Leadership & culture in healthcare

Leadership & Culture in Healthcare

Series 8 Finale: Shaun Lintern on Campaigns, Candour and Culture

Episode notes

Guest

Shaun Lintern, Health Editor, The Sunday Times. Twenty five years as a journalist, around fifteen of them as a specialist health investigative journalist. Previously at the Independent and the Health Service Journal. Began covering health after working as a local newspaper journalist in Stafford, where he worked with families exposing what became the Mid Staffs scandal.

Series 8 context

This episode closes Series 8, which featured families who turned personal tragedy into national campaigns:

● Jessie's Rule, with Andrew Brady, following his daughter's death

● Sepsis reform, with Melissa Mead, following the death of her son William

● Oliver McGowan's mandatory training, with Paula McGowan, following her son's death

Matthew also references John's campaign among the series' cases. This episode brings in Shaun Lintern as an investigative journalist who has covered these and comparable cases, to draw out the recurring themes across them.

Sequence of the conversation


Shaun Lintern's route into health journalism

Shaun Lintern describes himself as an “accidental health journalist”. He did not seek out the health beat and had wanted to cover crime or politics instead. He entered the field covering concerns raised about Stafford Hospital, working with affected families as a local reporter, and covering the subsequent public inquiry. That work led him into health journalism full time.

“I describe myself as an accidental health journalist in the sense that this was never a specialism that I was particularly seeking.”


Core ingredients behind scandals

Asked what causes organisations and individuals to make decisions with terrible consequences, Shaun identifies a recurring pattern rather than a single cause: failure to listen to patients and families, compounded by cognitive load on staff operating under pressure across finance, targets and understaffing. He describes this building into organisational drift, inward focus and, in some cases, pre-existing toxic behaviour.

“What it boils down to, I think, is really a failure to listen to the family and the patient.”

He distinguishes deliberate cover-up, which he says is rare in his experience, from what he calls accidental cover-ups: small early failures to be forthcoming that compound over time until the organisation can no longer move away from the story it has told itself, and has to be forced into the open by families, patients or journalists.

“By trying to avoid a scandal and a problem and admitting something went wrong, they almost actively create what they're trying to avoid.”

He locates responsibility at every level of leadership, not only the chief executive, extending down to ward and shift level.

Duty of candour: organisational and individual

Matthew raises the case of William Mead, where the organisation and integrated care board response became bound up in legal caution rather than transparency. Shaun Lintern responds that in his experience, families pursuing legal action are near universally seeking answers rather than compensation, and that NHS Resolution itself does not advise trusts against apologising and explaining.

“I don't think I've ever sat down with someone I've interviewed and they've not said to me, the only reason I'm taking this down the legal route... is because I want answers.”

He illustrates the alternative with an unnamed maternity case from his Health Service Journal years, where a trust engaged properly with a bereaved mother through the duty of candour process; the resulting story was, in his words, one of the few positive ones he has written.

On the distinction Matthew asks him to draw out: the statutory duty of candour introduced after the Francis Inquiry into Mid Staffs applies to organisations, not individuals. A trust must inform a patient or family when a serious or moderate harm incident occurs, and involve them in the investigation. Registered professionals (doctors, nurses) carry their own separate professional obligations of honesty, but there is no equivalent statutory duty on individual staff, something Lintern notes may change under proposed Hillsborough legislation. Breach of the organisational duty is a CQC regulatory matter, though enforcement and fines are described as comparatively light.

“An organisational duty only will only work if individuals in that organisation are following the same path.”


Personal reflections on not being listened to

Matthew shares that his father, aged 96, had stated he did not want active treatment, but found this treated as a negotiating position rather than a settled decision. Shaun Lintern shares that his mother died in November of motor neurone disease, diagnosed the previous March, and that he was her main care coordinator. He describes the clinical care itself as good wherever a clinician was directly engaged with his mother, with the recurring problem being coordination around her and around him as her advocate.

“We just were often not listened to by a lot of people and there was a lot of process.”


Taskification of care

Shaun Lintern raises what he describes, drawing on Professor Alison Leary's work, as the taskification of care: the risk that standardisation and protocol, while well intentioned, can reduce staff interaction with patients to completion of defined tasks rather than the wider observation and judgement that comes with fuller clinical roles. He connects this to the growing use of lower banded and support roles taking on tasks previously done by more senior staff.

“The patient doesn't care about that protocol and patients don't necessarily fit into these easy boxes.”

He is careful to also note that some poor care is not systemic but individual: he references Professor Mary Dixon-Woods' point that the NHS needs to be willing to discuss “bad apples” directly, rather than relying on the line that nobody comes to work intending to do a bad job.


Risk aversion in practice

Matthew connects this to organisational versus individual definitions of risk, citing Sheila O’Reardon of the Hospital at Home Society (“just because we can do something doesn't mean we should”) on respecting patient preference in frailty. Shaun Lintern illustrates with his mother's hospital admission for a PEG feed, planned as a three day stay, which extended to fifteen days because of sequential process dependencies (speech and language referral, dietician referral, and a scan requiring consultant sign off unavailable over a weekend) rather than clinical necessity.

“It was an aversion to risk which was keeping her in.”


Regulation of NHS managers

Matthew asks whether supporting clinicians and managers properly should sit within the same regulatory framework as clinical standards. Shaun Lintern argues for professional regulation of managers, framed primarily as training, standards and support rather than punitive striking off, referencing Tom Kark's review (Kark was chief counsel to the Mid Staffs inquiry) as a blueprint. He argues NHS trusts are large, complex organisations, in some cases with turnover exceeding a billion pounds, and that the current route into senior management is often accidental progression without structured training.

“The door staff on the local nightclub are more regulated than the chief executive of the local NHS Trust.”

He frames the punitive element (removing the worst performing managers) as a small, final part of a much larger programme of professionalisation, and says most chief executives he has spoken to would welcome a professional standard they could point to when challenged to act improperly.

Closing: grounds for optimism

Asked what gives him optimism, Shaun Lintern notes that his professional role is deliberately weighted toward scrutiny, not a representative account of the system as a whole. He points to strong front-line care, particularly in community settings (district nursing, ambulance service) and in genomics and clinical innovation, as reasons for confidence in the underlying system even while pressing for reform.

“There's a lot to be thankful for with the NHS... it could be so much better. And that's what motivates my journalism.”

Matthew closes by thanking the Series 8 guests: Chris Pointon, Andrew Brady, Melissa Mead, Julia Jones and Paula McGowan.

Matthew Winn, podcast host and an experienced leader in healthcare in the UK.

Paula McGowan is the mother of Oliver and the founder of the Oliver McGowan Mandatory Training on Learning Disability and Autism, now statutory across NHS England and social care. This episode is about her son Oliver, the clinical failures that led to his death in 2016, and how she turned grief into one of the most consequential patient safety campaigns in NHS history.

Oliver: Who he was

Oliver was born a month premature and at three weeks developed bacterial meningitis. Doctors did not expect him to survive. He did , but was left with mild cerebral palsy, and later diagnosed with autism and a mild intellectual disability. He played football for England, trained with Team Bath for the Paralympics, and loved museums, culture, and art. He had a formal advance decision on record: he was not to be given antipsychotic medication, based on catastrophic previous reactions.

"He was a huge advocate for people who were less able than himself. He really was a character full of life, full of tenacity, full of a determination to do and achieve the best that he ever could."

The failures:

In 2015, Oliver was admitted to a children's hospital with seizures. An antidepressant was prescribed, which, the family later learned, lowers the seizure threshold. Seizures increased. On readmission, an antipsychotic was given. Oliver's reaction was severe and frightening. He was transferred to a London hospital, then a mental health unit, transported without warning, in a black van, without his family.

"He was autistic. He didn't know these people. And yet he was transferred much like a criminal would have been, in a black van."

The psychiatric intensive care unit withdrew all medication quickly. Within days Oliver was home, training again, himself again. But months later, at an adult hospital in Bristol, the family came prepared, a hospital passport, documented history, explicit advance decision. They were not listened to. The antipsychotic was given again that night.

"I can still remember to this day them turning away as if we were not in the room."

Oliver developed neuroleptic malignant syndrome, a known side effect of the drug he had documented he must not receive. His brain swelled. He was left profoundly disabled. He died on 11th November 2016.

What was behind it: Diagnostic overshadowing

Paula never received a formal explanation. But she knows what she witnessed: clinicians seeing the disability before the person. Oliver was not displaying challenging behaviour, he was scared, anxious, talking repetitively, wanting to walk. His distress was human, not clinical. The community neuropsychiatrist who had met Oliver twice told Paula directly:

"Mum, you cannot be mum and doctor. You need to know your lane. You are mum. I am doctor."

Paula does not attribute this to malice. It was unconscious bias and a total absence of training in what autism and learning disability actually mean for a person in a clinical setting.

The campaign: From grief to legislation

After the inquest, the family moved to Australia. Walking through the bush, Paula told her husband she needed to start a parliamentary petition. She wrote it herself, joined social media from scratch, and began telling Oliver's story. She completed 64 presentations in eight weeks, all free, on her own time, visiting medical schools and nursing universities across the UK. She connected with Jane Cummins (then Chief Nursing Officer), health minister Caroline Dinenage, Baroness Sheila Hollins, and Sir Norman Lamb.

"It was about not pointing fingers. It was always about talking collaboratively about what could have been done better. I wanted to hear what they really thought and I wanted conversations."

Resistance came, mainly from some doctors. Name-calling, misrepresentation, defensiveness. Paula's response was consistent: rise above it, keep working collaboratively, bring people on the journey.

The training: Now in law

Oliver McGowan Mandatory Training is now statutory, embedded in NHS contracts, and has received 85% positive feedback described as unprecedented by government. The code of practice is explicit: lived experience must deliver the training; learning disability and autism must be taught separately. Amanda Pritchard completed both tiers herself. Ruth May and Duncan Barton have been consistent champions.

"It's now in legislation. It's in the NHS contracts. So we need to stop complaining that you've got to do it. It's how do we do it and how do we get on with doing that?"

Paula is direct about remaining gaps: the team is small, ICB funding must be tracked, and some providers are charging extortionate delivery fees when the answer is simpler local lived experience trainers, trusts collaborating, building internal capacity. The South West is leading the way.

Leadership: What actually makes the difference

"If you're going to be a leader, lead properly. Don't rely on middle management. Senior leaders need to get into the middle ground, be curious, ask questions, and stop being defensive."

She describes meeting a senior leader recently who did not know Oliver's training is in legislation. She sees too much information filtered out at middle management level, and too little genuine curiosity from the top. The tendency to "other" patients with learning disabilities to create a them-and-us, is the cultural problem that training alone cannot fix.

"We've got to move and evolve and try to be better. Because currently we're not better and we're getting it wrong. We have to question ourselves. As professionals, we have to question ourselves and say: what can we do better?"

The person behind the campaign

Matthew asks how Paula has led this campaign without anger or blame. Her answer is clear and characteristic.

"I see myself very much as Oliver's voice. I didn't want what happened to Oliver to change who I was as a person. I didn't want to become angry and bitter. And I know that Oliver wouldn't want to do that to me."

She keeps the specific act that ended Oliver's life compartmentalised not because accountability doesn't matter, but because she refuses to tar all clinicians with the same brush. And she is pragmatic: blame closes doors. Collaboration opens them.

"If we want to bring about real change, we've got to work together. Nobody deserves to have the finger pointed at them. If you do that people will walk away and they will not engage."

Further Quotes

"I almost cringe now when I hear families saying, 'I just want lessons to be learned.' Because I know those words are totally ignored. What are we actually doing to make real change?"

"Never allow an organisation to make you into something that you don't want to be."

"We can do this. Work together and we'll do it."

Links and resources:

• Oliver McGowan Mandatory Training: www.olivermcgowan.org

• NHS England — Oliver McGowan Training: england.nhs.uk/learning-disabilities/training/oliver-mcgowan-mandatory-training

• STOMP Campaign: england.nhs.uk/learning-disabilities/improving-health/stomp

Matthew Winn, podcast host and an experienced leader in healthcare in the UK.

Jess's Rule

Leadership and Culture in Healthcare | Series 8

Guest: Andrea Brady, mother of Jessica Brady and founder of the Jessica Brady Cedar Trust

Jessica's Story

Jess was 26 years old when she first became unwell, in the middle of the pandemic. Initial symptoms began with stomach problems, diagnosed remotely as a UTI without testing, her first course of antibiotics followed. Over the following months, Jess developed a persistent cough that made normal conversation difficult, forcing her to speak in a whispered voice. Further symptoms developed: post-nasal drip, morning vomiting, enlarged lymph nodes in the neck, significant weight loss, night sweats, and acute fatigue so severe that towards the end she struggled to get up to use the toilet. Jess was a radio frequency engineer who designed satellites ,organised, proactive, and very clear about knowing her own body. She didn't smoke, didn't drink, ate healthily and exercised, not a profile clinicians associated with serious illness.

“She was fractionally too old for young people's cancers.”

The Clinical Journey

Over five months, Jess contacted her GP surgery on 20 occasions. She was prescribed six courses of antibiotics, nasal sprays and steroids. She saw six different GPs at her surgery, never her nominated named GP. Of 20 contacts, only three resulted in face-to-face appointments. The diagnosis given was long COVID, despite Jess never having tested positive for COVID. Andrea attended one GP appointment with Jess and requested a referral to an ear, nose and throat specialist , the request was not granted. Jess pursued a private referral, leading to a biopsy of her lymph nodes. The result was secondary cancer, confirmed the following day via full body scan as stage 4 adenocarcinoma of unknown primary. The cancer had spread to her bones, lungs and liver. Jess died three weeks after diagnosis, aged just 27.

“It was horrible that she wasn't diagnosed and of course, I'm left and Jess was left with thinking, what if she had been listened to earlier?”

Andrea's Response — From Grief to Campaign

Andrea credits Jess herself as the reason the campaign exists, even while seriously ill, Jess wanted her GP practice to understand what had happened, not through litigation but through awareness. Andrea describes the concept of the doing cure — referenced from author Michael Rosen, who also lost a son, as the thing that kept her functioning through grief. Initially focused on what charity to support in Jess's name, Andrea quickly identified a gap: Jess was fractionally too old for young people's cancer charities, hadn't received Marie Curie support, and was too unwell to be treated in a hospice. The campaign petition, Jess's Rule, was launched one night after Jess died, focused on improving awareness and diagnosis of cancer in young adults. Hundreds of people contacted Andrea, making clear Jess was far from an isolated case.

“I don't think I would be here today and Jess's Rule wouldn't have been actioned if it hadn't been for Jess.”

“If I was going to function, I had to function with purpose.”

“She felt really strongly that she wanted her GP practice in particular to understand what had happened and what she'd gone through.”

Jess's Rule — The Campaign

The core principle: when a patient presents to their GP on a third occasion without resolution, their case should be elevated for review — symptoms investigated thoroughly and proactively, regardless of age or demographic. Andrea first raised this idea with Health Secretary Matt Hancock, as one of twelve points she brought forward. An oncologist at a Health Select Committee hearing confirmed this was historically known as "three strikes and you're in",old school training that had been lost. The petition launched in January 2021 and reached nearly half a million signatures by implementation. Andrea worked through multiple Health Secretaries during the campaign. A critical meeting with Wes Streeting in December 2024 led to a roundtable of experts to assess feasibility. Andrea worked closely with the Royal College of GPs and Claire Fuller from NHS England to shape how the rule would be implemented, listening carefully to clinical expertise while ensuring the nuance of Jess's experience was reflected. Jess's Rule was formally implemented in September 2025. It has since been introduced in the Isle of Man in March 2026, with interest from Scotland, Wales, Denmark, New Zealand and the United States.

“I began to carry the stories of other parents with me... I felt I was doing it for Jess, but then I felt I was doing it for so many other people who were diagnosed too late.”

The Jessica Brady Cedar Trust

The Trust was set up approximately nine months after Jess died, focused on primary care and early cancer diagnosis. It co-funded a learning module with the Royal College of GPs on early cancer recognition, and created its own learning module specifically on Jess's Rule for primary care clinicians, linked on NHS England's website. The Trust funded the printing and distribution of all Jess's Rule posters to GP surgeries at the point of implementation, and is supporting a three-year AI diagnostic tool project designed to sit within GP practices and help identify cancer earlier by drawing on patient-reported information.

What Gets in the Way — Barriers to Good Care

Unconscious bias plays a significant role, the assumption that a young, healthy, articulate person is unlikely to have something seriously wrong. Research cited in the episode notes that patients are interrupted on average within 17 to 23 seconds of speaking during a consultation. Unsubstantiated diagnoses embedding in patient records is another key barrier. Jess's long COVID coding carried forward to every subsequent GP, closing down further investigation rather than prompting review. Patients often feel anxious about wasting a doctor's time and may not say everything they need to say. Andrea is clear throughout that this has never been an attack on GPs: nobody intended to not diagnose Jess.

“There are two experts in the room — the medical expert who's had years of their training, and then there is the patient who's an expert in their own body.”

“It was never ever been an attack on GPs or doctors, because I absolutely know that nobody intended to not diagnose Jess.”

“Red flag is red flag, regardless of age and demographics.”

What Good Looks Like

GP surgeries emailing patients to declare their support for Jess's Rule. Answerphone messages acknowledging Jess's Rule when patients call for appointments. Surgeries writing to the Trust requesting additional posters for waiting rooms and consultation rooms. Doctors telling Andrea they thought of Jess mid-consultation and called a patient back. As Andrea says: "Jess is doing the job."

“I had a patient I saw recently and I thought of Jess and I brought them back in... Jess is doing the job.”

Looking Forward

Andrea's hope is that red flags are treated as red flags regardless of age or demographic, and that open-mindedness and a willingness to rethink an unsubstantiated diagnosis becomes embedded in everyday clinical practice. The central question she wants to see become routine is: what can I do to establish or rule out the worst case scenario at the earliest opportunity? With international interest growing and the Jessica Brady Cedar Trust's work continuing in primary care education and AI-assisted diagnosis, Jess's Rule is already saving lives and building a legacy worthy of the remarkable person it is named after.

“If it can just be something that open-mindedness to think again — that would be a really good legacy for Jess.”

Matthew Winn, podcast host and an experienced leader in healthcare in the UK.

In this episode, Matthew Winn speaks with Julia Jones, co-founder of John’s Campaign, a movement born from personal tragedy and grown into a powerful national force for the rights of family carers in healthcare settings. Julia shares the story that started it all the experience of her co-founder Nicci Gerrard’s father, Dr. John Gerrard, a man living well with Alzheimer’s who was admitted to hospital for a varicose vein procedure.

When a norovirus outbreak triggered a blanket visiting ban, his family, not understanding the devastating impact hospitalisation could have, stayed away. The consequences were swift and catastrophic. As Julia describes it, “he went in alert, mobile, smiling”, but within weeks he had lost his speech, his continence, his ability to eat. By the time Nicci got him home, “it was as if he’d gone over a cliff.” He died within six months.

The question that galvanised Julia and Nicci into action was a simple one: “If it had been one of our children in that hospital, would we have allowed ourselves to be turned away?” The answer was no and from that conversation, John’s Campaign was born.

Starting in 2014 with nothing more than a friendship, a story that needed telling, and a relationship with a newspaper editor, Nicci wrote a piece for the Observer about what had happened to her father. The response was overwhelming with reader after reader recognising their own experience.

“I thought it was just us,” was the refrain. It wasn’t.

The campaign’s founding principle is disarmingly simple: that family carers should be welcomed and supported in hospitals and care homes as partners in care, not treated as visitors to be managed. Julia recalls a pivotal insight from a director of nursing at Birmingham Children’s Hospital: “The point is to get the principle across. Once you’ve got the principle across, then you allow the professionals and the people on the spot to put that into practice in whatever way is best to their circumstances.” It’s a philosophy Julia says she has clung to ever since.

Before the pandemic, all acute hospital trusts in England had signed John’s Campaign pledges, with strong adoption across Wales, Scotland, and Northern Ireland, and growing momentum in the Republic of Ireland and beyond. But Julia is clear eyed about the limits of a pledge on a page: “When I look at that and I see they’ve all got exactly the same wording for their pledge, I think to myself, oh yeah, some kind of person has just… copy paste.” The real test, as Matthew puts it, is whether a carer arriving at a ward at nine o’clock at night is welcomed or turned away.

The pandemic set the campaign back sharply. The blanket bans on visits, particularly in care homes had devastating consequences for people with dementia and other vulnerabilities. Julia is unflinching about what was lost: “You can, as it were, die of a broken heart because you can simply give up the struggle to keep living.” The experience also exposed a harder truth, that some people, in some settings, relished saying no. Coming out of the pandemic, John’s Campaign shifted to advocate for something more formal: the legal right for any person admitted to hospital or a care home to be supported by one person who matters to them.

Julia’s own experience with her mother June, fiercely independent, terrified of hospitals, and ultimately allowed to die at home on her own terms, speaks to the heart of the campaign’s values. When a GP advised hospital admission near the end of her mother’s life, Julia produced their agreed care plan. The GP, she recalls, “visibly relaxed” and said, “I had to give you that advice. If your mother had been taken in, I expect we would have cured her infection and she’d be out again, but within a month she would be in again and the trauma in the meantime would have been extreme and damaging.”

That experience, of risk being understood not just as clinical risk but as the whole-person cost of a decision, runs through everything Julia and John’s Campaign stand for.

On what makes change happen, Julia is emphatic: “Leadership happens at all levels.” The places where John’s Campaign has worked best are those where someone, at any level of an organisation, has understood the principle and simply acted on it. What enables that is a culture where staff are trusted. As she puts it, a healthcare assistant needs to know “that your ward manager or your director of nursing or your chief executive officer is not going to come down a ton of bricks” if they use their judgement to welcome a carer in.

The best leaders, Julia says, set the frame and then get out of the way allowing “individual conversations, individual to individual” to happen, guided by a clear and shared principle.

Her closing thought is as direct as the campaign itself: “It’s encouraging all the people in your organisation to look at the people that they are there to treat and to care for and say - that’s somebody’s mum - That’s somebody’s daughter - That could be my mum. How would I want my mum to be treated?”

John’s Campaign continues as a voluntary, unfunded movement. To find out more or to make a pledge, visit the John’s Campaign website.
https://johnscampaign.org.uk/

To get in touch, email Julia Jones: julia@johnscampaign.org.uk and/or Nicci Gerrard: nicci.gerrard@icloud.com.

Matthew Winn, podcast host and an experienced leader in healthcare in the UK.

Episode two - series 8: Melissa Mead

In this deeply moving episode of Leadership and Culture in Healthcare, Matthew Winn is joined by Melissa Mead — parent, patient safety campaigner, and one of the most compelling voices for change in the NHS today.

Melissa’s story begins with her son William, a healthy, happy child who developed a cough shortly after starting nursery. Over six to seven weeks, the family visited their GP repeatedly as his condition worsened. Despite multiple contacts with out-of-hours services and 111, the sepsis William had developed was not recognised. Key observations were missed. As parents, they were not listened to. William died at home in 2014, just 17 days after his first birthday.

“The sepsis that he had developed wasn’t recognised. There were fundamental errors in his last visit to the doctor 36 hours before he died — and as parents, we weren’t really listened to.”

What followed was not only devastating grief, but a battle to understand what had gone wrong. Melissa describes being met with brick walls, emails unanswered, calls unreturned, and investigations carried out by organisations essentially marking their own homework. Reports came back saying nothing could have been done differently, yet Melissa knew that wasn’t true. She pushed back, questioned independent experts who weren’t truly independent, and persisted until a NHS England root cause analysis was produced, finding 16 failings in William’s care and four missed opportunities to save his life. The inquest concluded that he could have, and should have, been saved.

“I thought, who’s marked this homework? It very quickly dawned on me that organisations are essentially investigating themselves.”

Through all of this, Melissa articulates something important about what families actually need when things go wrong. She didn’t want revenge or litigation. She wanted a conversation. “All I wanted to do was sit down with those people that were involved and say — what happened? What went wrong?” That conversation eventually happened with the GP who had seen William on that final Friday. His first words to her were that William was the first thing he thought of in the morning and the last thing at night. It was, she reflects, what she had wanted from the very beginning, not punishment, but honesty, accountability, and the shared commitment to never let it happen again.

“If we had a culture where we could sit down in arbitration or mediation, rather than get to this very adversarial situation, I think there would be so many lives saved.”

What galvanised Melissa to campaign rather than retreat into grief was, in her words, simply William. After a long period of poor mental health following his death, she experienced a moment of clarity. “I felt like I heard someone say — it’s okay, Mummy, it’s okay. His death will not define you. His life defines who you are.” From that point, she understood that campaigning was her way of continuing to be his mum. “By sharing his death, I get to share his life.”

She joined the UK Sepsis Trust, then a small but clinically respected charity and helped thrust sepsis into the national spotlight. She met then Health Secretary Jeremy Hunt, who apologised to her when she met him in Parliament. Her response was direct - “The best apology is changed behaviour.”

The episode also explores the broader leadership and culture lessons Melissa has drawn from her experience working across NHS organisations. She is unflinching about what she sees in organisations that aren’t working well — command and control leadership, staff who feel invisible, targets prioritised over people, and a hierarchy that leaves those who spend the most time with patients feeling the least valued.

“There’s never going to be learning when the leadership team are not leading by example. Leaders need to be visible, approachable, supportive rather than punitive — focused on listening and learning.”

She uses a vivid analogy to challenge where blame lands when things go wrong: if a delivery driver’s van has broken brakes and someone is hurt, is it the driver’s fault or the company’s for failing to maintain the vehicle? The same logic applies in healthcare. When staff are unsupported, under pressure, and working in a culture of fear, mistakes become systemic, not personal.

“When that person does make a mistake, is that their fault or is it the culture in which they work?”

Melissa is equally clear about what good leadership looks like in practice and what the most important question any leader can ask is: “What can I do to best serve you?” That, she says, is what leaders should be saying to staff, and what staff should be saying to patients.

Looking forward, Melissa is genuinely optimistic. The UK Sepsis Trust now has a seat at the table that it spent a decade fighting to earn, and a new national Modern Service Framework for Sepsis has been agreed by government. She hopes it will bring consistent standards across all settings, not just acute care, but primary care and the community and lead to real reductions in mortality.

“A decade ago, we were fighting to get a seat at the table. Now we’ve got a seat at the table because they understand that we are a respected organisation in that space.”

She closes with a message that is simple, human, and one that every person working in healthcare would do well to hold onto: “Just listen. Just be kind, just be human and just remember how you want to be treated.”

References and links to organisations:

UK Sepsis Trust

The charity Melissa works with — information on sepsis, clinical tools, support for those affected, and campaign resources.
https://sepsistrust.org

Sepsis Modern Service Framework — UK Sepsis Trust

Detail on the newly agreed government framework for sepsis that Melissa references in the episode.
https://sepsistrust.org/sepsis-modern-service-framework/

NHS England — Patient Safety Incident Response Framework (PSIRF)

The framework Melissa references as PSIRF — the NHS approach to responding to patient safety incidents with compassionate engagement at its heart.
https://www.england.nhs.uk/patient-safety/patient-safety-insight/incident-response-framework/

NICE Sepsis Guideline (NG51)

The national clinical guideline for recognition, diagnosis and early management of sepsis across all care settings.
https://www.nice.org.uk/guidance/ng51

NHS — Sepsis information for patients and public

Public-facing NHS information on sepsis signs and symptoms.
https://www.nhs.uk/conditions/sepsis/

Martha’s Rule — NHS England

Referenced in the episode — the right for patients and families to request an urgent review if they are concerned about deterioration.
https://www.england.nhs.uk/patient-safety/marthas-rule/​​​​​​​​​​​​​​​​

Matthew Winn, podcast host and an experienced leader in healthcare in the UK.