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  1. Today
  2. News Article
    More than one in four patients with severe mental health conditions are missing diagnosis when they are admitted to hospital for other reasons, new research suggests. According to data analysed by scientists at University College London, those who are missing these mental illness diagnoses are more likely to be from ethnic minority groups or have a previously diagnosed mental illnesses. However, the situation has improved – in 2006 it was found that mental health diagnoses were missed in more than 50% of cases. "We found encouraging signs that clinicians are more frequently identifying severe mental illnesses in hospital patients than they were a decade ago,” Hassan Mansour, a research assistant at UCL psychiatry, said. “But there's a lot more that can be done, particularly to address disparities between ethnic groups, to ensure that everyone gets the best care available. Training in culturally-sensitive diagnosis may be needed to reduce inequalities in medical care." The researchers have suggested these findings may be due to language barriers or stigma felt by patients. It was also suggested that clinicians may be less able to detect these conditions in people from other ethnic and cultural groups. Read full story Source: The Independent, 18 September 2020
  3. News Article
    NHS hospitals have been banned from launching their own coronavirus testing for staff and patients who have symptoms – despite a nationwide shortage in tests. Leaked NHS documents, passed to The Independent, show the Department of Health and Social Care (DHSC) has now capped funding for COVID-19 testing in the health service, even though the lack of tests has left hospital doctors, nurses, teachers and other key workers forced to stay at home. The diktat warned hospitals that, if they did choose to go ahead, the six figure costs would have to come from their own budgets. The warning was sent just a day after testing tsar Baroness Dido Harding admitted to MPs that demand for coronavirus tests is three to four times the number available. One senior NHS director told The Independent that NHS trusts had the ability to buy Covid-19 test capacity in local laboratories but now faced the risk of not getting the money to pay for it. They said: “This is just barmy at a time when we have cases rising and we need to get test results for staff and patients who are isolating at home waiting for results. Read full story Source: The Independent, 18 September 2020
  4. News Article
    A decision not to "urgently" refer an anorexic woman whose condition had significantly deteriorated contributed to her death, a coroner said. Amanda Bowles, 45, was found at her Cambridge home in September 2017. An eating disorder psychiatrist who assessed her on 24 August apologised to Ms Bowles' family for not organising an admission under the Mental Health Act. Assistant coroner Sean Horstead said the decision not to arrange an assessment "contributed to her death". Mr Horstead told an inquest at Huntingdon Racecourse that also on the balance of probabilities the "decision not to significantly increase the level of in-person monitoring" following 24 August "contributed to the death". In his narrative conclusion, Mr Horstead said it was "possible... that had a robust system for monitoring Ms Bowles in the months preceding her death been in place, then the deterioration in her physical and mental health may have been detected earlier" and led to an earlier referral to the Adult Eating Disorder Service. He said this absence "was the direct consequence of the lack of formally commissioned monitoring in either primary or secondary care for eating disorder patients". Read full story Source: BBC News, 17 September 2020
  5. News Article
    Tens of thousands of people avoided going to hospital for life-threatening illnesses such as heart attacks during Britain's coronavirus crisis, data has revealed. Shocking figures reveal that admissions for seven deadly non-coronavirus conditions between March and June fell by more than 173,000 on the previous year. Previous data for England shows there were nearly 6,000 fewer admissions for heart attacks in March and April compared with last year, and almost 137,000 fewer cancer admissions from March to June. Analysis by the Daily Mail found that the trends were alarmingly similar across the board for patients who suffered strokes, diabetes, dementia, mental health conditions and eating disorders. Health experts said the statistics were 'troubling' and warned that many patients may have died or suffered longterm harm as a result. Gbemi Babalola, senior analyst at the King's Fund think-tank said: "People with some of the most serious health concerns are going without the healthcare they desperately need. Compared with the height of the pandemic, the NHS is seeing an increase in the number of patients as services restart, and significant effort is going into new ways to treat and support patients." "But the fact remains that fewer people are being treated by NHS services." Read full story Source: Daily Mail, 13 September 2020
  6. Yesterday
  7. Community Post
    I know that trusts and CCGs have been contacted regard identifying patient safety specialists. Once these are established there will be nationally supported networks set up. I would guess patient safety specialists will have a role in supporting effective implementation of PSIRF
  8. Community Post
    And this got me wondering. Are there national or regional networks of Patient safety managers?
  9. Community Post
    Thank you @Jon Holt. Hadn’t realised they were publicly available
  10. Content Article
    This resource is intended to help leaders guide conversations with colleagues to: Provide and elicit needed information and problem-solving to ensure staff well-being and the best care possible Use this time during the COVID-19 pandemic to break unnecessary rules and build more robust systems Tap into creative solutions identified by staff for both immediate needs and in an ongoing way Promote joy in work through healthy relationships and environments that support teams and personal growth while diminishing, as much as possible, current and future stress In using this guide, leaders are encouraged to use any opportunity to frequently communicate with team members — using brief in-person huddles, electronic methods, or other approaches — to promote staff well-being.
  11. News Article
    Yesterday marked the second World Patient Safety Day, and this year’s theme shined a light on health worker safety – those on the frontline of the pandemic have been selfless in their sacrifices to care for an ailing global population. What has become ever clearer is that a health system is nothing without those who work within it and that we must prioritise the safety and wellbeing of health workers, because without safe health workers we cannot have safe patients. Improving maternity safety has been a priority for some time – although rare, when things go wrong the consequences are unthinkable for families and the professionals caring for them. Maternity negligence makes up 50% of the total value of negligence claims across all NHS sectors, according to the latest NHS Resolution annual report and accounts. It states there were claims of around £2.4 billion in 2019/20, which is in the region of £6.5 million a day. This cost says nothing of the suffering families and professionals associated. However, without investing in the maternity frontline we cannot hope to make integral systemic changes to improve maternity safety and save mothers’ and babies’ lives, writes Sara Ledger, head of research and development at Baby Lifeline in the Independent. "We owe it to every mother and baby to rigorously and transparently scrutinise the safety of maternity services, which will be in no small way linked to the support staff receive." Read full story Source: The Independent, 17 September 2020
  12. Content Article
    Key findings The survey results point to conclusions that seem to be equally applicable across different regions. Health workers in all countries need sufficient education and awareness to recognise and report workplace hazards. Workplace cultures must be improved to mandate appropriate reporting of hazards and to improve safety practices and especially to eliminate preventable bullying and harassment that can be intensified during an organisationally destabilising pandemic experience. The global health worker job market is very mobile like COVID-19, so lessons learned in one country or region must be translated to others. Economic classification, region, occupation and sex all play key roles in health worker’s perception of health and safety risk and mitigation measures in the workplace. Despite significant results across different demographic measures, the overall consensus of participants was clear. In spite of calls to action by the international community, risks to healthcare workers remain and mitigation measures are insufficient or in some cases nonexistent. These issues will continue to haunt the healthcare sector and will continue to exacerbate staff shortages globally. In the face of COVID-19 and its impacts on workplaces, it is also another reminder to the global health community to help those countries in need.
  13. News Article
    Patients who receive good perioperative care can have fewer complications after surgery, shorter hospital stays, and quicker recovery times, shows a large review of research. The Centre for Perioperative Care, a partnership between the Royal College of Anaesthetists, other medical and nursing royal colleges, and NHS England, reviewed 27 382 articles published between 2000 and 2020 to understand the evidence about perioperative care, eventually focusing on 348 suitable studies. An estimated 10 million or so people have surgery in the NHS in the UK each year, with elective surgery costing £16bn a year. A perioperative approach can increase how prepared and empowered people feel before and after surgery. This can reduce complications and the amount of time that people stay in hospital after surgery, meaning that people feel better sooner and are able to resume their day-to-day life. Read full story (paywalled) Source: BMJ, 17 September 2020
  14. News Article
    More than 1,500 breast cancer patients in UK face long waits to have reconstructive surgery after hospitals could not operate on them during the pandemic because they were tackling COVID-19. The women are facing delays of “many months, possibly years” because the NHS has such a big backlog of cases to get through, according to research by the charity Breast Cancer Now. When the lockdown began in March the NHS stopped performing breast reconstructions for women seeking one after a mastectomy as part of its wider suspension of care. That was because so many operating theatres were being used as overflow intensive care units and because doctors and hospital bosses feared that patients coming into hospital might catch Covid. The NHS started doing them again in July, but not everywhere and not in the same numbers as before. “We are deeply concerned by our finding that over 1,500 breast cancer patients may now face lengthy and extremely upsetting delays for reconstructive surgery,” said Delyth Morgan, the chief executive of Breast Cancer Now. “This will leave many women who want to have reconstruction with one breast, no breasts or asymmetric breasts for months, possibly even years.” Lady Morgan said: “Reconstructive surgery is an essential part of recovery after breast cancer for those who choose it. “Women with breast cancer have told us these delays are causing them huge anxiety, low self-esteem and damaged body confidence, and all at a time when the Covid-19 pandemic has denied them access to face to face support from healthcare professionals and charities.” Read full story Source: The Guardian, 18 September 2020
  15. News Article
    Accidents on maternity wards cost the NHS nearly £1 billion last year, Jeremy Hunt, the chairman of the Commons health committee, has revealed. The former health secretary said the bill for maternity legal action was nearly twice the amount spent on maternity doctors in England. It was part of the NHS’s £2.4 billion total legal fees and compensation bill, up £137 million on the previous year. Mr Hunt has also told the Daily Mail there is evidence that hospitals are failing to provide details of avoidable deaths despite being ordered to do so three years ago as he highlighted “appalling high” figures which showed that up to 150 lives are being lost needlessly every week in public hospitals. Responding to the figures, Mr Hunt said: "Something has gone badly wrong." In 2017, he told trusts to publish data on the number of avoidable deaths among patients in their care. But freedom of information responses from 59 hospital trusts, about half the total, found less than a quarter gave meaningful data on avoidable deaths. Mr Hunt cited “major cultural challenges” which he blamed for preventing doctors and nurses from accepting any blame. He blamed lawyers who get involved “almost immediately” once something goes wrong with a patient’s care. “Doctors, nurses and midwives worry they could lose their licence if they are found to have made a mistake. Hospital managers worry about the reputation of their organisation,” he added. Mr Hunt said: “We have appallingly high levels of avoidable harm and death in our healthcare system. We seem to just accept it as inevitable.” An NHS spokesman said: “Delivering the safest possible health service for patients is a priority, and the national policy on learning from deaths is clear that hospitals must publish this information every three months, as well as an annual summary, so that they are clear about any problems that have been identified and how they are being addressed. Read full story Source: The Telegraph, 18 September 2020
  16. News Article
    An investigation into the outbreak of a bacterial infection that killed 15 people has found there were several “missed opportunities” in their care. Mid Essex Clinical Commissioning Group has released the outcome of a 10-month investigation into a Strep A outbreak in 2019, which killed 15 people and affected a further 24. The final report was critical of Provide, a community interest company based in Colchester, as well as the former Mid Essex Hospital Services Trust (now part of Mid and South Essex Foundation Trust). It said: “This investigation has identified that in some cases there were missed opportunities where treatment should have been more proactive, holistic and timely. These do not definitively indicate that their outcomes would have been different.” Investigators found that 13 of the 15 people that died had received poor wound care from Provide CIC. They reported that inappropriate wound dressings were used and record keeping was so poor that deterioration of wounds was not recognised. Even wounds that had not improved over 22 days were not escalated to senior team members for help or referred to the tissue viability service for specialist advice, with investigators told this was often due to concerns over team capacity. The report, commissioned by the CCG and conducted by consultancy firm Facere Melius, said: “[Some] individuals became increasingly unwell over a period of time in the community, yet their deterioration either went unnoticed or was not acted upon promptly. Sometimes their condition had become so serious that they were very ill before acute medical intervention was sought”. Other findings included delays in the community in the taking of wound swabs to determine if the wound was infected and by which bacteria. It said in one case nine days elapsed before the requested swab took place. Even after Public Health England asked for all wounds to be swabbed following the initial outbreak, this was only conducted on a single patient. In other cases there were delays in patients being given antibiotics and this “could have had an adverse impact on the treatment for infection”. It also found that sepsis guidelines were not accurately followed, wounds were not uncovered for inspection in A&E, and some patients were given penicillin-based antibiotics despite penicillin allergies being listed in their health records. Read full story (paywalled) Source: HSJ, 17 September 2020
  17. Last week
  18. Community Post
    Great, thanks for that Jon, really helpful. MJ
  19. Event
    until
    The story of Alison Bell, and her family's uncovering of the truth about what happened to her in the care of an NHS Trust will be told by her brother Tom. He will describe the nature of the various investigations that were held into Alison's death and the role of the prevailing cultures within the public sector organisations they have dealt with; the NHS, Police, CPS and Regulatory Bodies. This true and ongoing story shines a light on the personal, emotional and financially costly impact that public sector service cultures can have on the lives of their service-users and their own bottom-line. Tom’s lived and current experience will help us to explore the implications for our own practice and the organisations we might seek to influence, manage and lead. Registration
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