you have to go on to say periton, not peritinic, locally, peritinic or generally periton. All these things really make a difference when you go back to look at the notes. So decisions made and opinions formed, no action, er, decisions, er, and the thought processes. And I, this is really important storytelling now is a really big thing in corporate culture as well. The, you know, that, that they, they hire consultants at thousands of pounds a day to go and tell them how to tell stories in Corporates. Um, and these are for financial reasons and I think this is really important. That's something I'll be taking up as well. Um, as far as the surgical fraternity goes, I think is we need to know how to tell a story. It's not only for the medical, legal reasons but it's also for the fact that, um, uh, you know, when you pick up the phone you're, you're ringing your consultant or er, you're picking up your phone, talking to a colleague, you have to tell a story which is accurate, which is, um, uh, paints a picture uh to, to make them understand what the state of the patient is and it is, it then informs what happens next and really influences patient safety. So relevant clinical findings, um uh actions, decisions made, uh information given to the patient, medications treatment prescribed are recommended and who who has documented the encounter. And when the most senior person on a ward round, for example, the most senior per person in attendance, either operatively or reviewing the patient should be put down as well as the rest of the team members if appropriate. So, uh one question I've always asked and I've, I'm sorry, I take up two minutes answering this because it will come up and I'm happy to answer again later. Um uh the retrospective entry. So retrospective entries uh are commonly done in emergency situations, for example, trauma calls, um or crash calls, er and or genuine afterthoughts in relation to the clinical situation. So the GMC good medical practice paragraph may have changed because GMC guidance and good medical practice has changed recently. Um Basically states the documents you make including clinical records to formally record your work must be clear, accurate, eligible. You should make records at the same time as the events you are recording or uh as soon as possible afterwards. The rules basically are make it apparent that the entry is, entry being made is not contemporaneous ie you, you spell it out that that entry has been put in the notes after the event because of uh and that's perfectly, perfectly acceptable. Uh There is more than one person I can, I have in mind that has got into quite serious bother uh by going back and putting something in the notes that shouldn't have been there, the date, time and explanation as to why it's being made should be put in there and make the entry while the events are still fresh in your mind. If it's possible, um document all material facts available at the time, uh the original entry and any material facts that subsequently become available, uh reasoning processes and decision making again or conclusion as to why, uh not only the factual information as to but why you have to come back to it at that point. Um Quite a red line here, unjustifiable justification after the event is not acceptable. And I think unf unfortunately, the legal system just do not look upon that as um uh excusable. So, um just in conclusion, contran documentation, ev er evidence in clinical records carries weight and subsequent investigations. So I if an investigation is done, whether it's a Coroner's court, whether it's a course of, um, uh, litigation. Um, the, the contran is documentary evidence, it is really, really, really important, which brings us on to, um, it's thi this is just a, a case from 1968 very early on that highlights it again. I don't expect you to go away and read this, but this is very important in relation to contemporaneous evidence that any verbal evidence you end up giving either in the Coroner's Court or a course of litigation, er, is that it's about consistency and consistency. Lawyers are very good at picking you apart. Um, uh, and the, the methods of cross examination are basically to pick out whether someone who has been consistent or not consistent and it's really important that the notes that have been written some time ago are consistent with your verbal evidence. So you go back to your notes. This is why it's so important. So it's, it's about you possibly having to go back at some point and look over your own notes, being able to read them and go through the logic and demonstrate consistency. Um I've been in expert witness situations in court where, um, I've seen quite eminent, quite eminent surgeons being taken apart by barristers, uh, as far as consistency goes, uh, and it wasn't anything to do with their knowledge, it wasn't anything to do with their experience what it came down to was, they had put something in their expert witness statement and said something completely different. Uh And um it was picked up uh on by um council and really taken to task. So the domains of medical practice, um knowledge, skills, and development, patients, partnerships and communication, colleagues, culture and safety, uh trust and professionalism. I just put these up just as a flashcard. Um as everything we've talked about today really applies to all those domains. This is really important, look after yourselves. Um if something goes wrong, uh there is the second victim, unfortunately. Um and uh the stigma attached to uh when things go wrong for individuals is quite significant. And this is where you need the support and this is where hopefully things like the A S GBI uh and other support mechanisms come into place your colleagues, your senior um colleagues as well. Um But I'm again, II won't go into the depths of counseling, pastoral care or, or coaching. Uh Apart from saying, look, you really need to watch out for yourself. Uh If you are in that situation um coming towards the end now, communication, uh absolutely vital. It's always been considered a soft skill and um we never used to it when I was at medical school giving away my age. Um It, it, it, it came in and a lot of you guys probably went through formal communication sort of uh blocks or um er teaching. Uh but it ii can tell you from the expert witness aspect. Um and also from the litigation aspect, if you engage in dialogue with the patient orientate the patient. So when they come to clinic or when they're coming through as an emergency, give them two lines about what's gonna happen, why you're there. What the likelihood is? I know it's a really difficult situation at the moment with the healthcare er um environment but try and orientate them as much as you can facilitate their opinion, get them to ask questions, give them as much options as possible or ask them how many options do they want? I mean, you know, how much option do they want? Um, empathy humor and encouragement uh goes a long way. Uh a personalized approach. I mean, there, there's some patients that will come into clinic to see me and I, you know, I remember their occupation, you know, it's quite easy if they come and see me with a hernia because they're most likely gonna be, er, builders or painters and decorators or whatever. But II would always sort of comment on that again. How's, how's work, blah, blah, blah, set expectations. So, right at the beginning, you know, don't, don't give them uh a situation where you, you know, everything's gonna be fine and dandy, it's gonna be rosy, they're gonna have an ultrasound done within 20 minutes now, set the expectations um and, er, diagrams, er, and written or digital information is very important. I tend to draw a lot um when it comes to consent, like I said, consent is a different issue but just to, just to draw and explain and put it in the notes because the, the diagrams themselves are quite important, Shane, you've gone through a process with the patient. So finally to the quotes, I'll put the, er, the word bubble up there again. And um the reason is really, it does cover a lot of, uh, a lot of the aspects we talked about. Uh, and the quotes, the first one is from Mar or Marcus Ai and he's not the, not the guy from Gladiator, but this is the, uh the, the stoic. Uh I learned to read carefully and not to be satisfied with the rough understanding of the whole and not to agree too quickly with those who have a lot to say about something, really pick out the important bits. You know, there's lots of noise in the system these days, uh including, uh uh you know, day to day stuff, but also in education, um, and surgical arrogance had to take over. I had to put my own quote in, I apologize, er, or I don't apologize. In fact is if you display competence before confidence, um, it really does make a difference, especially in front of lawyers and judges, um, let alone the patients, which is where the important thing is. Um, it's a difficult one for surgeons cos, you know, uh I think we're all cut from a, a certain cloth. Uh But do remember that on display competence before confidence and you won't go far wrong. Sorry, I might have gone a little bit over my time, but thank you very much. Thank you. You're on time. Um I think we've got a bit of time to show you just, um, while Miss Corbett gets herself set up to, to, um, I can see this going on, on, on that. Uh So if patients are, uh if patients are allowed to covertly record consultations without asking clinicians for their consent, it wouldn't be mutually beneficial if the NHS adopted the policy whereby this is a really, really tricky one. Actually, this is very, very um there's a minefield about not only the actual consent process itself but data protection. Uh and so on at the moment, it's, it's a, if a, if a patient asks me, for example, if they can record a conversation, let's say, based on uh consent, um I generally ask for a good reason as to why. Um uh and then offer and again, it's about working with the patient. It's not about being confrontational. Um uh I generally ask as to why is there a genuine reason? For example, um you know, if it's uh a patient uh and a relative who've come in patient has memory problems, generally medically uh medical memory problems such as, you know, onset of dementia or learning difficulties and the carer with them are, you know, needs it for it to be recorded. I would also give them the option to say I will send you a comprehensive letter with all of this explained. Um in effect, as far as I'm aware, there are, there are a couple of cases in case law um that recorded evidence unless consent is being given is not admissible. Um I think the question there is uh should, should the NHS adopt a policy where the option is being taped? I think part of the reason why it wouldn't do that is because of it is a can of worms. Absolutely. A can of worms. I mean, you can imagine, um, if every conversation was taped or the option was given the amount that was taped. Um The, the legal throughput of that would be enormous and even if it didn't come to anything, the cost to the um NHS would be huge. I think, uh I think the best way at the moment is, and I think it should be continued is, is the, the note taking and, and patients are free, you know, free to take their own notes as well. Thank you. I think um we thank you. Thank you. So thank you for staying with us. Everyone. I'm hoping you're looking forward to our next speaker as much as our first. We have Miss Harry Corbett. She studied medicine at the University of Liverpool, undertook her specialist training in the UK and Australia and specialized in pediatric urology through a fellowship at Birmingham Children's Hospital now works in Older Children Hospital. She's an active member of older ha research community and is an honor senior lecturer in the Child Health at the University of Liverpool. She's passionate about surgical safety and after sitting on the advisory board is now the program director at cores where they're developing the safety and governance infrastructure of the surgical department. And so this capacity she's here today to discuss how we as surgical practitioners can best use cores to help us learn and document potentially some of our mistakes. So, Miss Corbett, thank you so much for joining us this evening. Thank you very much. Can you hear me? Ok. Yeah, I'm having great difficulty sharing my screen because the share button is um gray out. It's not allowing you to click on it, which um right. Hold on. Ok, hopefully. Has that helped me? Sadly not? No, let me just. Yep. So I'm going to present now then share your screen and it gives me the options and I know I want to share the entire screen. Um Yeah, it's still frustratingly gray out. I don't understand why anyone got good tech, tech skills um I high on you. So II, the way I did it, II saved the PDF and then went down to the arrow at the bottom of the screen and on to present. Now, whether that's going to help you just say, uh, well, everyone, just while we're working through this technical difficulty, if you have any other questions for MRSA on his, we stand everyone in silence. That was a lot of information to take on. Well, I think I, yeah, II just going back to while har it's, um, hopefully sorting the, er, the, it side of things. I think the way II won, I'll emphasize again is actually this sort of shift of thought from me. All things, medical, legal being a defensive aspect is the mindset that has to change to say if you are aware of the legal frameworks and you adhere to those ie the standards of care and the causations, you know, what may happen. If something is done or emitted, then it really is uh a great stride towards better patient safety. Um, and 11 thing I think to think about, especially for you guys who are gonna inherit this system, um, is, uh I'll, I'll stop in a second is to think about the corporate side of things which sometimes gets me into trouble, but I'll, I'll stop now. Thank you so much. All right, perfect. We'll pass on to you now. Thank you for everyone's patience here. Yes, thank you very much. Indeed. I'm, I'm hoping I'm only seeing a quite a small version of my slide. So I'm hoping that you're seeing a larger version of my slide. No, it looks, it looks good. Lovely. Well, thank you so much for inviting me to talk. I mean, Elizabeth has just given me a, a great introduction and giving you my background. So I won't go into that too much. Although listening to past talk, I was wondering if perhaps I should have given you a little bit more information on how I've got where I've got to be. But actually what Elizabeth said about the fact that I've worked on, on sort of the M and M processes at work before I've sort of delved further into becoming involved with CIS is really relevant. It's something that's been um, an interest of mine right from the word go. So, um, what I'm planning to do is talk to you, um, about Corus. I want to give you some background of how, how Coras came to be. Tell you a little bit about how it works. Um Go through some cases, um, and touch briefly on, on, on dealing with mistakes and, and options of, of how to look after yourselves there actually. Um And then I'm, I'm sort of an opening there for people to say how we can use chorus data in a better way if, if you can think of it, if I haven't touched on your ideas already. So I want to start off by talking to you about, um, where Corus came, came from and we have to thank the aviation world and I think people often go, oh, aviation surgery it's often linked together, 11 runs the same way as the other. But, um, I think that's from the sort of, um, concept of checklists and you probably know yourselves that the, the checklist idea is great, but it doesn't necessarily work across the board in medicine because an airplane is a, is a mechanical device and it doesn't come with all the, um, variation that human people do. Um, and we know that medicine does not, um, does not follow a clear textbook in many cases. So there's that aspect of, of the similarity with aviation, which isn't quite so good as we'd like it to be. Um, but actually the comparison that I want to make is with the, um, chirp system, the confidential Human Factors incident reporting system, which was set up by the Civil Aviation Authority. Um, they've worked on the basis that there are many events out there which are a near miss. Um, and if people had known about that near miss happening on that day, they could have potentially done something that would have prevented that near miss that became not a near miss, an actual event another day. Um, and they felt that people would report errors and, and near misses if the conditions were right. And obviously they weren't right when they set up this process, otherwise they wouldn't have done it. Um And of course, we can learn from other people every time you hear a story, every time I read my MDU case notes, for example, I always think of something, I think. Oh, gosh, yes, that thing that happened. That could have been me. I might have made that mistake myself or I might have missed that thing myself. So if we can learn from others, we may be able to change systems and prevent other errors. So, so that was sort of the background idea for where chorus um came from. And we, and we really thank the Civil Aviation Authority. In fact, perhaps I'll just go back a slide briefly to, to, to remind myself to talk to you about how the chorus itself sort of evolved surgeons. Actually, the surgeons who designed chorus were nearly all pilots. So they all knew about Chirp. Um and they had that sort of recognition of the outputs from Chirp and realizing how helpful they were. And they went to the then chief executive of Chirp, who was a gentleman called Peter Tate. And I'm very sad to say that Peter Tate um passed away unexpectedly last year, really without us having the opportunity to thank him again for all the work he did. He helped um the surgeons who designed chorus found the process and he was a key member of the um of the board of trustees up until his death last year. So huge thanks go to Peter and we remember every time we give this talk. So um how, how does it work? So, I keep tapping the wrong button. Here, here we go, went to sort of bring out this concept of precursor events. And I think the aviation field really led the way in recognizing how multiple small unsafe acts or near misses could potentially then lead on to more minor accidents that are more than a near miss through to serious accidents and potentially then through to tragic accidents that result in death. Um Henrick introduced this concept but Frank Bird who's mentioned there down at the bottom, devised this model, which is sort of a simple way to it, really all of those unsafe acts that you can see there in that sort of yellow bar at the bottom can feed into a significant number of near misses to accident, minor accidents, more serious and death. And if you can influence the number of unsafe acts and near misses at the bottom, you can significantly reduce the bars up above. And there's some good examples here from aviation actually. And I think the one that, that scares me or perhaps makes me the saddest is the, um the challenge of shuttle failure. I don't know how many of you remember that event, the challenger shuttle um blew up killing everybody in it. Um Because of an O ring failure. O rings are those little black rings that you use to seal things where you don't want air or water um, or gasses I should say to leak, um turns out there had been quite a few, um, oing failures in previous launches leading up to that time, but none of them had happened at a time that was as catastrophic as the challenge of failure was. Now, if they'd picked up on all those over ring failures, they might have been able to prevent the one that resulted in the challenge tragedy. Um, and another big ticket item in terms of aviation events was the Concord disaster. Um There'd been several previous um, minor events with um, debris on the runway causing minor damage and it was debris on the runway that caused Concord to have that catastrophic failure. So those things, if they'd been reported and looked into could potentially have been acted on and then you would have hopefully been able to prevent those big things. Now, it's medicine's been a bit slow to catch on to, to picking up on these minor events, but there are some examples. Um perhaps they haven't been all precursor events, some of them have been minor accidents. So for example, you'll all be really familiar with nasogastric tubes and purple syringes. Well, certainly when I started medicine, in fact, probably when I was first a consultant, those did not exist, um, nasogastric tubes all had an ordinary lure lock connection on. So any syringe could be attached to it. But um, as you can imagine, at some point in time, gastric contents or gastric or, or, or medications, substances designed to go into the enteral tract and not intravenously, were indeed given intravenously. And I'm, I'm sad to say the same goes for spinal needles as well. Um But, but so there are now separate systems involved as a result of those multiple. Um Well, hopefully some small but some, sadly not so small events, so medicine can do it and we can learn from our aviation colleagues. Um So why are we not so good at picking up these events because we wouldn't be here actually, if, if we were already doing this perfectly. Um And like, as I've said, timely detection might well prevent more serious things, but there do seem to be barriers to why people don't talk. Now. I I'm sad about the top one really that people might fear retribution if they point out minor minor problems. I like to think that's becoming less and less of an issue, but it certainly has been an issue in the past. People don't feel able or confident to talk up to say that mishap happened on my watch and it was small, but it might lead to something bigger. I really hope that culture is slipping away with time. Um I think probably the bigger one is the failure of people to recognize a situation or an event as a precursor. And I'm sure if you put your mind to it, you will be able to think of something of your own. I'm going to give you an example of mine from a few years ago, um whereby I was positioning a, a child for a piler plasty, um they still had their gown over the um over the abdomen. So um you couldn't see the sight mark at that time and II positioned my patients right to the edge of the table according to the side on which I'm operating. And I confidently took charge of the moving of the patient and said, right, put him over onto this side of the table, please. And we did, we moved him onto the side of the table. At which 0.1 of the theater staff went. Are we doing the other side? And I'm like, oh my goodness there, but for the grace off, um that I like to think we would have picked that up before it actually prepped draped and put knife to skin. Um But what if I hadn't, what if my sight mark had been rubbed off because it was the wrong kind of pen? Um I'm thinking of the Swiss Cheese model here. There's lots of little things. What if I, I'd actually had to leave the room and somebody else had then continued, um positioning the patient and prepped and draped and covered up my psych mark and they're not meant to, you're not meant to do that. And our who checklist specifically says, can you see your psych mark? But, but what if, what if all of those little steps have missed. Um So that to me was a big precursor event. Something led me to put the patient on the wrong side of the table on that occasion. And I don't to this day know why I did. Luckily we did the operation on the correct side. So failure to recognize is huge. Uh lethargy and time constraints perhaps lethargy. II hope that's not too much of an issue, but time constraints definitely are. How often do you have time to go and fill in a Datex or whatever system it is that your hospital uses to say this small event happened, which could have caused problems and and I fear that the forms are quite long and bulky and difficult to complete and they many of these small precursor events are are not reported because of that. Uh of course, there might be bureaucracy reasons or, or it may be that the safety culture in in the workplace is not as good as it should be. And II think that ties in with the first one, doesn't it? I like to think this is getting better. Um But there are definitely still barriers out there. Another key problem that we have to think about in health care is what we call the implementation gap. So the gap between the recognition of those events and actually then doing something about it. And there's a quote there from the King's Fund which, which sort of says, you know, everyone has their best intentions. But there's still this gap about what we can do um between people doing the doing um and keeping the patients safe. So chorus has come as a result of those sort of concepts, seeing chirp working well for the um for the aviation system. If you're interested, they've got a nice website and they publish regular reports and they have a feedback system. Actually, that's one of the ideas I've sort of thought about is we don't have quite as much feedback from our reports as I was like, we don't have a newsletter. For example, that might be one of the things that we can do to, to promote the core learning points in the future, but it's well worth a look. So just to tell you about Corer itself, so it's a charity which is independent of any other organization. So, although you may see that our address is the Royal College of Surgeons of England. That's more of a convenience. We are in no way allied to the Royal College of Surgeons or indeed any other Royal College. Um Although we do report via their publications, it's run by surgeons and very much out there for the, the anyone in the surgical team and obviously to benefit the patients as well, we handle what we call self reported incidents. So ideally the person who's been involved in that incident or who's recognized that near Miss will report that event. Uh I'll tell you how in a second. And those are then analyzed by a panel of, of um cor advisory board members. We publish reports based on those reports and the discussions that we have among the panel of experts. And the aim is for us to educate through those reports and also present to events like this so that we can spread the word and we firmly believe in a no blame culture and certainly would never ever ever point a finger. So chorus is um also there's a few other things for you to know about us. So you are independent. As I've said, we, we focus on errors, real or potential. Um It's really easy to report. I'm gonna tell you how in a second and it is confidential. I should point out confidential isn't the same as anonymous. So when you give, when somebody gives a report, their name will come through to me as the program director, but that name never goes anywhere else beyond me. And once we have the information we need from the reporter, then then that name is taken away from our records. Um Slight disadvantage of that is of course that once we've discussed the case, we might not be able to go back to people and get more information, do occasionally get asked for more information. And we can't usually do that because we try so hard to make sure that we are not storing information that people would not want us to store. So how do we report? We have a website, the address of that website is down at the bottom. We have had a few problems with our website being blocked by a few firewalls which was incredibly frustrating. So I hope um that you might have a look at our website through your hospital system maybe tomorrow or the next day that you're in work and see if you can access it. If you can't. Please do, let us know because we hope we find out all of the problems um with the firewall issues. But, but I'm not sure if we have actually. Um so one of the ways that you can report is is through the website, you can do that any time. It's a very simple form. Um And as I say, although your name comes in to me as the program director, it does not go any further um than myself. We have an administrator. Um And, and she's um always making sure I delete things as, as soon as we possibly can, once the information is no longer required, the other way you can report is to use our app. And you are very welcome to go into the app store or whichever process you use to get, get your apps and download this app. Um You can dictate into the app. So, as I said, the last time I spoke to a group of people about this, I'd just walked through some incredibly long hospital corridors that were incredibly empty. I said, let's say you're walking away from your theater or away from the event that you've just um seen potentially happen and not quite happen. You can be walking down the corridor away from them and, and report as you go, we've tried our hardest to make it as easy as possible to, to do the reports because I don't know about you. But reporting sort of as soon after an event is usually best because you life is busy. You, you get distracted by the next thing along. So take the opportunity to report as quickly as you can if you wouldn't eat. So, yes, please do download our app. What happens after the after you've done the report, either through the website or the app is the report will come to me as the program director. Um I will look at those reports and sometimes I'm going to use the word Tinker if you don't mind, Tinker with them a little bit just to ensure they are as unidentified as possible. Very occasionally. Um In fact, I have myself reported a case which had been in the news some years before. Admittedly, I'd waited a while before I reported that case, but II didn't want anyone else who'd been involved in that case to feel that I was inadvertently pointing a finger at them. So II, II changed that case as I reported it actually. But if we get a case in where I think, oh, that might be a little bit too identifiable. Perhaps, has been something in the news II would, um, sometimes for example, change the patient's age or, or, or maybe change their sex might just reword it a little bit. But the basic message of the case will be that and then we will discuss those cases um at the advisory board and we have a panel of sometimes as many as 30 people. Thankfully, not usually that many actually because it's almost too many people to have a conversation with. But we do have a large number of advisory board members from across the spectrum of surgeons and uh from pathology from the M HRA. And we're always keen to have an anesthetic representative that we do have at the minute and so on. Um Once we've discussed the cases, then we'll write sort of chorus comment notes which published and we give personal feedback to the reporter if appropriate. It, it's not often that we need to get that personal feedback in that usually the published feedback is appropriate for everybody to read. Um And as I say, the original reporting, um email or link has, has been destroyed. They go into a database. Our database is not very easily searchable at the moment, but Elizabeth and one of her colleagues are doing a great job in helping us do that whilst they do a little bit of research on that database. So it will be much easier to search soon. Um, but lots of old chorus reports are available on the website, but you'd have to, at the moment have to read through the individual publications to get them that will change. I hope that by the, uh, by the end of this year that will be a much easier system and you can go back and look at those reports, um, and learn from even the most, the ones which seem most far removed from your practice have usually got a learning point for everybody to see anyone who sends in a case report to us will get a certificate to say that they've reported, it will not say anything about the case itself so that we keep that that process confidential. Um So if you put that report, for example, into your portfolio, um nobody could pick up on the fact that you reported a particular case that they may or may not have wished you to report. It's, it's, um, it's neutral in that sense. OK. So that's how it works. We have a website as I've already mentioned. And on that website, we have case of the month. You can, you can go and look up who's on the advisory board and who's um on our board of trustees and you can go and read reports. You can give us feedback through the website. Uh As I say, I'd be grateful if a few of you at least would have a little look and make sure it works through your hospital um firewalls because we've had problems recently. We have published outputs at the moment. We are limited to the surgeons news, which is the Royal College of Surgeons of Edinburgh and the Annals of the Royal College of Surgeons because the other colleges don't have a published um like print journal, but we are working with them to see if we can get our cus reports published in online format with them as well. Well, it's probably worth pointing out that not surprisingly, there are real themes about the sort of cases that we, that we see. Um, none of those will surprise you. I'm afraid drug errors, um, wrong site surgery, sadly, never events. I did have quite a few slides in about never events previously, but I feel people are usually quite well versed. So I didn't want to talk to you much about that. Um Sadly, the old occasion of the wrong patient or drains falling out and lots of problems with communication. Now, I was going to go through a few case studies. I'm mindful at the time. So perhaps maybe just um one or two of our cases and that will give time for some questions. Um So this one's quite interesting. We've had, we've got a series of three or four incidents in our, in our archives. The classic one was um a case where the diathermy pedal had got wedged underneath the corner of the table when the table had been moved slightly. Um, and somebody had turned down the volume on the diathermy. So, er, although the diathermy, um, they couldn't hear it, they couldn't tell that it was activated, it was actually active all of the time. Thankfully, the diathermy itself was in the, um, in the quiver and protected. So, no patient harm came from that. But, um, you can see how easily the, the moving the table which went on top of the pedal and the fact that they had the volume turned down, if the volume had been turned up, it would have been really easy to pick up. So that was an, an, an interesting cluster of cases. Um This is a, a, an interesting case, uh, a patient who came in for in hernia repair under local anesthesia. Now, the surgeon who reported this, um, gave a bit of background and they'd had an event maybe AAA few weeks before I forget exactly when, whereby they'd um put their site mark too close to their incision and weren't happy about that. They, they didn't want the site mark to be so close to where they were incising. I think people worry about um the tattooing potential. Um There's a little caveat to that, but so on this occasion, they put the site mark much further away from the site as than they usually would. Um And then it had been covered up by the patient's clothes, uh, and the, um, went ahead and gave a local block because the patient was having local anesthesia. Um, on the incorrect side, thankfully, that got picked up before they put knife to skin and they didn't proceed and do a hernia repair on the wrong side. But the, the surgeon was really reflective er about the fact that they put their site mark in a different position intentionally trying to avoid a different problem but thereby causing another problem. Um I think it's worth saying here that I use um, official um, skin marker pens during hyper spad surgery. I'm not, you may not be familiar with that, but we use an awful lot of purple pen on the skin which then gets incorporated into the layers of the tissue as you do the repair, they do not tattoo. So I, I'd like to reassure you that um surgical skin marking pens don't tattoo. So it's important to make sure that you're using that kind of pen rather than anything else and hopefully that wouldn't be a problem. So the next case, I've actually given you a little bit of detail and I'm not sure if you can read this well enough. Um, but I think it's a relevant case for, for sort of surgeons in training, um, because I think it could potentially catch any of us out really. So a 25 year old lady, right, eye fossa pain, um diagnosed with appendicitis had a laparoscopic procedure and given postoperative antibiotics and went off home on day three. The histology report was not reviewed while she was in hospital, which I think is noteworthy. She came back in on day six. Perhaps it's not noteworthy actually, perhaps the report was never available. Um On day six, she was unwell fever high C RP pretty high, wasn't it? See, at 320 she had act which um identified an abscess and that was drained percutaneously. She was quite unwell and took a long time to recover, requiring TPN. Um for quite a while, did get better, but then went home um and came back to outpatients again, complaining of pain and had another CT scan performed which to everyone's surprise identified her appendix. And when they went back to the histology of the tissue removed at the first operation, it was evident then that um the appendix had not been removed. I suspect the whole um area was very, very inflamed, something was removed, it was fat, not an appendix. Um And perhaps the saddest thing here is that the previous ct scan had also show identified an appendix, but perhaps that hadn't been reflected in the report. I think that was on a retrospective review. So lots of things there. Uh The reporter gave us some comments of their own, um just noting really important um that uh it's, it sounds to me from the reporter's comments that, that perhaps a quite a junior surgeon was doing this procedure. It was perhaps more difficult than anticipated. Um, maybe they would have benefited from some assistance in theater. It's difficult to know, isn't it? Without a bit more detail there? But, um I think it's key, isn't it that the CT scan was misleading? Um The clinical information said, you know, appendicectomy. So probably on, on the report they wrote appendicectomy and didn't look closely enough, missed the fact that the appendix was there. But we've also got the factor that the histology department were sent an appendix that wasn't an appendix. And we don't really know what happened to that report. Um It reminds me of a time when a patient under my care, sadly, had an ultrasound scan which showed no blood flow in the testis, but nobody nn no sort of alert was given at the time and it was a couple of hours before that report was seen. Um, like is there some process whereby we can be alerted to unexpected findings? Yeah. And uh as as the reporter said, there, the hardest thing about appendicitis is often finding the appendix itself. So we, we get quite a few reports of miss appendicitis actually. Um And I won't um I won't dwell on that one too much, too much further, but you can see where the issues went wrong. Um Oh, sorry, I need to click on that one. I think this might be my last case. Um to discuss so that we have a little bit of time for, for chat. So I thought this one was quite interesting because it was about an emergency case. Elizabeth said emergency care was, was your preference? Um This case didn't actually take part place in the UK. We have a member of our advisory board who works overseas. So they've reported this one which may account for the slightly different processes that you pick up here. So, a fracture following a road traffic accident, DVT prophylaxis commenced on day two. You may argue that should have been sooner on day three. Just prior to her surgery, she developed chest pain and shortness of breath and was found to have a pe she was well, so she was um anticoagulated. Uh they still needed to, to repair, you know, fix her femoral fracture um and decided to place a temporary IVC filter. Um I'm no expert in the processes around managing DVTs and placing filters. So, um it was really crucial to have our advisory board breadth of knowledge when we discussed this case. Um And the lady went on to have her surgery that day, unfortunately, then developing pain in her back at which point they found out that the filter had become extravascular, which was quite troublesome for her and she needed quite a lot of pain relief afterwards. Um We had quite a mixed discussion about this about the fact that the DVT prophylaxis was perhaps delayed. Um did she need to have a filter put in or didn't she? And I think the feeling was UK practice would have not have been to put one in. So you can see how important it is to have a broad range of people on our advisory board when we're discussing these cases. Um The reporter made some comments to say that they felt that there was a problem during the placement of the um inferior vena cava filter and then it became evident that the product they used was new. Now, we don't know if it was completely new and completely different to their previous product or was it similar, er, or was it actually the same brand with just a slight variance? We don't have that information, unfortunately. Um, but you can see how important it is to know about new bits of equipment when they come into the hospital. Um, this lady's pain may have been prevented if, if that um release mechanism was familiar to the surgeons or the, the intervention radiologist placing that device. Um, now I said that was going to be my last case. Um I thought this one actually was pretty interesting too. So a patient referred in, I promise this will be the last one with groin pain and a tender inguinal hernia, um difficulty mobilizing seemed to be in pain, struggled to get onto the trolley. Um Surgical registrar examined them wasn't particularly impressed with the, with the hernia. So um sent them off for a CT because they were particularly tender. Indeed, there was a hernia on the CT and they decided that the patient warranted an urgent hernia repairer. And it was actually down to a, a very astute anesthetist who spotted that the patient's leg seemed short and rotated and questioned whether there might be a femoral neck of femur fracture there. And indeed on the CT scan, there was a femoral neck fracture present. Um And they abandoned the hernia repair feeling that the um femoral fracture was the cause of the problems. Although that's really interesting, isn't it? Confirmation bias? They were expecting the hernia to be the problem and there was a hernia and even though they have this doubt that the hernia was, was causing so many symptoms, um still, still got almost to the point where they repaired the hernia. It may not have done the patient any harm to have the hernia repaired, of course. Um But they still needed management of that fracture. Ok. So I am going to, I promise cut to the end because um we have lots of cases. Um I think it would be really important to just focus on, on this. I know I said this as well. You know, we've all been involved in things when things go wrong. Um And I love, I love this quote from Winnie the pooh. Do you want to talk about it? It's important not to not talk about these things or not, find some way of processing them. And just a, there are a few sort of useful resources out there that you can turn to. I mean, I like to think you'll be able to turn to talking to people be they more senior, be they your colleagues and peers. But this webinar, I sorry, this podcast I listened to myself recently and it was really good talking about that concept of doing something wrong and doing it and failing well or failing badly. One of the main people talking on that podcast has also um written a couple of books as well. So I'm gonna call it, call it to the end. Um We probably won't have time to discuss how we can make Corus better. But um if anyone ever wants to come back to me and give me feedback, please do Elizabeth knows has to contact me. Thank you very much and thank you too for our supporters, Axa Health being our primary supporter at current time. Thank you, Miss. That was really interesting as well. Obviously, as you mentioned, I've sort of been involved in a little bit with yourselves and as a surgical trainee who admittedly hadn't come across it and her and my trust before. And I found it really interesting and there's a different method to learning from our potential mistakes. Like you see, not, not all of them have to be mistakes as such. It could be a pre mistake that we're discussing. And so I would, I would say to any of you that are watching this, even if it's not something you've come across before to certainly go and have a look at it. It's certainly been eye opening for me. Now, I appreciate we've got about five minutes left on the time, um, that we had scheduled for this evening. Um, but there may, there may be more questions, questions than that question. The um if not, like Miss Corbett said, I'll be giving some details for both of our speakers um to our attendees later. I be at 10 like if need be all quiet. So perhaps perhaps people don't have any questions, any questions. Got a big echo, I'm afraid, but please do consider reporting some cases near misses even better. Do looks like we may have hold on. It looks like we might have here, right? So um skin marker pens, no, the ones we use um have been designed specifically to be compatible with our skin prep. Um So they do not rub off. Uh and they do not tattoo on my patients with hyperplasia. So I don't see why they would tattoo anywhere else. Um Perhaps if any doubt, go to the go to the company that makes the skin markers that you use. But as I say, ours, we use ones which are gray with a orange lid. They're made by Chloraprep because we use chop prep sticks. Um I mean, we use them primarily for sight marking because they don't rub off. Um, if there's no further questions at the moment, if I could just add not to continue my at all. But just a quick question, I did put up on the title that, um, uh, attending court. Um, so the, the, the two, the two instances, you may, well, two instances you may get called up either a coroner's court, which is a co course of fact, it's not, um, it's a fact finding, uh, call. Um, and you may be asked to attend, uh, a course of, um, there's been a civil, um, civil procedure going on. Um, but the report or sorry, the third one is, uh, where you're a witness of facts. So you've treated someone, for example, for an assault, a road traffic accident where there's been a litigation occurring. Um, really, um, I, I'll just reiterate what I said, it's really about keeping a good set of notes. So when you refer back to your notes, the report that you're asked for, it's either gonna be a fact, uh, or an expert with this, which you won't get involved with for a little while. Yeah, but as witness of fact goes, it's all really dependent on making sure 10 years down the line you can look back on it and like you really, um, uh, put down a really good account, logical account for if you can tell the story, story and put it, it's much easier. Yeah, I think I personally find that quite interesting. MRSA. You're talking about the, um, retrospective entry and notes? I must admit that, um, I've always been good at documenting that. It was a retrospective note entry but not, never why it was a retrospective note entry. And I suppose at the time, um, it's so obvious to you why you're writing in retrospect. But if you were asked 10 years later, oh, why didn't you document that at the time? If you've not documented it in the notes, the reason that would probably be quite easy to forget. Um Maybe if it's something straightforward, like a trauma call or something, it makes more sense. But from example of like surgical practice myself as a trainee, you sometimes get called to theater in the middle of seeing somebody and, um, and say, oh, I'll write it later when I get the CT report back or whatnot. Um I thought that was something that I'll definitely take forward into my practice and just to make a note of, oh, writing in retrospect because of this. And I did think that was quite a helpful, useful tip. But like you see, if you end up in court, it's something that'll be, you'll be glad you did. I imagine. I appreciate we're obviously coming to the end of our, our time everyone. But I must say thank you again for attending and thank you for the good feedback already we're receiving on the chat there. And if you have any other questions, please put them in the messages just now. Um Otherwise I may call it an evening, even get away. So, thank you again. You have been, I may well be in touch, by the way. No problem. You're good to talk. Thank you for the invitation. Elizabeth. Thank you for the invitation. Even. Have a nice evening.