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Patient Safety Learning

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  1. Content Article
    Devolution and decentralisation policies involving health and other government sectors have been promoted with a view to improve efficiency and equity in local service provision. Evaluations of these reforms have focused on specific health or care measures, but little is known about their full impact on local health systems. This study evaluated the impact of devolution in Greater Manchester (England) on multiple outcomes using a whole system approach.
  2. News Article
    The General Medical Council (GMC) has relaxed its fitness to practise (FTP) processes for doctors so that ‘minor’ concerns such as ‘pushing a colleague’ are not taken to tribunal. In an update to its guidance, the regulator has given FTP decision makers and case examiners ‘more discretion’ to throw out complaints if they represent a lower risk to public protection. Concerns which are ‘minor in nature and did not impact patient care’ will fall under this guidance. This is part of the GMC’s efforts to carry out ‘more efficient and proportionate investigations’ and to ‘minimise’ stress for doctors during the FTP process. Two examples of concerns which will no longer need to be investigated, if there are ‘no aggravating factors’, are: A doctor giving false details to a market research company, in order qualify for free products. A doctor pushing a colleague out the way following a heated argument. The regulator has said: "Decision makers will now be able to weigh the full circumstances of a concern earlier in the fitness to practise process to assess the overall risk to public protection including to public confidence in the profession– meaning some concerns may not need to be investigated or referred to a tribunal." However, the guidance, which covers concerns relating to violence and dishonesty, emphasises that allegations which raise a risk to public protection will continue to be investigated. Read full story Source: Pulse, 4 April 2024
  3. News Article
    A new private ambulance service will offer faster travel to A&E for those caught out by half-day waits for NHS ambulances, The Independent can reveal, in a sign of a growing “two-tier” health service. MET Medical ambulance service will begin by charging £99 for a call-out, and could serve thousands of people a week, its chief executive Dave Hawkins has said. Mr Hawkins, who is a paramedic himself, said he launched the service after seeing his elderly relatives wait too long for NHS ambulance services following falls. It comes as waiting times for ambulance service reached a crisis point in the last year, with frail and vulnerable people waiting hours for an ambulance. Ambulance response times hit record highs over 2022-23, with people who should have an ambulance within 20 minutes waiting an hour and 30 minutes in December 2023. According to estimates from the Association of Ambulance Chief Executives, 34,000 patients were likely to have suffered harm due to these delays – this hit a high of more than 60,000 in December 2022. MET Medical will still have to wait to deliver patients if they are seen as a priority, but it said its patients are likely to be lower priority and can be dropped at A&E without waiting for a handover. Mr Hawkins said vulnerable patients waiting for an ambulance can wait up to 12 hours. “It’s that moment when you’re out of options, it’s really a horrible place to be, particularly if it’s a loved one … It is a shame, like we’ve seen from the stats and everything, that the health service is failing us." Read full story Source: The Independent, 3 April 2024
  4. News Article
    Almost 10 million people across England could be waiting for an NHS appointment or treatment, 2 million more than previously estimated, according to a survey by the Office for National Statistics (ONS). The ONS survey of about 90,000 adults found that 21% of patients were waiting for a hospital appointment or to start receiving treatment on the NHS. When extrapolated, this equates to 9.7 million people. In January, the waiting list stood at 7.6 million, according to official NHS statistics. The survey found that the delays were most prominent among 16-24-year-olds, one in five of whom said they had experienced waiting times of more than a year. Conducted in January and February, the survey was part of the annual winter coronavirus infection study of adults aged 16 and over. The ONS said the survey was the first of its kind to assess the experiences of adults awaiting hospital appointments, tests or medical treatments. It said the data was experimental, based on self-reported data, and may differ from other statistics on waiting lists. Read full story Source: The Guardian, 3 April 2024
  5. News Article
    The NHS is experiencing an “avalanche of need” over autism and attention deficit hyperactivity disorder (ADHD), but the system in place to cope with surging demand for assessments and treatments is “obsolete”, a health thinktank has warned. There must be a “radical rethink” of how people with the conditions are cared for in England if the health service is to meet the rapidly expanding need for services, according to the Nuffield Trust. The thinktank is calling for a “whole-system approach” across education, society and the NHS, amid changing social attitudes and better awareness of the conditions. It comes days after the NHS announced a major review of ADHD services. Thea Stein, the chief executive of the Nuffield Trust, said: “The extraordinary, unpredicted and unprecedented rise in demand for autism assessments and ADHD treatments have completely overtaken the NHS’s capacity to meet them. It is frankly impossible to imagine how the system can grow fast enough to fulfil this demand. “We shouldn’t underestimate what this means for children in particular: many schools expect an assessment and formal diagnosis to access support – and children and their families suffer while they wait.” Read full story Source: The Guardian, 4 April 2024
  6. Content Article
    Long waiting times for autism and attention deficit hyperactivity disorder (ADHD) assessments can prevent people from getting the vital care and medication they need. Health and education support often relies on a formal diagnosis, without which there can be severe negative consequences. Estimates show that there might be as many as 1.2 million autistic people and 2.2 million people with ADHD in England, and providing them with the right support is no small task. Recent news reports have highlighted a huge rise in demand for autism and ADHD diagnoses amid increased awareness and understanding of neurodiversity. Exploring referrals and waits for autism and ADHD assessments is a key first step to understanding the scale of the issue, which can then be used to drive improvements and change. This blog from the Nuffield Trust looks at what the data is telling us.
  7. Content Article
    The recently published results of the British Social Attitudes survey and the NHS Staff Survey, and recent performance data provide an in-depth backdrop to the health and care landscape in 2024 - a year that's likely to see a general election called. Ruth Robertson is joined by a panel of experts from The King's Fund to discuss the state of health and care. Throughout the conversation, the panel reflects on the prospect of a general election and the impact this might have on health and care services, both in the run up and after. They also discuss the tendency to rely on short-termism in policy-making, and why a long-term strategy might help build a stronger health and care system that will last.
  8. Content Article
    When Adam Luck’s mother, Ann, was admitted to hospital with a suspected stroke, it was the beginning of a distressing seven-week stay. The previously cheerful 82-year-old became stuck in a dysfunctional health system. Her story is presented here via her son Adam’s diary of her hospitalisation.
  9. News Article
    The new NHS gender identity clinics for young people are “understaffed” and “nowhere near ready”, it was claimed on Monday as they officially started taking on patients. A London hub, alongside a second in the northwest, will begin to see patients this week as they replace the Gender Identity Development Service (Gids) at the Tavistock and Portman NHS Foundation Trust. The Gids clinic was ordered to close after a review by Dr Hilary Cass found it was “not a safe or viable long-term option”. However, whistleblowers described as senior staff at Gids have expressed concerns about the preparedness and expertise of the new hubs, just as they open. One, who spoke to the i newspaper under the condition of anonymity, said: “It’s been shoddy, disorganised, messy and unclear. And at times, it’s felt unsafe.” Read full story (paywalled) Source: The Times, 1 April 2024
  10. News Article
    Drugs are a cornerstone of medicine, but sometimes doctors make mistakes when prescribing them and patients don’t take them properly. A new AI tool developed at Oxford University aims to tackle both those problems. DrugGPT offers a safety net for clinicians when they prescribe medicines and gives them information that may help their patients better understand why and how to take them. Doctors and other healthcare professionals who prescribe medicines will be able to get an instant second opinion by entering a patient’s conditions into the chatbot. Prototype versions respond with a list of recommended drugs and flag up possible adverse effects and drug-drug interactions. “One of the great things is that it then explains why,” said Prof David Clifton, whose team at Oxford’s AI for Healthcare lab led the project. “It will show you the guidance – the research, flowcharts and references – and why it recommends this particular drug.” Read full story Source: The Guardian, 31 March 2024
  11. News Article
    Trusts could be exposed to increased negligence claims as a result of new NHS England guidance for a rare spinal condition, a royal college has claimed. The Royal College of Emergency Medicine (RCEM) has said updated national guidance on treating cauda equina syndrome could also lead to greater “inequity of access” due to issues accessing timely MRI scans at many accident and emergency departments. An NHS Resolution report in 2022 found delayed MRI scans were a significant factor in high-value clinical negligence claims, particularly those relating to management of spinal conditions. The guidance issued by NHSE’s Getting It Right First Time programme national pathway guidance says emergency MRIs for suspected CES should be taken within four hours of requests to radiology, and where this is not possible, “standard operating procedures” involving local spinal and radiology services should be in place for urgent out-of-hours scanning. Local provision for this “must be in place by June 2024,” the guidance says. NHSE said the GIRFT guidance has been endorsed by 11 clinical and patient bodies, including the Royal College of Radiologists and the Spinal Injuries Association. But RCEM, understood to be the only clinical body not to endorse the guidance, has issued a position statement last month stating that “few EDs, outside of tertiary centres, have access to 24/7 MRI scanning”. Read full story (paywalled) Source: HSJ, 3 April 2024
  12. News Article
    Catherine O’Connor was 17 when she died, having lost 14 litres of blood during high-risk surgery on her back. At her inquest, the surgeon who operated on her, John Bradley Williamson, told the coroner the procedure at Salford Royal Hospital in Greater Manchester had “progressed uneventfully” and “the blood loss was perhaps a little higher than one would usually anticipate but was certainly not extreme”. The coroner recorded a verdict of death by misadventure. Now Greater Manchester police are examining O’Connor’s death, in February 2007, and whether Williamson misled the coroner during the inquest in September that year. Catherine's family are now demanding a new inquest into her death in 2007. This is because in the days after O’Connor’s death, Williamson sent an internal letter to the head of the hospital’s haematology department, Simon Jowitt, describing the surgery as “difficult” and having involved “a catastrophic haemorrhage”. Williamson had also ignored advice to have a second surgeon present during the operation. Officers led by Detective Inspector Michael Sharples have commissioned two expert reports and sought advice from the Crown Prosecution Service ahead of a meeting with the coroner, who has been asked to consider reopening O’Connor’s inquest. Read full story (paywalled) Source: The Times, 31 March 2024
  13. Event
    until
    NHS Resolution’s Safety and Learning team in collaboration with the NW panel law firms, are hosting a virtual forum series on learning from claims to promote reflection and improve patient care. The purpose is to raise awareness of the support offered by NHS Resolution as your General Practice indemnifier along with the North West panel firms; Weightmans, Hempsons and Hill Dickinson. This will be of interest to both clinical and non-clinical staff involved in patient care across primary and urgent care . The format is interactive, with presentations followed by questions and panel discussion. Session 4: Pitfalls to prescribing better care Event programme: The invaluable role of pharmacists Common medicine error claims recommendations Q&A panel discussion Contributors: Joanne Hughes- Partner | Hill Dickinson Dr Anwar Khan - Senior Clinical Advisor for General Practice |NHS Resolution Register
  14. Event
    until
    NHS Resolution’s Safety and Learning team in collaboration with the NW panel law firms, are hosting a virtual forum series on learning from claims to promote reflection and improve patient care. The purpose is to raise awareness of the support offered by NHS Resolution as your General Practice indemnifier along with the North West panel firms; Weightmans, Hempsons and Hill Dickinson. This will be of interest to both clinical and non-clinical staff involved in patient care across primary and urgent care . The format is interactive, with presentations followed by questions and panel discussion. Session 3: Dissecting a claim part 2 Event programme: Exploration through the use of an illustrative case studyQ&A panel discussion Contributors: Chris Dexter - Partner | Weightmans Alison Brennan - Principal associate |Weightmans Register
  15. Event
    NHS Resolution’s Safety and Learning team in collaboration with the NW panel law firms, are hosting a virtual forum series on learning from claims to promote reflection and improve patient care. The purpose is to raise awareness of the support offered by NHS Resolution as your General Practice indemnifier along with the North West panel firms; Weightmans, Hempsons and Hill Dickinson. This will be of interest to both clinical and non-clinical staff involved in patient care across primary and urgent care . The format is interactive, with presentations followed by questions and panel discussion. Session 2: Helping general practice manage and learn from claims part 1 Event programme: Exploration through the use of an illustrative case study Q&A panel discussion Contributors: Chris Dexter - Partner | Weightmans Alison Brennan- Principal associate |NHS Resolution Register
  16. Event
    until
    NHS Resolution’s Safety and Learning team in collaboration with the NW panel law firms, are hosting a virtual forum series on learning from claims to promote reflection and improve patient care. The purpose is to raise awareness of the support offered by NHS Resolution as your General Practice indemnifier along with the North West panel firms; Weightmans, Hempsons and Hill Dickinson. This will be of interest to both clinical and non-clinical staff involved in patient care across primary and urgent care . The format is interactive, with presentations followed by questions and panel discussion. Session 1: Seeking support for claims The session will explain how NHS Resolution, and its panel firms, will support you in responding to claims along with an overview of the legal tests used to determine a claim and the steps involved. Event programme: Introduction to the GP Indemnity scheme and clinical negligence Q&A panel discussion Contributors: • Patricia Roe - Partner | Hempsons • Dr Anwar Khan - Senior Clinical Advisor for General Practice, NHS Resolution Register
  17. Content Article
    On 27 February 2024, NHS Resolution's Safety and Learning team delivered a virtual forum on delivering health in the prison and justice system. The aim of the session was to discuss the realities, best practice, challenges and recommendations around collaborating to support healthcare delivery in the justice system.
  18. News Article
    Families have been told they will have to prove liability for the harm caused to mothers and children at East Kent Hospitals University Foundation Trust before getting compensation. This is despite the inquiry having examined each case in detail and concluding 45 babies could have survived, while 12 who sustained brain damage could have had a different outcome. It also determined 23 women who either died or suffered injuries might have had better outcomes had care been given to “nationally recognised” standards. However, NHS Resolution – which handles claims for clinical negligence – now says families must prove causation and a breach of duty of care before any compensation can be made. This stipulation has been made even in cases where the inquiry found different treatment would have been reasonably expected to make a difference to the outcome. The investigation into the trust’s maternity care led by Bill Kirkup reported 18 months ago. Speaking to HSJ, its author said: “I am disappointed that East Kent families are facing these problems after everything that has happened to them. Of course, it is true that the independent investigation panel was not in a position to rule on negligence, but we did provide a robust clinical assessment of each case. “I would have hoped that this could be taken into account in deciding to offer early settlement instead of a protracted dispute. It seems sad that a more compassionate approach has not been adopted.” Read full story (paywalled) Source: HSJ, 2 April 2024
  19. News Article
    Kara Dilliway was just three years old when she came down with a common ear infection in October 2022. She recovered quickly, as was expected, but just days after the infection cleared her parents found she was struggling to hear and talk. “We’d noticed she’d just started to say yes and no to things, that’s when we thought something is going on,” says her mother Sam Dilliway, a 41-year-old community care worker from Basildon, Essex. Doctors said she could have glue ear, a common condition in children – fluid build-up had started to cause problems with her hearing, and would need draining. But what should have been a minor ailment has turned into a never-ending ordeal for the family. What was a simple case of glue ear could now leave her with hearing loss for up to two years as she awaits routine treatment. It comes after data released in January found that over 10 million people have been left on NHS waiting lists for basic ear care services. Dr Aymat says that the long-term effects of such conditions being left untreated in children can be severe. While glue ear is unlikely to leave permanent damage, there is always a small risk of permanent hearing loss. However, the developmental effects are far more likely and potentially long-lasting. Read full story Source: The Independent, 1 April 2024
  20. Content Article
    Prime Minister Rishi Sunak promised speedier care, but specialists believe long waits for hospital beds are costing thousands of lives. The pledge he made in January last year, as one of five priorities on which he said voters should judge him, was that “NHS waiting lists will fall and people will get the care they need more quickly”. New calculations by the Royal College of Emergency Medicine (RCEM) show that, with regard to the broader aim of delivering speedier treatment, his government is falling shockingly short.
  21. News Article
    Hospitals are preparing to cut spending on doctors and nurses by hundreds of millions of pounds after being ordered to plug a £4.5 billion hole in the NHS budget. Chief executives at hospitals, mental health trusts and community services in England have been ordered to review staffing levels and draw up plans to close some services and merge others. They are also looking at banning or restricting the use of some agency workers. NHS bosses have been alerted in recent days to the scale of the cuts needed after negotiating financial plans for next year. The health service in England has a budget of £165 billion for the 2024-25 financial year, which starts next week. The budget rose by 3.2% in real terms between 2018-19 and 2023-24. Spending has been put under additional pressure by the cost of covering strikes by junior doctors which NHS England has said has cost more than £1.5 billion and affected more than 430,000 patients’ appointments. Saffron Cordery, deputy chief executive of NHS Providers, said services had been stretched by the need to pick up the pieces from a shortage of social care and other community services. She said an ageing population and poor public health meant patients in hospital were sicker and staying longer, needing more care. She said: “Trust leaders are being pushed to the very limits of what is possible, and there will be a situation where they have to make difficult choices about keeping basic services going versus investing in quality and improvement for the future. We are in a situation where we will be patching something that’s already a bit patched-together.” Read full story (paywalled) Source: Times, 31 March 2024
  22. Content Article
    Lit Health will be lighting a fire underneath the status quo of healthcare through interviews with authors, healthcare leaders, and policymakers working to create a healthcare environment that is equitable, transparent, and that welcomes the needs of every patient – especially our vulnerable populations including the mentally ill, people of colour and women who feel they are at risk in our current system, the elderly, and anyone who feels bias or the isms affect their health and quality of life.
  23. Content Article
    Health Services Research (HSR) conceptual models examine the complexity and “basic science” of patient safety. HSR methods can help quantify patient safety problems, enhance their understanding, and develop and test solutions. However, preventable harm persists and even worsened during the pandemic. One reason is inadequate attention and investment in patient safety over the past two decades. Significant investments are still needed to measure the burden of different patient safety events across settings and to address emerging safety threats. Solutions need to be developed, evaluated, and implemented through rigorous research to ensure widespread, effective adoption. Multidisciplinary strategies are required both to mitigate safety threats before they lead to patient harm, and to close the implementation gap. Outside of AHRQ and VA funding, patient safety research in the United States is underfunded. Efforts to translate HSR to patient care, policy, and clinical practice is essential for patient safety improvements. These efforts require health services researchers to go beyond publishing a paper; they must work closely with healthcare organizational leaders, clinicians, policymakers, and patients to ensure their findings are acted upon, and to help propose and test solutions. The National Center for Patient Safety (NCPS) offers an excellent model to do so by funding dedicated patient safety centres of inquiry (PSCIs) nationally. PSCIs focus on research and implementation activities that promote organization-wide learning. The PSCI model adds significant value to creating a learning health system for safety that invests in patient safety data gathering, analysis, learning, and actionable improvements.
  24. Content Article
    In March 2018, Elliot Peters, 14, died after becoming suddenly and seriously ill before being diagnosed with Ornithine transcarbamylase (OTC) deficiency. His mum, Holly, is dedicated to speaking out about Elliot’s story to raise awareness and prevent more deaths.
  25. Content Article
    As Rob Behren steps down as the Parliamentary and Health Service Ombudsman (PHSO) he records an episode of Radio Ombudsman, reflecting on his seven years in office. He also tells us about his early life, his career before PHSO and shares his future plans.
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