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  1. Today
  2. Content Article
    Back to Our Purpose: The Reboot of Safety Partnering with Patients to Improve Diagnostic Safety Incorporating CPPS™ Certification into Academic Curriculum
  3. Event
    Cardiovascular disease (CVD) is one of the leading causes of morbidity, disability and mortality in England and a significant driver of health inequalities. It disproportionately affects people in deprived and ethnic minority communities and accounts for one-fifth of the gap in life expectancy between most and least deprived areas. The King’s Fund report, Cardiovascular disease in England, highlights the need to prevent and manage CVD. CVD accounts for one in four of all deaths in England. The yearly health care costs related to CVD are estimated at £7.4 billion with an annual cost to the wider economy of £15.8 billion. At a time when the NHS and social care workforce and finances are facing unprecedented and rising pressures, urgent comprehensive action across the public health, health and care sectors is needed to significantly reduce the adverse health impacts of CVD and associated workloads and costs. Leaders and experts from across the NHS and its partners will gather to discuss how best to prioritise and deliver services to reduce the prevalence of CVD and its risk factors across the population, and to improve early detection, management and treatment of CVD and its risk factors. Register
  4. Content Article
    "We want to be more supportive, compassionate and engaging to patients, their families and staff – and we’re going to improve how we learn from such incidents. This change is in line with NHS England’s Patient Safety Incident Response Framework (PSIRF), the new national policy. The framework supports a focus on understanding how and why incidents happen, rather than apportioning blame, to improve learning and make care safer. We want the public to help shape these changes and design our new approach to patient safety. If you would like to share any experience of having been involved in an investigation at Oxford Health in the past, or want to share your ideas for how things need to change, we would really like to hear from you. You can give feedback anonymously by completing this survey. The information will be used to inform how we improve. Also, if want to share your experience in more detail, please email patient.safety@oxfordhealth.nhs.uk – we can speak to you one-to-one or in group sessions, face-to-face to remotely."
  5. News Article
    The leaders of University Hospitals Birmingham (UHB) must acknowledge and seek to tackle the organisation’s pervasive bullying culture, and those who cannot may need to leave, the lead author of its patient safety review has warned. In an interview with HSJ, Mike Bewick said humility is required to address major cultural issues identified through conversations he had with senior medics and former employees. Professor Bewick’s overall view was that UHB was a “safe” place to receive care, but his team had been “disturbed” by consistent reporting of a bullying culture. Professor Bewick wrote in his report that even during his six-week review, initial goodwill from the trust had “dissipated”, adding his team has seen an organisation that is “culturally very reluctant to accept criticism”. Speaking to HSJ, he acknowledged there were people within UHB who do not accept cultural problems, adding: “I would hope they see the right thing to do is to accept [they] didn’t get everything right, to do a bit of mea culpa, have some humility, and move on. Because I don’t think there’s necessarily a place for people who can’t move on.” Read full story (paywalled) Source: HSJ, 28 March 2023
  6. Content Article
    Recommendations Keep the focus on patients: Co-design digital solutions with patients. Run electronic medicines product information (ePI) pilots to validate solutions within a variety of real-life settings and platforms, for example, hospital, community, NHS website and app. Work with patients, pharmacists and HCPs to identify digital ePI use cases, including use cases for HCP-facing medicines information and prompts for interacting with patients. Specifically focus on co-designing solutions for patients who have difficulty accessing information or who have particular needs, such as patients with cognitive or sensory differences, health literacy or digital literacy needs. Co-develop a digital-first approach to provide ePI, ensuring that no patient is left behind. Provide appropriate training for HCPs to help them identify health and digital literacy needs and proactively ensure alternative access where ‘digital exclusion’ is identified. Optimising the impact of technology by: Demonstrating trustworthiness through development of good governance, transparency, privacy and security. Focusing on defining the problem, gathering evidence, and conducting small tests of change. Explore working with NHS England to implement structured ePI and develop standards and funding for a sustainable digital model. Over time, making ePI an integral part of the digital health landscape so that technology providers can build innovative solutions which address the needs identified in this report – establishing the UK as a global leader in this arena. Supporting patients to make best use of ePI as it becomes available. With a multi stakeholder roadmap approach, evolving towards personalised medicines product information, connecting with the electronic health record. Ensure strong connections with regulation & policy setters: Review legislation and regulation to identify potential adaptation in support of patient and carbon-friendly digital first approaches. Strengthen the real-world evidence base to understand how medicines information impacts on patient activation, adherence and outcomes. Obtain government support at the highest level to implement these recommendations.
  7. News Article
    An inquest report into the death of a young boy who died at home in his sleep has called for health bodies to take action to prevent further deaths. Louis Rogers' death was initially categorised as Sudden Unexplained Death in Childhood (SUDC) but the report recorded febrile seizures contributed. The recommendations include: A greater emphasis on medical education, research and public information for sudden unexpected deaths associated with febrile seizures Referrals for assessment of febrile seizures should be undertaken earlier to exclude more severe underlying illnesses The NHS website and pamphlet given to parents and guardians following a child's febrile seizure should be updated to help assist them in picking up potential early indicators of a more severe illness "Robust national guidance" and education should be given to GPs so that timely referrals could be made A checklist should be provided for health practitioners so that a child was not given a misdiagnosis of a febrile seizure Records of all contact with health practitioners - including GPs and paramedics - should be available for all The recommendations were made to six health authorities: Royal College of Paediatricians, Joint Royal Colleges Ambulance Liaison Committee, National Institute for Health and Care Excellence (NICE), Royal College of General Practice, Royal College of Emergency Medicine and NHS England. Read full story Source: BBC News, 29 March 2023
  8. News Article
    People dying in the UK face “uncontrollable” pain and “unbearable suffering”, which palliative care alone cannot fix, according to the first evidence to a major new parliamentary inquiry asking if assisted dying should finally be legalised. In a shocking submission in favour of a law change, Molly Meacher told the Commons health and social care committee that the reality of end of life could include vomiting faeces, endless nausea and decaying tumours that smelled so bad they drove people out of hospital wards. People “are existing, they’re not living”, the crossbench peer and chair of the charity Dignity in Dying told the committee inquiry, which comes eight years after the House of Commons last considered changing legislation in 2015. Arguing strongly against any law change, Ilora Finlay, a crossbench peer and palliative care physician warned of the risk of “elder abuse” being worsened by a law change and said wider availability of palliative care, which remains patchy in the UK, must instead be a priority. Charles Falconer, a Labour peer and former Lord Chancellor, described the current situation, where dying people sometimes withdraw their own treatment rather than taking drugs to end their life, as “a mess”. He proposed that assisted dying should be available only to terminally ill people and not those facing “unbearable suffering”, as others have suggested. A diagnosis would be needed from two doctors plus approval from high court judge. “The bills that have been proposed [previously but defeated] say the person who decides to have an assisted death must have the capacity to make that decision,” he said. Read full story Source: The Guardian, 28 March 2023
  9. News Article
    Public satisfaction with the NHS has slumped to its lowest level ever recorded by the long-running British Social Attitudes survey. Just 29% said they were satisfied with the NHS in 2022, with waiting times and staff shortages the biggest concerns. That is seven percentage points down on last year and a drop from the 2010-high of 70% satisfaction. The poll - the gold standard measure of the public's view of the health service - has been running since 1983. A&E saw the biggest drop in satisfaction, but ratings for all services from GPs and dentistry to general hospital care fell. The fall in overall satisfaction was seen across all ages, income groups, sexes and supporters of different political parties. Read full story Source: BBC News, 29 March 2023
  10. News Article
    Mothers and babies are being put at risk because maternity services are still providing unsafe care, despite a series of scandals that have cost lives, the NHS ombudsman has warned. More tragedies will occur unless the health service takes decisive action to put an end to repeated and deeply ingrained problems which lead to “the same mistakes over and over again”, he said. Rob Behrens, the NHS ombudsman for England, voiced his concerns when he launched a report on Tuesday which details the failings several women experienced while giving birth. It also sets out the lessons the NHS needs to learn, but Behrens claimed that too many trusts were not doing so. Behrens voiced alarm that, although efforts have been made to improve the care mothers and their children receive, progress is too slow – and that means patients remain in danger. His report says that: “We recognise that people working in maternity services want to provide high-quality care. Culture, systems and processes can get in the way of achieving that goal. “But improvements are not happening quickly enough, and we have not seen sustainable change. We must do more to make services safer for everyone.” Read full story Source: The Guardian, 28 March 2023 Further reading on the hub: Patient Safety Learning - Mind the implementation gap: The persistence of avoidable harm in the NHS
  11. Content Article
    The National Safety Standards for Invasive Procedures 2 (NatSIPPs 2) are intended to share the learning and best practice to support multidisciplinary teams and organisations to deliver safer care. They consist to two inter-related sets of standards: Organisational standards – clear expectations of what Trusts and external bodies should do to support teams to deliver safe invasive care. Sequential standards – the procedural steps that should be taken where appropriate by individuals and teams, for every patient undergoing an invasive procedure. The flow chart below combines the NatSIPPs 2 sequential standards with the WHO Surgical Safety Checklist to provide a simple visual reminder tool for health and care staff. Its author is Nigel Roberts, Head Theatre Practitioner (Head of Nursing) at Birmingham Women’s and Children’s NHS Foundation Trust, and the flow chart was produced with support from Patient Safety Learning and Dr Annie Hunningher. Are you a healthcare professional interested in learning more about NatSIPPs? On the hub we host the National NatSIPPs Network, a voluntary group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. You can join by signing up to the hub today. When putting in your details, please tick ‘National NatSIPPs Network’ in the ‘Join a private group’ section’. If you are already a member of the hub, please email hello@patientsafetylearning.org.
  12. Content Article
    The review were assured that services at the Trust remain safe and patients and service users should continue to access care as needed with confidence. However, the review found a number of areas of concern, particularly with regards to governance and leadership, culture and staff welfare and has made a series of recommendations for further action. The review was commissioned following concerns raised in December 2022 relating to patient safety, leadership, culture and governance. As part of this response, NHS Birmingham and Solihull (ICB) announced three independent reviews focusing on: Patient safety and governance (Bewick Review) - commissioned by the ICB, overseen by experienced senior independent clinician, Professor Mike Bewick, former NHS England Deputy Medical Director. Well-Led review of leadership and governance – in conjunction with NHS England, using established methodology. Culture - commissioned externally by UHB’s Interim Chair, incorporating findings from above. In order to bring the conclusions and recommendations of these two pieces of work together and provide additional independent assurance, Professor Mike Bewick has been commissioned to support both remaining reviews and also return at a later date to update on progress on implementing the recommendations following this report. In the patient safety review, the independent review team set out two concerns and four groups of recommendations. As part of this, they also make clear that their ‘overall view is that the Trust is a safe place to receive care’. The review team have highlighted the need for better understanding of raised Hospital Standard Mortality Rates, concerns regarding levels of staffing, particularly nursing at Good Hope Hospital. The review also finds that ‘any continuance of a culture that is corrosively affecting morale and in particular threatens long term staff recruitment and retention will put at risk the care of patients’. This was supported by feedback from the Trust’s Medical Staff Committee. The review team make 17 recommendations (available in the full report) across clinical safety, governance and leadership, staff welfare and culture, including: Haemato-oncology: A specific review of mortality should be conducted by an external specialist in this field with support from a governance lead. The terms of reference should include: An independent retrospective review of all the deaths first analysed by Dr Nikolousis to establish any lessons learned Consideration as to whether there an outstanding DoC responsibility relating to this patient cohort All deaths in the year 2021/22 An assessment of how integrated the department is following the merger in 2018 with a focus on how leadership and accountability of the service currently functions. That prospective appointments of senior medical, nursing, and managerial leadership are reviewed with a focus on developing core skills, including those required for leadership, collaborative working methods, professional interaction, and disciplinary processes. In light of the tragic death by suicide of Dr Kumar - Together with HEE, a review of the processes to support doctors in training who are concerned about their mental health, ability to speak up freely about concerns with colleagues and a clear message that they will be listened to. That the concerns of senior clinicians, expressed by the Medical Staff Committee in January 2023, are addressed specifically as part of the Phase 2 cultural review. That the Trust commissions a partner to deliver awareness training on how to identify issues of bullying, coercion, intimidation and misogyny.
  13. News Article
    Repeated cases of bullying and a toxic environment at one of England's largest NHS trusts have been found in a review. The Bewick report was ordered after a BBC Newsnight investigation heard from staff at University Hospitals Birmingham (UHB) saying a climate of fear had put patients at risk. A first phase of the rapid review, headed by independent consultants IQ4U and led by Prof Mike Bewick, was published Tuesday. It is one of three major reviews into the trust, commissioned following a series of reports by Newsnight and BBC West Midlands in which current and former staff raised concerns. Summarising the findings, Prof Bewick, a former NHS England deputy medical director, said: "Our overall view is that the trust is a safe place to receive care. "But any continuance of a culture that is corrosively affecting morale and in particular threatens long-term staff recruitment and retention will put at risk the care of patients across the organisation - particularly in the current nationwide NHS staffing crisis. "Because these concerns cover such a wide range of issues, from management organisation through to leadership and confidence, we believe there is much more work to be done in the next phases of review to assist the trust on its journey to recovery." The West Midlands trust said it fully accepted the report's recommendations. Read full story Source: BBC News, 28 March 2023
  14. News Article
    A scandal-hit children’s mental health hospital will close months after an investigation by The Independent uncovered claims of poor care and systemic abuse. Taplow Manor hospital, in Maidenhead, was threatened with closure by the NHS safety watchdog, the Care Quality Commission, only last week if it failed to make improvements following a damning report. Active Care Group, which runs the hospital, confirmed it would close by the end of May, saying a decision by the NHS to stop admitting patients had rendered its “service untenable”. The move comes after an investigation by The Independent and Sky News heard from more than 50 patients who alleged “systemic abuse” by the provider, while Taplow Manor is facing two police probes – one into a patient death and a second into the alleged rape of a child involving staff. Read full story Source: The Independent, 29 March 2023
  15. Yesterday
  16. News Article
    Hospices will be forced to turn dying patients away because they are struggling with steeply rising costs at a time when the NHS is not increasing funding. Hospices look after 300,000 patients and families every year across the UK. It costs about £1.5 billion a year for them to provide this care, with only a third of that coming from the NHS. The rest relies on charitable donations and fundraising in local communities as well as sales in charity shops. As hospices battle to keep going, the Treasury has rejected pleas for a £30 million rescue package this year. The money, those in the sector say, would prevent some from having to close inpatient units and beds or reduce their hospice-at-home teams, which care for patients in the community. Some are already making staff redundant and getting rid of beds. Toby Porter, chief executive of Hospice UK, said the government was making “a huge avoidable mistake”, adding: “People will have a lesser experience at an incredibly important moment and it will lead to system pressures affecting the whole health system.” Read full story (paywalled) Source: The Times, 26 March 2023
  17. News Article
    “There’s a gap today that no locum filled, so I am carrying both bleeps and doing the work of two people.” That recent tweet, by a children’s doctor, is one of many examples posted on social media by medics illustrating how NHS staff shortages affect them, patients, the smooth running of important services – and, sometimes, the safety of those who are receiving care. It is a concern shared by every organisation that represents frontline staff, by regulators such as the Care Quality Commission (CQC), and by NHS England, the body that oversees the service. In January the CQC reported that an inspection it had undertaken of Colchester hospital in Essex found patients were missing out on meals because there were too few staff on duty to feed them. Some patients were wearing dirty dressings, and others did not have their call bells answered promptly, for the same reason. In a letter to the trust that runs the hospital, it said: “All wards’ actual staffing levels and skill mix meant staff were often overstretched. All staff we spoke with expressed concern about the impact on patient care and personal wellbeing. “Some staff we spoke to were tearful, reported feeling exhausted and concerned that they were unable to care for patients well enough to keep them safe.” Read full story Source: The Guardian, 26 March 2023
  18. News Article
    Last year the World Health Organization (WHO) released a report warning of a “ticking time bomb” threatening health systems in Europe and Central Asia: a growing shortage of health workers. With quickly ageing populations and an ageing health workforce—40% of doctors in Europe are close to retirement in a third of countries—along with a surge in chronic illnesses and the ongoing effects of the covid pandemic, WHO warned that many countries could soon see their healthcare systems collapse unless they take urgent action. Six months on, the situation has worsened, as healthcare workers throughout Europe increasingly resort to industrial action over pay and conditions. Hans Kluge, WHO regional director for Europe, said, “The health workforce crisis in Europe is no longer a looming threat—it is here and now. Health providers and workers across our region are clamouring for help and support... “We cannot wait any longer to address the pressing challenges facing our health workforce. The health and wellbeing of our societies are at stake—there is simply no time to lose.” Read full story (paywalled) Source: BMJ, 24 March 2023
  19. Event
    Baby Lifeline has announced that their fourth annual National Maternity Safety Conference will take place on Thursday 21st September 2023 at the Hilton Metropole Hotel in Birmingham. Once again it will be focussing on learning together for a safer maternity future, building on the overwhelming success of the previous three conferences. Baby Lifeline is always keen to showcase best practice in healthcare and are pleased to welcome poster presentation abstracts again this year. They are particularly keen to hear about maternity service quality improvement measures which speak to one or more of the following themes: Listening to families and staff Promoting safety culture Teamworking Reducing mortality & morbidity. Register
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