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A request for compensation or even the prospect of litigation should not automatically bring the complaints process to a halt. In many cases, the complaint investigation serves a different purpose to legal proceedings by identifying what happened, addressing any failings and demonstrating openness. Keeping those processes separate, while ensuring the investigation does not prejudice any legal case, is often the most balanced approach. It can also help reassure boards that continuing a fair and well-documented complaints investigation is about good governance and organisational learning, not admitting liability. Ultimately, a thorough complaints process can benefit both the organisation and the person raising the concerns, regardless of whether legal proceedings follow.

This is an important area of research. From our experience at Serene Soul Care, providing home carer services, we often see how timely assessment and appropriate referral can make a significant difference for people, particularly older adults receiving care at home. With initiatives like Pharmacy First, there's a growing need for accurate point-of-care UTI diagnostics that support faster decision-making and appropriate antibiotic prescribing. I'm also interested in evidence around patient experiences, costs, and current care pathways in community pharmacies and primary care. If anyone can recommend recent studies or real-world data on this topic, I'd be grateful.

The Chartered Institute of Ergonomics and Human Factors (CIEHF) would like to better understand the landscape of Human Factors/Ergonomics (HF/E) in healthcare in the UK. Our aim is to support better use of, and integration of, HF/E into the healthcare environment. In order to do this, they want to understand the current picture - how many people work in an HF/E related job? How many work in NHS trusts/private hospitals? What sort of roles do they do? Etc. Please complete this survey. It should only take a maximum of 5 minutes to complete. Human Factors & Ergonomics In Healthcare - UK ONLY survey Please feel free to share this with anyone who you think might be relevant. This includes health and safety and manual handling roles. Responses are anonymous and CIEHF will not collect your personal data. Thank you, The CIEHF Team Deadline: 12th July 2026

Digital health technologies have transformed many aspects of healthcare, from electronic health records and telemedicine to remote patient monitoring and AI-assisted decision support. While these innovations have the potential to improve patient outcomes, many healthcare professionals also report challenges such as alert fatigue, increased documentation, and workflow disruptions. I'm interested in hearing from others working in healthcare: Which digital health tools have had the biggest positive impact on patient safety in your organisation? Have you experienced situations where technology created new risks or made clinical workflows more complicated? What strategies have helped balance innovation with usability for frontline staff? How can healthcare providers ensure that digital transformation genuinely supports clinicians rather than adding administrative burden? It would be great to hear real-world experiences, lessons learned, and examples of digital solutions that have successfully improved both patient safety and efficiency.

Thanks @Jules I've used AI to summarise this. Will watch the full presnetation too! “Can improvement and innovation save the NHS?” by Professor Mary Dixon-Woods Below is an AI generated concise summary report of the video “Can improvement and innovation save the NHS?”, a keynote by Professor Mary Dixon-Woods published by THIS Institute in May 2026. The lecture argues that improvement and innovation can help the NHS, but only when they are evidence-based, realistically implemented, attentive to inequality, and supported by well-functioning organisations rather than treated as universal solutions in themselves.[1][2] Executive summary The lecture presents a sober assessment of current NHS performance across access, timeliness, quality, effectiveness, and equity, using examples such as elective delays, cancer treatment delays, unwarranted variation in diabetes and breast cancer care, and persistent inequities in maternity outcomes. Professor Dixon-Woods argues that these problems are not simply deficits of effort or goodwill, but symptoms of deeper organisational, policy, and system design failures that limit the impact of improvement work.[2] Her central message is that innovation and improvement are necessary but insufficient unless they are grounded in evidence, matched to context, and protected from hype, overclaiming, and poorly designed large-scale programmes. She cautions that the NHS has often adopted interventions with excessive optimism, weak evaluation, and inadequate attention to implementation, creating cycles of enthusiasm followed by disappointment.[2] Main arguments The lecture identifies several core challenges facing the NHS: care is not consistently accessible, timely, high quality, effective, or equitable, and these deficits vary substantially by geography, deprivation, ethnicity, and sex. Examples cited include falling public satisfaction, persistent elective backlogs, non-compliance with guidance in some diagnostic testing, and marked disparities in maternal mortality and severe morbidity.[2] A major theme is that variation should not be dismissed as inevitable background noise, because it often indicates remediable organisational weakness, uneven capability, or failure to apply existing knowledge reliably. The lecture also highlights the continued use of some low-value activity alongside failures to deliver proven beneficial care, showing that both underuse and overuse coexist in the NHS.[2] Improvement lessons Professor Dixon-Woods argues that improvement succeeds least when it is treated as a slogan, a centrally imposed programme, or an assumption that any change is inherently beneficial. She emphasizes that large-scale initiatives often fail when they are oversold, under-specified, weakly evaluated, and inattentive to frontline realities, staffing pressures, and competing operational demands.[2] The lecture supports a more disciplined model of improvement: test interventions properly, understand mechanisms, use robust evidence, and distinguish genuinely effective innovation from attractive but weakly evidenced ideas. In practice, this means improvement should be designed as serious applied inquiry rather than as advocacy, branding, or policy theatre.[2] Governance implications For board and governance audiences, the lecture implies that oversight should focus not only on performance outcomes but on the organisational conditions that make safe and effective improvement possible. These conditions include the ability to identify risk early, hear uncomfortable information, respond to variation, evaluate change honestly, and sustain attention on inequity as well as aggregate performance.[2] The talk is particularly relevant to patient safety governance because it links poor outcomes to structural and cultural issues rather than isolated individual failings. It therefore supports governance approaches that emphasise system surveillance, speaking up, learning capability, and critical scrutiny of improvement claims before scale-up.[2] Actions for leaders A practical reading of the lecture suggests five priorities for NHS leaders and boards: · Treat major improvement claims as propositions requiring evidence, not as self-validating solutions.[2] · Target unwarranted variation as a governance signal of uneven quality and possible safety risk.[2] · Examine inequity explicitly, especially where deprivation, ethnicity, sex, or geography are linked to worse outcomes.[2] · Avoid adopting innovations at scale without credible implementation planning and evaluation.[2] · Strengthen organisational conditions for learning, challenge, and candour so that weak signals are detected earlier.[2] An example of the lecture’s practical relevance is its treatment of maternity inequity: disparities in mortality and morbidity are presented not as unfortunate externalities but as evidence that service design and care delivery are failing some groups more than others. That framing is directly applicable to board assurance, quality committees, and patient safety improvement programmes.[2] Would you like this converted into a more formal board paper style with headings such as background, key issues, implications, and recommendations? 1. https://www.youtube.com/watch?v=E_iCWIazGtU 2. https://support.google.com/youtube/answer/15930243?hl=en-GB

A highly recommended watch for anyone interested in leadership, patient safety, quality improvement and implementation. That is, if you haven'y yet come across it. Mary Dixon-Woods' lecture Can improvement and innovation save the NHS? is both thought-provoking and refreshing. It provides an opportunity to pause and reflect on where we are in our improvement journey. Among the many nuggets is a reflection on the "priority thickets" described in recent NHS literature, and the reality that health systems are often trying to improve everything, everywhere, all at once. One observation particularly resonated with me. Reflecting on decades of inquiries and reports into healthcare failings, she notes that sometimes the only thing that changes between one report and the next is the font. A sobering thought. The good news is that this lecture is not simply a critique. It also points towards practical ways forward, supported by evidence, resources and examples. An hour very well spent. Watch the video here: https://www.thisinstitute.cam.ac.uk/blog/can-improvement-and-innovation-save-the-nhs/

thank you Urmila, so please that I'm not an outlier when one looks at the evidence - there is no clear guidance - but we should be doing all we can - as you allude to

Dear Sue, Thank you sue for this to discuss. Of course there are many PICC related thrombosis in our trust too. There is no such guideline that could be prevented. Definitely proper PICC line care, regular flushing with heparin and monitoring of PICC arm (DVT sign and symptoms) practices will minimise the risk but can not prevent the clot. We record as PICC related HAT.

I am so sorry to hear that you have been subjected to completely unnecessary pain. You are one of thousands that we know about - the tip of the iceberg. “ trial by hysteroscopy “ should have no place in the 21st century, yet instead of improving, gynaecological “ care” appears to be regressing. Your account of being subjected to pain by lovely people is a very familiar one. To avoid the risk of repeating myself, could I refer you to my reply of 18th February to Carrie. It would be very helpful if you could fill in the Campaign Against Painful Hysteroscopy’s survey to record your experience - this is anonymous, and helps us to collect evidence that is frequently denied and / or ignored by hysteroscopists.

How awful, I'm so sorry it wsa so ghastly for you. I agree, it is inequitable, why some procudures routinely offer sedation and others don't. Convention and geneder bias I guess. It's not good enough.

I've just got home from my hysteroscopy appointment. I'd like to start off by saying that everyone I saw today was lovely and couldn't be faulted. That being said, it goes down as the most painful experience I've ever had. I went into the appointment thinking it would be a little painful but that I would be fine. I have a high pain threshold and I had taken two codeine tablets an hour before. The consultant injected a local anaesthetic into the cervix (relatively painless) and then proceeded with the camera. This was where things began to hurt. The consultant asked me several times if I was ok and did I wish to stop. I asked him to keep going as I really wanted to push through and get it done. When I saw on the screen that the camera was inside the womb, I thought the worst was over but I couldn't have been more wrong. I have a large submucosal fibroid which takes up most of the womb. As fluid was pumped in to make more space, the pain became unbearable. The camera was only able to advance a short distance before I couldn't take anymore and the procedure had to be halted. I am so cross with myself for not being able to push through the pain, but it really was on another level. I had a colonoscopy last year and refused the offered sedation. It was uncomfortable and a little painful, but nothing compared to today. I questioned this with the consultant, and he said that's completely different, a hysteroscopy is a much more painful procedure. My question would be, why then, is sedation the norm for a colonoscopy, but for a hysteroscopy (recognised as being much more painful) woman are told to 'just take a couple of paracetamol before you arrive'. I would be happy to never hear the word hysteroscopy again, but the consultant has booked me in to have the procedure under a general anaesthetic as he really wants to get a biopsy. In summary, the staff were amazing, and stopped the moment I said it was too much, but the procedure was incredibly painful and really shouldn't be downplayed by likening it to period pain that may need a couple of paracetamol...

I am looking for precision diagnostics in the UTI space. Either at home or at point of care. I am also looking for evidence of presentation at points of care for ITIs and any evidence of lived experience, impact and costs of current pathways. In particular in pharmacy first, peimary care

We, I mean a great F2, is looking into this as we have had an incident where the LMWH was held preop and the patient had an iliofemoral DVT. There is quite a b it of data showing that LMWH can be given same day pre surgery and certainly within 12 hours - time frame seems to be 2-24 hours!! I asked co-pilot for some help - I've also asked for references - and have updated this attachement PLEASE BE AWARE THIS IS AI GENERATED - but some good food for thought and a starter for 10 Katie has done a great formal literature search and when she has finished - she is happy to share - and then we can write some advice in our VTE prevention policy!! co-pilot search for preop LMWH.pdf

I had the Kyleena coil fitted which was slightly smaller than the Mirena. I was told it would feel like 3 period cramps when being fitted. I had a local anaesthetic gel to help with the pain of the clamp but I still felt it. I was crying because I was so anxious and worked up and I hadn’t expected it. The nurse said ‘did you not bring anyone with you?’, and luckily my boyfriend had come with me, only because I was extremely anxious. Had I not been anxious, as I am not usually, or had he have been at work, I would’ve just gone by myself. Throughout, I was taking deep breaths but the pain took my breath away, I was crying the entire time and was yelling out in pain or holding my breath. I was sweating and writhing in pain, I was really struggling to stay still and I am usually not bothered by medical procedures. I also felt extremely sick and dizzy afterwards. I got told cramping would last for a few hours to a day… two weeks later I still have cramps. There is absolutely no way I could’ve driven myself home! I had to ride home with the window open with a bag in my hands, hunched over. I got home and the pain eventually made me sick. I was dosing up on paracetamol and ibuprofen, then I tried feminax, and I was using two hot water bottles at a time and none of it made a difference. I feel absolutely traumatised and I still feel sick when thinking about the pain 2 weeks on. I can’t bring myself to check the strings are in the right place because I’m still having cramps and don’t want to do anything to make it worse. I’m terrified to get it replaced in 5 years!

Many healthcare organisations are introducing Artificial Intelligence (AI) into work systems that were not designed for high levels of automation. In practice, this often means that new tools are added locally while team structures, responsibilities, interfaces, and escalation routes remain unchanged. The result can be more cognitive load, fragmented coordination, and unclear ownership rather than safer care. A safer approach is to redesign the work system itself: the teams, tasks, technologies, and governance that shape day-to-day clinical work. One practical step is to model team structures and work processes explicitly so that roles, interfaces, risks, and control measures are visible, traceable, and reusable. This can also provide a structured basis for Large Language Models (LLMs) to support governance tasks such as incident summaries, handover drafts, and training scenarios, all under human oversight. In healthcare, the question is not whether Artificial Intelligence will be used, but whether it will be introduced into work systems that are already difficult for staff to coordinate safely. When a new tool is added without clarifying responsibilities, interfaces, or decision authority, the likely result is not transformation but cognitive load: more interruptions, more workarounds, and less clarity about who should do what, when, and on what basis. That matters for patient safety because poorly aligned work systems can weaken handovers, delay escalation, and increase cognitive burden in already demanding settings. For that reason, I believe the starting point should be the work system, not the tool. Team organisation needs to be designed around the real demands of care: the patient journey, the coordination load between professions, the need for escalation, and the information required to act safely. In practical terms, that means defining clear team boundaries, explicit interface agreements between teams, and reliable modes of collaboration for shared problem-solving and specialist support. This makes accountability more transparent and reduces the risk that important tasks fall through the cracks. A useful next step is to model team structures explicitly. Using, e.g., Sparx Systems Enterprise Architect and SysML (Systems Modelling Language), it is possible to describe not only system structure but also behaviour, requirements, and team interfaces consistently. In a healthcare context, that can include teams, roles, responsibilities, decision points, escalation routes, handover dependencies, risks, and existing control measures. The value is not modelling for its own sake. The value is that operational knowledge becomes structured, reviewable and reusable across governance, training and redesign work. Once this information is modelled in a disciplined way, there is also a plausible route to safer use of Large Language Models. Rather than asking an LLM to generate advice from unstructured discussion alone, organisations can use structured models as a controlled knowledge base, the "Single-Source-Of-Truth". Under human review, that can support practical outputs such as incident summaries, handover drafts, training cases, draft requirements, and options for redesign. The important point is that the model provides consistency and traceability: users can see which role, task, interface, or risk the output is based on. In a patient safety setting, that is far more defensible than relying on text-based documents alone. This last point is an informed systems-engineering inference from structured modelling practice. My view is that healthcare organisations will get more value from AI when they first make their work systems visible. If we want safer care, we need to design for human-AI collaboration in the same disciplined way that we design for staffing, escalation, and accountability. Models will not replace professional judgment, but they can make coordination, governance, and learning more reliable. That is where the patient safety opportunity lies.

The national survey of patient safety partners is now live Researchers from THIS Institute are inviting patient safety partners across the NHS to take part in a new survey exploring how the role is developing. This national survey will help them understand: Who is taking on the role What patient safety partners do in practice How the role is evolving and how it can be supported Your contribution will play an important part in building evidence to support patient safety roles nationally. The survey closes on 15 June 2026. 👉 Take part here: https://www.thiscovery.org/project/patient-safety-partner-t2

Waiting for an ADHD diagnosis can be incredibly frustrating. I had to wait months just to get my first appointment, and even longer to start treatment. During that time, daily tasks felt overwhelming, and it was hard not knowing exactly what I was dealing with. What helped me most was learning small coping strategies and connecting with others going through the same thing. It doesn’t fix the wait, but it makes it a bit more manageable. Hopefully, access improves so people can get the support they need sooner.

Just got my third IUD in as someone with a tilted/retroverted uterus and the uncomfort and pain sucked. I have a high tolerance for pain too so I cannot imagine someone with less tolerance doing this. With a tilted uterus, the doctors had trouble measuring my uterus and it took about 30-40 minutes to get the IUD in. The removal was super easy, but the insertion wasn't great. The doctor kept trying different tricks and techniques to put it in, which meant prolonged cramping sensations from all the poking and proding. Unfortunately, my second IUD wasn't placed correctly and was embedded because they couldn't measure properly.... That led to other abdominal complications.

Thanks Simon when you find a cohort - what is your process for getting it signed off my the medical director?

Hi Sue, yes cohorts are getting more tricky as with the example you give and much more invasive/complex surgery being done as day case. We don't have a cohort quality statement as such but refer to an old East Mids agreed list. Please fid attached. UHL and East Midlands approved List of Day Case procedures where VTE risk assessment can be done by cohort1.pdf

We are reviewing our cohorts Can anyone share there 'Qualify Statements' re cohorts. One rationale for reviewing - patients are now staying in ED for >12 hours - so a previous cohort of, for example - admitted to medical short stay with LOS < 12 hours - is no longer safe and we need to revise our metrics

Yes; omit if surgery is on the same day. That is the plan....

I’m so sorry to hear of how badly your barbaric hysteroscopy has affected you. I’m a member of the Campaign Against Painful Hysteroscopy, ( CAPH ) and I can assure you that sadly, you are far from alone in reacting by avoiding any other diagnostic procedures as a result of your experience. I had a hysteroscopy with no pain relief or sedation in 2006, having previously had one under a general anaesthetic at the same time as a laparoscopy, and not only was I never a candidate for the procedure, I certainly did not give my informed consent, nor can I ever forget it. I was gaslighted into believing that my experience was as rare as hen’s teeth, and blamed for passing out. However, the result of my experience is that I will never, ever give my consent to any procedure without doing extensive research beforehand. I don’t trust HCPs to tell the truth, and I was a practicing RN when I had the hysteroscopy. What I would say is that as colonoscopies are also carried out on men, then the possibility of pain is actually taken into account. My husband has had numerous colonoscopies, and has always been given adequate sedation and pain relief. Indeed, the first question that he is asked in the telephone pre - assessment is if he would like sedation, which has always been accompanied by pain relief. I believe that a woman would also be asked the same questions. Please don’t let your awful experience of hysteroscopy put you off having what could possibly be a life - saving procedure, should it be necessary.

Five years on from my painful and harrowing hysteroscopy I still can't face medical procedures. Just cancelled home bowel screening again as I know I wouldn't be listened to if I had to have a colonoscopy. I do not trust NHS staff to tell the truth or that they would stop a procedure if I was in too much pain. Just wonder what other women have done when faced with other endoscopy procedures and what impact their response has had; did the NHS even care?

Six years ago, the Director-General of the World Health Organization (WHO) declared the outbreak of a new coronavirus disease (later known as COVID-19) a Public Health Emergency of International Concern. Six year's later, WHO is asking: Is the world better prepared for the next pandemic?