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  1. Today
  2. Community Post
    We have seen some of this practice here - omitting the night before ERCP or biopsies and sometimes the evening after. I can't think of a good reason for omitting any prophylactic doses around the time of ERCP and the practice has been challenged.
  3. News Article
    The Royal College of Psychiatrists (RCPsych) is calling on MPs to consider serious concerns about the Terminally Ill Adults (End of Life) Bill for England and Wales, ahead of the pivotal Commons Report stage debate and Third Reading. With too many unanswered questions about the safeguarding of people with mental illness, the College has concluded that it cannot support the Bill in its current form. RCPsych is once again sharing its expert clinical insight to support MPs in making informed decisions ahead of the debate in Westminster on Friday 16 May 2025. During the Committee stage of the parliamentary process, the College raised questions about the assessments of the coordinating doctor and independent doctor, and is now raising further questions about the multidisciplinary panel (which would include a psychiatrist) being proposed by the Bill. Dr Lade Smith CBE, President of the Royal College of Psychiatrists, said: "After extensive engagement with our members, and with the expertise of our assisted dying/assisted suicide working group, the RCPsych has reached the conclusion that we are not confident in the Terminally Ill Adults Bill in its current form, and we therefore cannot support the Bill as it stands. "It’s integral to a psychiatrist’s role to consider how people’s unmet needs affect their desire to live. The Bill, as proposed, does not honour this role, or require other clinicians involved in the process to consider whether someone’s decision to die might change with better support. "We are urging MPs to look again at our concerns for this once-in-a-generation Bill and prevent inadequate assisted dying/assisted suicide proposals from becoming law." Read press release Source: RCPsych, 13 May 2025
  4. News Article
    Health trusts have repeatedly tried to prevent coroners from issuing Prevention of Future Death reports in order to protect their reputations, an inquiry has heard. Deborah Coles, director of the charity Inquest, told the BBC the "reprehensible" behaviour was a pattern "played out across the country" but was "exemplified" in Essex. She gave evidence at the Lampard Inquiry, which is looking into the deaths of more than 2,000 people being treated by NHS mental health services in Essex between 2000 and 2023. In her evidence to the inquiry, Ms Coles said the "lack of candour" on the part of mental health trusts in Essex was the reason a statutory public inquiry needed to be held. "It's difficult to say how traumatising that is for families when they sit in at an inquest… and then see legal representatives try and effectively stop a coroner from making a Prevention of Future Deaths report, external, which is ultimately about trying to safeguard lives in the future - and I find that reprehensible," she said. "We are talking here about trying to protect lives and also remember those who've died where those deaths were preventable." Read full story Source: BBC News, 13 May 2025
  5. News Article
    Family doctors in England are deeply divided on the issue of assisted dying, BBC research on plans to legalise the practice suggests. The findings give a unique insight into how strongly many GPs feel about the proposed new law - and highlight how personal beliefs and experiences are shaping doctors' views on the issue. BBC News sent more than 5,000 GPs a questionnaire asking whether they agreed with changing the law to allow assisted dying for certain terminally ill people in England and Wales. More than 1,000 GPs replied, with about 500 telling us they were against an assisted dying law and about 400 saying they were in favour. Some of the 500 GPs who told us they were against the law change called the bill "appalling", "highly dangerous", and "cruel". "We are doctors, not murderers," one said. Of the 400 who said they supported assisted dying, some described the bill as "long overdue" and "a basic human right". It comes as MPs will this week again debate proposed changes to the controversial bill, with a vote in parliament expected on whether to pass or block it next month. If assisted dying does become legal in England and Wales, it would be a historic change for society. Read full story Source: BBC News, 14 May 2025
  6. News Article
    The government is abolishing NHS England without a clear plan for how it will be achieved and how it will benefit frontline care, a cross-party group of MPs has warned. Ministers announced in March that the body responsible for overseeing the health service in England would go, with its functions brought into the Department of Health and Social Care. But the Public Accounts Committee said it was concerned about the uncertainty being caused and urged the government to set out a clear plan within the next three months. The government said the move would eliminate "wasteful duplication" and that detailed planning had started. Alongside the changes at a national level, the 42 local health boards responsible for planning services are also having to shed around half of their 25,000 staff. Committee chair and Tory MP Sir Geoffrey Clifton-Brown said the changes to NHS England and local health boards amounted to a major structural reform. He said strong decision-making and experienced staff would be vital to manage a period of "huge pressure" for the NHS. "It has been two months since the government's decision to remove what, up until now, has been seen as a key piece of machinery, without articulating a clear plan for what comes next – and the future for patients and staff remains hazy," he added. Read full story Source: BBC News, 14 May 2025
  7. News Article
    The NHS’s total liabilities for medical negligence have hit an “astounding” £58.2bn amid ministers’ failure to improve patient safety, an influential group of MPs have warned. The Commons public accounts committee (PAC) said the “jaw-dropping” sums being paid to victims of botched treatment and government inaction to reduce errors were “unacceptable”. The Department of Health and Social Care (DHSC) has set aside £58.2bn to settle lawsuits arising from clinical negligence that occurred in England before 1 April 2024, the PAC disclosed. “The fact that government has set aside tens of billions of pounds for clinical negligence payments, its second most costly liability after some of the world’s most complex nuclear decommissioning projects, should give our entire society pause,” said Sir Geoffrey Clifton-Brown, the PAC chair. “This is a sign of a system struggling to do right by the people it is designed to help,” he added. The PAC urged ministers to take urgent steps to reduce “tragic incidences of patient harm” and to also end a situation where lawyers take an “astronomical” 19% of the compensation awarded to those who are successful in suing the NHS. That amounted to £536m of the £2.8bn that the health service in England paid out in damages in 2023-24 – its record bill for mistakes. “Far too many patients still suffer clinical negligence which can cause devastating harm to those affected,” and the ensuing damages drain vital funds from the NHS, the report said. Read full story Source: The Guardian, 14 May 2025
  8. Community Post
    Hi Alex I haven't heard of that, as far as I know, it can go ahead 12 hrs after thromboprophylaxis.
  9. Content Article
    The work of the Department of Health and Social Care (DHSC) and its organisations touches the lives of an average of 1.7 million patients per day and costs the UK taxpayer around £187.3 billion per year. This report presents the Public Accounts Committee’s analysis of the DHSC Accounts for 2023/24. The Public Accounts Committee is a Select Committee in the House of Commons that examines value for money of Government projects, programmes and service delivery. This report highlights a number of issues of concern, including the two areas highlighted below. Abolition of NHS England The Committee points to several issues where it believes further clarity is required from the Government in this respect: The lack of a clear plan for how DHSC and NHS England will achieve significant headcount reductions, and the costs involved. How the reductions fit in with the wider 10 Year Health Plan for the NHS. How savings made from reducing NHSE staff costs help frontline services. How the institutional knowledge of NHSE would be preserved following its abolition. The scale of headcount reductions in the DHSC, and the geographical spread of the planned 50% headcount reductions in NHSE and across local Integrated Care Boards. Clinical negligence The Committee has expressed disappointment in this area and stressed the need for significant improvements, stating that: “Both patients and public money need to be better protected by the Department. Far too many patients still suffer clinical negligence which can cause devasting harm to those affected. It also results in large sums of public money being spent on legal fees and compensation, drawing resources from the wider health service.” Concerns it highlights include: £58.2bn has been set aside to cover the potential cost of clinical negligence events in the latest accounts – the second largest liability across government after nuclear decommissioning. 19% of money awarded to claimants in 2023-24 goes to their lawyers (£536m of the total £2.8bn paid that year), on top of the fees payable for the Government Legal Team. It recommends that within six months, DHSC should set out a plan with clear actions to: Reduce tragic incidences of patient harm to as low a level as possible Manage the costs of clinical negligence more effectively, including introducing a mechanism to reduce legal fees. Improve patient safety across the NHS and in particular in maternity services
  10. Content Article
    At the beginning of 2025 we launched our video interview series Speaking up for patient safety. The series is hosted by Peter Duffy, NHS whistleblower and Chair of the Healthcare Working Group at WhistleblowersUK, and Helen Hughes, Patient Safety Learning’s Chief Executive.  In each interview we hear from someone who has raised concerns about patient safety in healthcare, often at great cost to their own career and personal life. They share their story and their reflections on what needs to be done to improve organisational cultures so that when staff raise patient safety issues, their concerns are responded to appropriately and not dismissed because they are inconvenient to address. Alongside the thread of bravery and tenacity that runs through each contributor, a number of common themes come up time and again as people share their experiences. In this blog, Helen and Peter look at some of these themes and outline their implications for people who speak up or whistleblow. We are now three months into the series, which seems like a good time to stop and reflect on what we have learned so far. Our introductory blog about ‘Speaking up for patient safety’ explains why we launched the series and what we hope it will achieve. It also explains in more detail what we mean when we talk about speaking up and whistleblowing. Briefly, speaking up in healthcare is when a member of staff raises concerns about something that is worrying them to a manager or someone else within, or outside of, their organisation. In some cases—but not all—when someone speaks up, it is also defined as ‘whistleblowing’. Whistleblowing always involves a concern that is in the public interest and might relate to a criminal offence, health and safety risks, failures to carry out legal obligations, a miscarriage of justice, or an attempt to conceal and cover up any of these things. Three key themes from the interviews so far These are the top three recurring themes we have noticed coming up in the interviews so far. Other issues we have noticed include the lack of clarity about who should take responsibility for whistleblowing and the reality of threats and bullying, and we will continue to explore these issues going forward. 1. “I didn’t realise I was speaking up, I was just doing my job!” Perhaps the comment we have heard most frequently is that people didn’t realise they were formally speaking up or whistleblowing—they just thought they were doing their job. Every healthcare profession has a set of professional standards which all practitioners are expected to keep to. For example, the General Medical Council (GMC) states that all doctors have a duty to take action by raising concerns if they believe patient care or safety are at risk.[1] In addition, each healthcare organisation has a code of conduct, which will include requirements for staff to be honest, open and accountable for their work. For the interviewees we spoke to, to not raise their concerns would be a failure to fulfil their duty to both their patients and their organisation. When people speak up, they often find themselves in the middle of a process that they had no idea they were entering. This can be very disorientating and leave them unprepared for the path ahead of them. At the end of this blog, we share some advice from our interviewees about what to do if you find yourself in this position. 2. There is a whistleblowing ‘playbook’ Most organisations have policies and support in place to listen to staff members who raise concerns, including access to a Freedom to Speak Up Guardian. We have interviewed Jayne Chidgey-Clark, the National Guardian, who described the good practice that many are developing. However, we are hearing about several common tactics that some organisations use when dealing with people who speak up or blow the whistle. The experiences of our interviewees suggest that these approaches may be deliberately designed to disadvantage the individual throughout the process—from investigation through to employment tribunals. Some of the key activities we have heard about include: Organisations not responding—or responding at the very last minute—to communications from the staff member. Interviewees said they received emails with key information at 5pm on a Friday, which left them with no opportunity to ask questions or respond until the next working week. They expressed their belief that this may be a deliberate tactic to exert pressure on the individual speaking up, which amounts to emotional bullying. The use of occupational health as a way to cast doubt on the mental state of the person. Occupational health providers are often very supportive, but we are concerned that organisations are fishing for reasons to question the believability and motives of staff who speak up. Over-focus on HR issues, rather than focusing on the patient safety issues someone has raised. Mandated isolation from colleagues while investigations take place. This can have a very damaging effect on the person’s mental health as well as restricting their ability to source evidence from other staff in support of the concerns they have raised. We have heard examples of colleagues agreeing to provide supportive testimony, but then feeling pressurised to withdraw this support. Retaliatory referrals against the person speaking up to professional regulators, such as the General Medical Council and Nursing and Midwifery Council, which can have a detrimental effect on a healthcare professional’s reputation and career. Regulators are aware of how such referrals can be used to intimidate whistleblowers and discourage them from raising concerns. Some have approaches to ensure that fitness to practice concerns are appropriately addressed without unfairly impacting doctors who have raised whistleblowing concerns. We believe it is important to identify and call out these tactics so that people raising concerns are aware of them and can seek support and advice. Organisational leaders need to look at their own practice and recognise the ethics of their approaches and whether their actions match their stated organisational values. They need to be aware of the significant damage these tactics cause to people who raise concerns and the chilling impact it might have on their organisational culture, effectively preventing others’ raising concerns. 3. Employment tribunals are unfit, unfair and imbalanced Every person we spoke to who had attempted to pursue justice at an employment tribunal commented that the process was unfit for purpose and not the right place for whistleblowing cases to be heard. Employment tribunals take no interest in the safety issues being raised. The main issue we keep hearing is that the tribunal system is weighted in favour of whichever side has the most financial resources—which will almost always be the employer. A single individual who has lost their employment can rarely succeed against the millions of pounds that organisations are willing to spend on highly specialised lawyers who have tried and tested ways of winning. The playbook we identified above also runs into employment tribunals, with whistleblowers reporting: The employer and their legal advisers withholding key documents, and emails, minutes, notes and other vital information going missing. Key witnesses, often in senior leadership positions, being unable to recall events. Receiving last minute threats from their former employer to come after them for costs and often being given a limited time to consider signing a non-disclosure (NDA) to settle a case. If rejected, often the NHS organisation will seek the full costs from the whistleblower, including expensive external legal costs and internal staff costs, which can amount to thousands of pounds—few whistleblowers can afford to take this financial risk, even if they and their advisers think they have a strong case. Advice from our interviewees if you find yourself speaking up Reflecting on their experiences, our contributors have made some observations about how you can protect yourself when speaking up, should the issue escalate. Try to resolve issues locally first. This is not always possible, but if a concern can be raised and dealt with within a team or with a manager, in some cases this will prevent the situation from escalating to a formal process. Keep a record of concerns and events as they happen. This means you will have some facts and clear observations to refer back to, if the situation does escalate. Don’t go to meetings alone. Take a trusted colleague with you so that every conversation is witnessed. Get your union involved if you are called to meetings about your concerns or receive counter-complaints or accusations. Regulation of NHS managers Some of the interviewees highlighted that regulating NHS managers may be a potential means of tackling some of these issues. The Department of Health and Social Care recently held a public consultation on proposals that could see managers who use misconduct to silence whistleblowers barred from working in the NHS. Patient Safety Learning has formally responded to the consultation, stating that there is a clear case for the regulation of NHS managers, for the protection and benefit of both staff and patients. Everyone in healthcare should be honest and transparent when something goes wrong. Patient Safety Learning’s response expressed support for a professional register of NHS managers and the requirement for individuals in NHS leadership to have a professional duty of candour. These measures would be a positive step in increasing accountability for healthcare organisations in how they respond to staff raising patient safety concerns. But this is only one part of a much wider set of changes needed—significant cultural change also needs to take place in tandem with these reforms. Staff across many organisations are still afraid to speak up, as indicated by the most recent NHS staff survey results. Thank you to our contributors, and an invitation to get involved We’d like to take this opportunity to express our gratitude again to each person who has been willing to share their experiences and insights with us—it can be very difficult to retell traumatic events that have changed the course of your life. We are also aware that there are many other individuals who have experienced unjust treatment because they have spoken up for safety. If that’s you, thank you for your commitment to standing up for safe, ethical care. We invite everyone with experience in this area to contribute to this vital conversation. We would particularly like to hear from: Allied health professionals. Staff from Black and minority ethnic backgrounds Staff in non-clinical roles such as administration. If you would like to share your story, you can: Contribute to our community conversation (you’ll need to sign up first). Comment on any hub post (you’ll need to sign up first). You can find information about organisations that offer support and guidance for staff about speaking up and whistleblowing on the hub. Watch the interviews Helené Donnelly Martyn Pitman Jayne Chidgey-Clark Gordon Caldwell Bernie Rochford Beatrice Fraenkel References General Medical Council. Professional Standards: Raising and acting on concerns about patient safety, 13 December 2024
  11. Yesterday
  12. News Article
    Should health systems tell patients when they’re using AI? UC San Diego Health says yes. The health system uses a generative AI tool from Epic that drafts MyChart patient portal messages for providers. But UC San Diego Health notifies patients when the responses are drafted by AI with the disclosure: “Part of this message was generated automatically and was reviewed and edited by [name of physician],” according to a May 9 NEJM AI article. Members of the organisation’s AI governance committee debated whether it was necessary, as providers use other documentation shortcuts and generative AI could elicit concern from patients, but ultimately came to the same conclusion. “Transparency is necessary, as AI-assisted replies may stand out to patients — especially if they differ from clinicians’ usual communication style,” wrote the authors, UC San Diego Health Chief Medical Information Officer Marlene Millen, MD, Professor Ming Tai-Seale, MD, and Chief Clinical and Innovation Officer Christopher Longhurst, MD. Lack of transparency “could lead to patients questioning the authenticity of the replies, potentially damaging the crucial doctor-patient trust,” the authors wrote. “With tens of thousands of physicians nationwide using AI to support patient communication, now is the time to begin transparent disclosure.” Read full story Source: Becker's Health IT, 12 May 2025
  13. Content Article
    In this podcast, Ricky Tenchavez shares his journey of implementing Scan4Safety at Doncaster and Bassetlaw NHS Trust. Discover how his clinical background and focus on staff engagement proved crucial to success, transforming initial resistance into enthusiastic adoption. Learn practical strategies for change management, from comprehensive staff training to building a champions network, and hear how the trust achieved rapid rollout across 28 theatres through effective communication and continuous support for staff. You can view some of the resources Ricky developed here scan4safety.nhs.uk/how-clinical-en…undation-trust/ Visit the Scan4Safety website scan4safety.nhs.uk/ A transcript of this episode is available.
  14. Content Article
    The global nursing workforce has grown from 27.9 million in 2018 to 29.8 million in 2023, but wide disparities in the availability of nurses remain across regions and countries, according to the State of the World’s Nursing 2025 report, published by the World Health Organization (WHO), International Council of Nurses (ICN) and partners. Inequities in the global nursing workforce leave many of the world’s population without access to essential health services, which could threaten progress towards universal health coverage (UHC), global health security and the health-related development goals.  The new report released on International Nurses Day provides a comprehensive and up-to-date analysis of the nursing workforce at global, regional and country levels. Consolidating information from WHO’s 194 Member States, the evidence indicates global progress in reducing the nursing workforce shortage from 6.2 million in 2020 to 5.8 million in 2023, with a projection to decline to 4.1 million by 2030. But, the overall progress still masks deep regional disparities: approximately 78% of the world’s nurses are concentrated in countries representing just 49% of the global population.   Low- and middle-income countries are facing challenges in graduating, employing and retaining nurses in the health system and will need to raise domestic investments to create and sustain jobs. In parallel, high-income countries need to be prepared to manage high levels of retiring nurses and review their reliance on foreign-trained nurses, strengthening bilateral agreements with the countries they recruit from.   
  15. Content Article
    Corridor care is increasingly being used in the NHS as demand for emergency care grows and hospital departments struggle with patient numbers. In a series of blogs for the hub, we shine a light on some of the key patient safety issues surrounding corridor care. Corridor care can broadly be defined as care being provided to patients in corridors, non-clinical areas or unsuitable clinical areas because of a lack of hospital bed capacity. Documenting the experiences of more than 5,000 nursing staff, a recent report from the Royal College of Nursing has set out in stark terms how corridor care has become normalised in the NHS. Almost 7 in 10 (66.8%) of those surveyed said they were delivering care in over-crowded or unsuitable places. More than 9 in 10 (90.8%) of those surveyed said patient safety is being compromised. Corridor care has now become so normalised that in September 2024 NHS England published new guidance setting out principles for providing safe and good quality care in what it describes as ‘temporary escalation spaces’ (TES). Key patient safety concerns At Patient Safety Learning we will continue to raise awareness of the significant patient safety concerns relating to corridor care, including: Delayed treatment. Inadequate monitoring. Compromised infection control. Patient dignity not being supported. Relatives not being able to support patients who may not otherwise be closely monitored. Moral injury and impact on staff delivering poor standards of care. Manual handling safely. Trip hazards and obstructions. Blocked evacuation routes in the case of fires of other major incidents. Corridor care blogs In a series of blogs for the hub, we shine a light on some of the safety concerns surrounding corridor care. The crisis of corridor care in the NHS: patient safety concerns and incident reporting On the 16 January 2025, the Royal College of Nursing (RCN) published a new report presenting the findings of a survey of nursing staff outlining the extent of corridor care across the UK. This blog sets out Patient Safety Learning’s response to this report. The crisis of corridor care in the NHS: patient safety concerns and incident reporting In this blog, Patient Safety Learning’s Director Clare Wade reflects on the challenges that growing prevalence of corridor care poses to reporting and acting on patient safety concerns in the NHS. How corridor care in the NHS is affecting safety culture: A blog by Claire Cox Patient Safety Learning’s Associate Director Claire Cox looked at how corridor care within the NHS is affecting safety culture and examined its implications for both healthcare professionals and patients. Corridor care: are the health and safety risks being addressed? Patient Safety Learning’s Associate Director Claire Cox writes about the associated health and safety risks, questioning whether these are being properly addressed. Claire draws out key areas for consideration and suggests practical measures that can help protect patient safety in such challenging working environments. A nurse's response to the NHSE guidance on their principles for providing safe and good quality care in temporary escalation spaces In this blog, an anonymous nurse reflects on the recent NHS England (NHSE) guidance on the use of "temporary escalation spaces" and why this is so far removed from 'work as done' on the frontline. A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift In this anonymous account, a nurse shares their experience of corridor nursing, highlighting that corridor settings lack essential infrastructure and pose many safety risks for patients. They also outline the practical difficulties providing corridor care causes for staff, as well as the potential for moral injury. Using the System Engineering Initiative for Patient Safety (SEIPS) framework, they describe the work system, the processes and how that influences the outcomes. Share your insights Do you have experience of corridor care either as a patient or a healthcare professional? What impact have you seen on patient safety? You can comment below (sign up here for free first) or email the editorial team at [email protected]
  16. Content Article
    The Parkinson’s Excellence Network have released a series of resources to support UK healthcare professionals in hospitals to improve the delivery of time critical medication for people with Parkinson’s. Parkinson's UK time critical medication dashboard. The new dashboard estimates the benefits of improving time critical medication management for people with Parkinson's in hospitals in England, Scotland and Wales. The dashboard estimates the direct cost for hospitals and impact on patient outcomes of delayed or missed medication doses. Audit and awareness: how staff at Hexham General Hospital improved the delivery of time critical medication. This case study details how a staff nurse's dissertation led to an increase in Parkinson's medication delivered on time on a ward at Hexham General Hospital. Webinar: Driving improvement on time critical Parkinson's medication. In February our fully subscribed webinar included a session on practical benchmarking against the 10 recommendations. Watch the webinar recording and read the Q&A document now. Time critical medication patients' stories: in their own words. In these new short films, people with Parkinson’s share their experiences of receiving their Parkinson's medication in hospital and how this impacted on their health and well being. These films have been developed to raise awareness and support education and training of health professionals. Read more in the latest time critical medication blog by former nurse Patsy Cotton. Access all of the time critical medication resources.
  17. News Article
    A surgeon found to have left patients in "agony" after using artificial mesh to treat prolapsed bowels faces allegations he falsified medical notes. Tony Dixon was suspended after the surgery was found to have caused harm to hundreds of patients at two hospitals in Bristol. Now, a new hearing will examine Dr Dixon's records. He is accused of dishonestly creating patient records long after he was involved in their care, something he "strongly denies". The Medical Practitioners Tribunal Service (MPTS) will begin Monday. It will examine claims medical records for seven patients contained false information, and were not created at the correct time. A spokesperson for Dr Dixon said: "[He] always endeavoured to provide the highest standard of care to his patients. "He strongly disputes falsifying any medical records and will provide his detailed evidence about those serious allegations to the tribunal, initially by way of a detailed witness statement which he has provided to the General Medical Council." Read full story Source: BBC News, 12 May 2025
  18. News Article
    People from minority ethnic backgrounds in the most deprived areas of England are up to three times more likely to need emergency treatment for asthma than their white counterparts, analysis has found. Analysis of NHS statistics conducted by the charity Asthma and Lung UK found that Asian people with asthma from the most deprived quintile in England are almost three times more likely to have an emergency admission to hospital than their white counterparts. Black people with asthma in the most deprived quintile are more than twice as likely than their white counterparts to be admitted to hospital. People with chronic obstructive pulmonary disease (COPD) aged between 45 and 54 in the most deprived quintile are nine times more likely to be admitted as an emergency than those in the least deprived quintile, according to the analysis. Sarah Sleet, the charity’s chief executive, said the figures highlighted “shocking health inequalities in our society”. Sleet said: “The UK has the worst death rate in Europe for lung conditions and they are more closely linked to inequality than any other major health condition. The fact that people from the most deprived communities and from ethnic minority backgrounds are much more likely to reach crisis point is yet another wake-up call. “Social disadvantages – including poor housing, mould, damp and air pollution – can both cause chronic lung conditions and make them worse. And it’s the poorest in society and those in ethnic minority communities who are more likely to be living in low-quality housing and in areas with high levels of air pollution.” Read full story Source: The Guardian, 12 May 2025
  19. News Article
    Thousands of people in a mental health crisis are enduring waits of up to three days in A&E before they get a bed, with conditions “close to torture” for those in such a distressed state. At one hospital, some patients have become so upset at the delays in being admitted that they have left and tried to kill themselves nearby, leading nurses and the fire brigade to follow in an attempt to stop them. A&E staff are so busy dealing with patients seeking help with physical health emergencies that security guards rather than nurses sometimes end up looking after mental health patients. The findings are included in research by the Royal College of Nursing. Its leader, Prof Nicola Ranger, called the long waits facing those in serious mental ill health, and the difficulties faced by A&E staff seeking to care for them, “a scandal in plain sight”. The RCN’s research into “prolonged and degrading” long stays in A&E also disclosed that: Some trusts that previously had no long waits for mental health patients now have hundreds. The number of people seeking help at A&E for mental health emergencies is rising steadily and reached 216,182 last year. The recruitment of mental health nurses has lagged far behind the rise in demand. The number of beds in mental health units has fallen by 3,699 since 2014. Rachelle McCarthy, a senior charge nurse at Nottingham university hospitals NHS trust, said: “It is not uncommon for patients with severe mental ill health to wait three days. Many become distressed and I totally understand why. I think if I was sat in an A&E department for three days waiting for a bed I would be distressed too.” Read full story Source: The Guardian, 13 May 2025
  20. News Article
    Vulnerable patients at a struggling A&E died or needed intensive care after their needs “were not met” while being cared for in corridors and waiting areas, inspectors have warned after an unannounced inspection. The Care Quality Commission has raised concerns about how some of the “most vulnerable patients” were being treated in temporary escalation spaces at the Royal Cornwall Hospital in Truro, according to a document published in board papers this month. NHSE has said systems should “consider reporting the number of patients” in temporary escalation spaces, which include corridors or makeshift wards. Its guidance followed the broadcast of a Channel 4 documentary that included scenes of patients being neglected in corridors in the Royal Shrewsbury Hospital. Published CQC reports have since raised concerns about corridor care, but senior figures told HSJ the findings at the Royal Cornwall were among the most severe of this kind. The inspectors said one 96-year-old woman in a temporary escalation space died following a fall and staff “were unaware of the risk of falls due to lack of verbal handover”. Another patient “with a history of delirium” suffered a fractured collarbone from a fall in the same area of the hospital. In another case, an incontinent patient was transferred to a “fit to sit” area but by the end of the day “had deteriorated and was in intensive care”. The CQC’s letter said: “We were concerned the most vulnerable patients were not having their needs met when cared for in a temporary escalation space. “We weren’t assured that every ward is accounting for additional patients in the temporary escalation areas in terms of staffing numbers and skill mix.” Read full story (paywalled) Source: HSJ, 13 May 2025 Further reading on the hub: Corridor care: are the health and safety risks being addressed? The crisis of corridor care in the NHS: patient safety concerns and incident reporting A nurse's response to the NHSE guidance on their principles for providing safe and good quality care in temporary escalation spaces
  21. News Article
    A Northern Ireland nurse failed to properly manage a dying patient's pain on the last night of her life, a tribunal has heard. Veteran staff nurse Bernard McGrail has been issued with a four-month suspension order over his failings in dealing with an end-of-life care resident while on a night shift at a Spa Nursing Homes Group facility in July, 2021. A Nursing and Midwifery Council fitness to practice panel said Mr McGrail's misconduct had caused "emotional distress" to the family of the woman, identified as Resident A. It added: "There was a real risk of harm to Resident A through the inadequate management of their pain on their last evening." A remorseful and apologetic Mr McGrail admitted a series of allegations including: a failure to appropriately manage Resident A’s pain; failure to investigate whether Resident A’s syringe driver was working correctly and a failure to escalate that the alarm on Resident A’s syringe driver sounded repeatedly. Mr McGrail also admitted that without clinical justification, he administered a 5mg doses of Apixiban to Resident B on three dates on October 2020. And on occasions between April 2020 and May 2022 failed to administer and/or record the administration of named medications to six other residents. Read full story (paywalled) Source: Belfast Telegraph, 12 May 2025
  22. News Article
    A former health ombudsman has condemned mental health services for their handling of two vulnerable young men who died in their care. Sir Rob Behrens, who was parliamentary and health service ombudsman (PHSO) from 2017 to 2024, spoke at the Lampard Inquiry, which is examining the deaths of more than 2,000 people under mental health services in Essex over a 24-year period. Sir Rob said it was "a disgrace" how Essex Partnership University NHS Foundation Trust (EPUT) had failed in its care of 20-year-old Matthew Leahy, who died in 2012, and a 20-year-old man referred to as Mr R, who died in 2008. "This was the National Health Service at its worst and needed calling out," Sir Rob said. Sir Rob referred in his inquiry appearance to several reports made during his tenure, including "Missed Opportunities", which looked into the circumstances surrounding the deaths of Mr Leahy and Mr R. Mr Leahy was found unresponsive at the Linden Centre in Chelmsford. He reported being raped there just days before he died. Sir Rob told the inquiry the PHSO identified "19 instances of maladministration" in Mr Leahy's case by North Essex Partnership University NHS Foundation Trust - a predecessor to EPUT - including that his care plan was falsified. The former ombudsman said there had been "a near-complete failure of the leadership of this trust, certainly before it was merged" with South Essex Partnership Trust to become EPUT. "This was an indictment of the health service," he added. Read full story Source: BBC News, 6 May 2025
  23. Content Article
    In June 2023 the Secretary of State for Health and Social Care announced that HSSIB would undertake a series of investigations focused on mental health inpatient settings. This overarching report brings together and explores cross-cutting patient safety risks across five individual investigations. The aim of this report is to examine patient safety risks identified across the following HSSIB investigations: Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of suicide risk and safety planning (12 September 2024) Creating conditions for the delivery of safe and therapeutic care to adults in mental health inpatient settings (24 October 2024) Mental health inpatient settings: out of area placements (21 November 2024) Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s mental health services to adult mental health services (12 December 2024) Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge (30 January 2025) Findings Safety, investigation, and learning culture There remains a fear of blame in mental health settings when safety events happen. This contributes to a more defensive culture despite staff actively wanting to learn. Many recommendations to support learning for improvements in mental health care do not lead to implemented actions. Reasons for this include a lack of impact assessment resulting in unintended consequences, no clear recipient involved in the development of recommendations, and duplicated recommendations across organisations. System integration and accountability The integration of health and social care within an integrated care system currently relies on relationships, with an expectation and hope that they will work well. However, where this is not the case, a lack of clear accountability can result in poor outcomes for people with mental illness and severe mental illness. The delivery of care for people with mental illness and severe mental illness is challenging because health and social care services are not always integrated and their goals are not always aligned. Physical health of patients in mental health inpatient settings There are gaps in the provision of physical health care for people with severe mental illness, including inconsistent health checks, poor emergency responses, and misattribution of physical symptoms to mental illness. The misattribution of physical symptoms to patients’ mental health was observed and had the potential to contribute to worsened patient outcomes. National reports, strategies and research have made recommendations to improve the physical health of people with severe mental illness. However, there is evidence that recommendations are delayed in implementation and people continue to die prematurely. Integrated care boards lack the required data and the necessary analytical capability to assess disparities in access, experience and outcomes related to the physical health needs of people with severe mental illness. There is variation in how the physical health checks are carried out on mental health inpatient wards, with limitations in processes for following up on patients’ physical health needs. There is variation in the knowledge, skills and experience of staff who undertake physical health checks and in the environments in which these checks take place. Patients may not always be supported in terms of health education about their physical health risks and modifiable risk factors, for example smoking, dietary advice and physical activity. Caring for people in the community Integrated care boards cannot consistently draw reliable insights from data at national, system or local level, to optimise and improve services, patient care, and outcomes across mental health pathways of care. This results in variability in service provision which does not always meet the needs of individual patients or local populations. Inpatient ‘bed days’ are taken up by people who no longer need them, because people who are clinically fit for discharge are delayed in being transferred to their home or a suitable residence (appropriate placement). Reasons for delayed discharges include issues with housing support and establishing suitable accommodation. This means patients are not always in the right place of care. Barriers to discharge affect patient flow and may result in delays in admission for people with severe mental illness. This means they have to be cared for in a community setting while waiting for an inpatient bed. There is variation across the country in how drug and alcohol services are provided. The variation does not allow for fair and equitable treatment for all patients. Community services are vital to support people to stay as well as possible and to prevent hospital admissions. However, there is variation in community service provision across the country. Staffing and resourcing Staffing and resource constraints in inpatient and community mental health settings impact their ability to provide safe and therapeutic care. In inpatient settings, constraints contribute to mental health wards aiming to staff for ‘safety’ but not always for ‘therapy’. Challenges for staff include the emotionally demanding nature of their work; this can lead to staff burnout and sickness, and further strain on services. There are gaps in mental health workforce planning, particularly in community services where there is no evidence based workforce planning tool to support a standardised staffing establishment setting model. Digital support for safe and therapeutic care A lack of interoperability or integration between digital systems affects the provision of care across mental health, acute and community providers. Challenges in securing appropriate funding impacts on the ability of hospitals to integrate and update their digital services and infrastructure. Electronic patient record functionality is often not available or does not meet staff needs, and so it is not used. Examples include absent functions for food and fluid balance monitoring and risk assessment of venous thromboembolism (blood clots). Challenges in providing and maintaining patient-facing technology, for example televisions and payphones, impacts on the therapeutic environment and the ability of patients to maintain contact with families and loved ones. Where technology for monitoring patients had been introduced, implementation has required considerations to ensure it is used appropriately, is patient-centred, maintains therapeutic engagement, and supports patients to feel safe. Suicide risk and safety assessment ‘Doing’ tasks, like ‘ticking’ checklists, overshadow meaningful, empathetic ‘being’ interactions with patients. Open, compassionate conversations that build trust and therapeutic relationships, enabling patients to own their risk while feeling supported, can help mitigate this. Investigation processes can contribute to a fear of blame, and subsequently contribute to defensive practices such as checklists and a ‘tick box’ culture. This inhibits open and honest conversations and the ability to put the patient, as their authentic self, at the heart of them. Safety recommendations HSSIB recommends that the Department of Health and Social Care continues to work with the ‘recommendations but no action working group’ and other relevant organisations, to ensure that recommendations made by national organisations specific to mental health inpatient settings are reviewed. This work should consider the mechanisms that supported or hindered the implementation of actions from these recommendations. This may help the Department of Health and Social Care understand what has worked when implementing actions from recommendations and enable learning about why some recommendations have not achieved their intention. HSSIB recommends that the Secretary of State for Health and Social Care directs and oversees the identification and development of a patient safety responsibilities and accountabilities strategy related to health and social care integration. This is to support the management of patient safety risks and issues that span integrated care systems. Safety observation National bodies can improve patient safety in mental health inpatient settings in England by supporting provider investment in equipment, digital systems and physical environments to enable conditions within which staff are able to provide, and patients can receive, safe and therapeutic care.
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  25. News Article
    The Academy for Healthcare Science (AHCS) has announced that Stage 1 of the Honorary Fellowships 2025 is now open. The AHCS Honorary Fellowships set up in 2016 to recognise the work, vision, support and input individuals who have supported AHSC in theirdevelopment and growth, in one or more of the below key areas: To the formation, development, running or ideals and standards of the AHCS. To the promotion and development of key aspects of Healthcare Science. In areas relating to Healthcare Science and your help in promoting the professions and raising public awareness of Healthcare Science In providing excellence in UK healthcare in your capacity as Presidents of Royal Colleges, medical journalists, civil servants, manufacturers, etc. Nominations are received and reviewed by the Honorary Fellows Nominations Group and their recommendations submitted to the Professional Council for approval. Eligibility criteria for an individual to be considered for Honorary Fellowship are an outstanding contribution: a) To the formation, development and operation of the AHCS and/or b) To the development and delivery of Healthcare Science in the UK. International nominations can be considered if the contribution has influenced the delivery of healthcare science in the UK and/or c) To the significant promotion within the profession and/or in raising public awareness of the contribution of Healthcare Science in the UK and/or d) By individuals who have worked for the AHCS, either as staff members or in a voluntary capacity. Read more Source: AHCS.
  26. Content Article
    WHO champions patient-centred health care, where patients and their families shape health care decisions. Watch this video to learn about how engaging patients may help to ensure patient safety.
  27. Content Article
    An estimated one in every 10 patients experience harm in health care facilities, and each year, there are more than three million deaths globally due to unsafe health care. Most of the patient harm is preventable, with patient and family engagement being one of the most important strategies for reducing harm. This video shows how listening to the voices of patients, families and caregivers can lead to safer health care for all.
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