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Patient Safety Learning

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  1. Patient Safety Learning
    The government has announced that the “restoration of other NHS services” will start today on a “hospital-by-hospital” basis.
    Health and social care secretary Matt Hancock in his daily ministerial coronavirus briefing announced the resumption of healthcare which has been suspended due to coronavirus will begin today. He said the initial focus would be on the most urgent services, citing cancer and mental health as examples.
    They will be reintroduced on a locally decided basis, depending on the level the virus is currently impacting different areas and trusts, which varies widely, and how easily they can reintroduce the work, he said.
    Mr Hancock, asked about the plan by HSJ during the briefing, indicated that a large-scale return would be enabled because the government is setting out to avoid a so-called second peak of the virus spreading, so the NHS will not need to keep tens of thousands of extra beds free in readiness. Experts and governments around the globe are concerned about the prospect of further peaks of the virus spread as they move to release distancing measures. 
    Further NHS England guidance on the plan is expected later this week. 
    Read full story
    Source: HSJ, 27 April 2020
  2. Patient Safety Learning
    NHS staff are to be given access to testing for covid-19, the government said this morning, but it remains unclear how the policy will be applied.
    A Department of Health and Social Care spokesman said at lunchtime: “Our testing regime is set up to provide for those who need tests the most. This includes key workers, such as NHS staff. We will set out more details shortly.”
    It remains unclear how this will be applied.
    The announcement follows concerns from healthcare professionals they are not being tested for the virus, even if they had been exposed to infected patients.
    Read full story (paywalled)
    Source: HSJ, 17 March 2020
  3. Patient Safety Learning
    A senior judge has said friends and family can legally visit their loved ones in care homes, in an apparent challenge to recent government policy that has in effect banned routine visits in areas of high COVID-19 infection.
    Mr Justice Hayden, vice-president of the court of protection which makes decisions for people who lack mental capacity, said courts are concerned about the impact on elderly people of lockdowns. He has circulated a memo that sets out his analysis that regulations do “permit contact with relatives” and friends and visits are “lawful”.
    He was responding to guidance from the Department of Health and Social Care (DHSC) last month telling thousands of care homes in England that visiting should be stopped in areas with tier 2 and tier 3 lock down restrictions, apart from in exceptional circumstances such as the end of life.
    It triggered blanket prohibitions by some councils and sparked anguish from relatives who warn a lack of contact is leading to misery and early death in some cases. Within a week, Gloucestershire county council told care homes in its area to stop visits until next spring.
    With the England-wide lockdown starting on Thursday, care home providers, families and groups including Age UK and Alzheimer’s Society, have called on ministers to this time make clearer provisions for visiting. 
    Hayden said exceptions in the existing regulations mean contact with residents staying in care homes is lawful for close family members and friends. He said the court of protection was concerned about “the impact the present arrangements may have on elderly people living in care homes,” citing their suffering.
    Read full story
    Source: The Guardian, 2 November 2020
  4. Patient Safety Learning
    Significant concerns about the NHS’ refusal to share data with councils have emerged in a letter from a leading council chief executive and clinical commissioning group accountable officer. 
    Steven Pleasant, chief executive of Tameside Metropolitan Borough Council and accountable officer of Tameside and Glossop CCG, said the failures are “becoming increasingly exasperating”, in a letter intended for the Ministry of Housing, Communities and Local Government’s shielding sounding board.
    Steven said he understands NHS Digital has decided the most recent version of the list cannot be shared with councils even though it is being shared with police, fire, voluntary organisations and companies offering logistical support.
    “I am sure that you will appreciate that this is counterproductive and frustrating given that local authorities are leading and coordinating the response to the most vulnerable in communities,” he wrote.
    He also raised concerns about how the NHS’ shielded patients team is passing on to councils information about people needing additional support — for instance, if the recipient’s food parcel stock is running low, requiring the council to step in. Welfare concerns and medication information could also need to be passed on. Mr Pleasant said although his council had asked for this information to be provided via email, staff “have been told by the NHS shielding team that they do not have permission to do this and that details can only be provided verbally over the phone”.
    “We believe this significantly increases the chances of error and presents significant risk… around incorrect information being captured,” he wrote.
    Read full story
    Source: HSJ, 21 April 2020
  5. Patient Safety Learning
    Visiting A&E or relatives is considered much riskier than attending hospital for other reasons, according to the first in-depth piece of research into the subject. 
    The research, authored by the University of Leicester and NIHR Leicester Biomedical Research Centre Bioinformatics Hub, asked 400 participants how they felt about attending hospital across a range of scenarios during the pandemic. It also revealed that consistent staff use of PPE is seen as a top priority by patients, with staff testing receiving significant but much less support. 
    Participants in the Leicester research were asked to rank how ”safe and confident” they felt coming into hospital for a number of reasons on a scale 1-100. The median score given to “visiting a friend or family member” was 49. The score for attending accident and emergency was 50.
    Attendance at A&E’s fell sharply during the pandemic peak. It is now rising, but has not reached pre-covid levels. The research suggests that fear could still be playing a significant part in the drop off.
    Attending hospital for elective care received a median score of 61. Participants were most confident in visiting hospital for essential surgery (median score 78), and clinical scans or x-ray (77).
    Read full story (paywalled)
    Source: HSJ, 3 September 2020
  6. Patient Safety Learning
    Women and NHS staff have warned that mothers are being “forgotten” after giving birth, with a staff crisis only making matters worse.
    Kate, a 32-year-old from Leeds, says she has been left in “excruciating” pain for nine years after horrifying postnatal care.
    Other women have told The Independent stories of care ranging from “disjointed” to “disastrous”.
    It comes as midwives warn there are “horrendous” shortages in community services, which have prevented women from accessing adequate antenatal and postnatal care.
    Mary Ross-Davie, the Royal College of Midwives’ director for professional midwifery, said that with each Covid wave midwifery staffing has been hit worse than the last.
    To provide safe care during labour, antenatal and postnatal care, teams are sent into wards putting “huge pressure on care”.
    She said this could mean clinicians end up “missing things”, such as women struggling emotionally after birth.
    The warnings over poor antenatal and postnatal care come after experts at the University of Oxford said in November there were “stark” gaps in postnatal care, despite the highest number of deaths being recorded in the postnatal period.
    Dr Sunita Sharma, lead consultant for postnatal care at Chelsea and Westminster Trust, said that when NHS maternity inpatient staffing overall is in crisis “often the first place staff are moved from is the postnatal ward, which is clinically very appropriate, but it can come at a cost of putting more pressure on postnatal care for other mothers”.
    Dr Sharma said postnatal teams were doing their best to improve services but need national drivers and funding to sustain improvement.
    Read full story
    Source: The Independent, 16 March 2022
  7. Patient Safety Learning
    A London NHS trust has been ordered to pay a leading heart doctor more than £870,000 after he was sacked for whistleblowing about safety concerns following a patient’s death.
    Dr Kevin Beatt, one of the UK’s most respected consultant cardiologists, was fired from Croydon Health Services in 2012 after reporting staff shortages, inadequate equipment and workplace bullying at the trust.  
    The tribunal heard Dr Beatt’s dismissal “had a devastating effect on his career and his wellbeing”.
    He told the Evening Standard: “I was forced into a position where I lost my career for trying to highlight dangerous practices in the NHS. It has taken seven years to get to this point, which is just appalling. It has been a huge ordeal and I have the greatest sympathy for any whistleblower who has to go through something like this.”
    Read full story
    Source: Evening Standard, 11 March 2020
  8. Patient Safety Learning
    Doctors who look after patients in a vegetative or minimally conscious state must ensure they initiate regular conversations with relatives about what is in the best interests of the person so that they do not get “lost in the system,” says new guidance.
    The Royal College of Physicians has published new and revised guidelines on prolonged disorders of consciousness (PDOC) to take into account changes in the law and developments in assessment and management.
    Read full story (paywalled)
    Source: BMJ, 6 March 2020
  9. Patient Safety Learning
    Michael Seres, an entrepreneur, patient advocate, husband and father of three, died on Saturday in Orange County, California, of a sepsis infection. He was 51. 
    Seres was widely considered to be one of the first and most prominent “e-patients,” a term which has become popular to denote patients who are informed and engaged in their health, often sharing their experiences online. He is also one of a small number of patient inventors who helped design and build a medical device – a digitally enhanced ostomy bag – that got FDA clearance in 2014. His invention eased the suffering of millions of people with bowel injuries, chronic gut illnesses and cancer.
    Source: CNBC, 2 June 2020
    Read more about Michael and his innovative patient work in our hub blog
  10. Patient Safety Learning
    Prisoners are at risk of being transferred without crucial medication, according to the latest Healthcare Safety Investigation Branch (HSIB) report.
    The report reveals errors and delays in the prison healthcare system. The investigation looks into the case study of Martin, a 43-year old inmate, who suffered multiple seizures after his epilepsy medication wasn’t transferred with him to a new prison.
    Each day around 120 prisoners with ongoing medication needs are moved between jails. Martin’s case is just one example of a serious outcome when medication was missed. Prisoners may also need to be treated in the community at local hospitals, with prison security staff being taken away from planned duties to accompany them.
    Dr Lesley Kay, Deputy Medical Director at HSIB and a Consultant Rheumatologist, has experience of working with prisoners that have long-term conditions: “I have seen first-hand the impact that the lack of medication management can have on patients, particularly when they have long-term conditions. This also places additional pressure on an already stretched NHS and prison service.
    “With over 2,400 transfers a month where medication is needed, we recognise how busy prison healthcare staff are and how challenging it is to get medication to the right place at the right time. We know that the system needs to be better and the recommendations we have made are aimed at making the whole process smoother and safer for everyone.”
    Read story and full report
    Source: HSIB, 10 October 2019
  11. Patient Safety Learning
    UK researchers have developed a new risk prediction tool that estimates a person’s chance of hospitalisation and death from COVID-19.
    The algorithm, which was constructed using data from more than eight million people across England, uses key factors such as age, ethnicity and body mass index to help identify individuals in the UK at risk of developing severe illness.
    It’s hoped that the risk prediction tool, known as QCOVID, will be used to support public health policy throughout the rest of the pandemic, in shaping decisions over shielding, treatment or vaccine prioritisation.
    The research, published in The BMJ, was put together by a team of scientists across the UK, and has been praised for the depth and accuracy of its findings.
    “This study presents robust risk prediction models that could be used to stratify risk in populations for public health purposes in the event of a ‘second wave’ of the pandemic and support shared management of risk,” the researchers say.
    “We anticipate that the algorithms will be updated regularly as understanding of COVID-19 increases, as more data become available, as behaviour in the population changes, or in response to new policy interventions.”
    Read full story
    Source: The Independent, 21 October 2020
  12. Patient Safety Learning
    The privatisation of NHS care accelerated by Tory policies a decade ago has corresponded with a decline in quality and “significantly increased” rates of death from treatable causes, the first study of its kind says.
    The hugely controversial shakeup of the health service in England in 2012 by the health secretary, Andrew Lansley, in the Tory-Lib Dem coalition government, forced local health bodies to put contracts for services out to tender.
    Billions of pounds of taxpayers’ cash has since been handed to private companies to treat NHS patients, according to the landmark review.
    It shows the growth in health contracts being tendered to private companies has been associated with a drop in care quality and higher rates of treatable mortality – patient deaths considered avoidable with timely, effective healthcare.
    The analysis by the University of Oxford has been published in the Lancet Public Health journal. “The privatisation of the NHS in England, through the outsourcing of services to for-profit companies, consistently increased [after 2012],” it says.
    “Private-sector outsourcing corresponded with significantly increased rates of treatable mortality, potentially as a result of a decline in the quality of healthcare services.”
    Read full story
    Source: The Guardian, 29 June 2022
  13. Patient Safety Learning
    When Dan Scoble came down with the coronavirus in March, all the classic symptoms landed in one fell swoop. “I had everything under the sun: a fever, temperature, fatigue and chest pain,” he said. “My head felt like a balloon.”
    The 22-year-old, a personal trainer from Oxford who normally breezed through 10-mile runs, suddenly found himself bed-bound. He presumed it would soon blow over, but 12 weeks after falling ill as the country went into lockdown, he is still not back to normal.
    Dan has left his house just five times in three months — twice to see his GP and three times to hospital. He still suffers from crippling fatigue, recurrent migraines and a persistent sore throat, as well as abdominal and musculoskeletal pain.
    Read full story (paywalled)
    Source: The Times, 14 June 2020
  14. Patient Safety Learning
    Ambulance services have been urged to look at how suspected overdose and poisoning cases are prioritised after paramedics took 45 minutes to reach a woman with known mental health problems.
    Helen Sheath, 33, had been discharged from a mental health unit in early July last year and was still waiting for an outpatient appointment with a psychological assessment and treatment service when she took a fatal dose of sodium nitrate on 20 August.
    Her father called an ambulance at 6.20pm when she had locked herself in a bathroom and was threatening to take the sodium nitrate. But Bedfordshire and Luton senior coroner Emma Whitting said her father could not tell whether or not she had taken it, and that in view of her history of suicidal ideation, the call should have been treated as a category two – with an 18 minutes response target – rather than a category three incident.
    The first ambulance which was sent to her was diverted on route and it was only after a second call to the East of England Ambulance Service at 6.48pm, that the call was upgraded to category two – when the call handler selected a different set of questions, after being told she had ingested the chemical. A rapid response vehicle arrived at 7.05pm and the mental health street triage team attended six minutes later. Shortly afterwards she became acutely unwell and was taken to Bedford Hospital, where she received treatment but died shortly afterwards.
    In a prevention of future deaths report Ms Whitting said: “If the first call had been coded as a category two, it seems likely that the rapid response vehicle, mental health street triage team (and even possibly the double staffed ambulance) would have arrived on scene much earlier (potentially just before or just after Helen had ingested the sodium nitrate) which could potentially have altered the outcome.” 
    The case comes just months after two other ambulance trusts were criticised in cases involving suspected or threatened overdoses.
    The prevention of future deaths report was sent to the Association of Ambulance Chief Executives and the emergency call prioritisation advisory group, which is run by NHS England. Neither would comment other than saying they would respond to the coroner.
    Read full story
    Source: HSJ, 15 June 2020
  15. Patient Safety Learning
    Death rates from cancer in the US have fallen by 32% over the three decades from 1991 to 2019, according to the American Cancer Society.
    The decline is thanks to prevention, screening, early diagnosis and treatment of common cancers, including lung and breast cancer.
    The drop has meant 3.5m fewer deaths. However, cancers are still the second leading cause of death in the US, after heart disease.
    In 1991, the cancer death rate was 215 per 100,000 people and in 2019 it dropped to 146 per 100,000 people.
    Lung cancer, of which there are 230,000more cases each year, kills the most patients, 350 per day.
    But people are being diagnosed sooner, and technological advancements have increased the survival rate by three years.
    The report also examined racial and economic disparities in cancer outcomes.
    The Covid-19 pandemic added to already existing difficulties for marginalised groups to get cancer screenings and treatment.
    For nearly every type of cancer, white people have a higher survival rate than black people. Black women with breast cancer face a 41% higher death rate than white women.
    Read full story
    Source: BBC News, 12 January 2023
  16. Patient Safety Learning
    “Unacceptable” failures by a mental health hospital to manage the physical healthcare of a woman detained under the mental health act contributed to her starving to death, The Independent has learned.
    A second inquest into the death of a 45-year-old woman, Jennifer Lewis, has found that the mental health hospital to which she was admitted “failed to manage her declining physical health” as she suffered from the effects of malnutrition.
    Ms Lewis had a long-term diagnosis of schizophrenia. Her family described how she had lived a full life, completed a degree, and given lectures about living with mental illness. However, after undergoing bariatric surgery, against the wishes of her family, her mental state declined and she was admitted to the Bracton Centre, run by Oxleas, in 2014.
    In an interview with The independent, her sister, Angela, described how, in the year before her death, Ms Lewis lost her hair, suffered from diarrhoea, and developed sores on her legs as she effectively “starved to death” from malnutrition.
    Ms Lewis’s sister told The Independent that in the year leading up to her death, when the family warned doctors she was “starving to death”, their concerns were dismissed and they were told that the hospital “will not let it come to that”.
    Mental health charity Rethink has called for improvements to physical healthcare for patients with severe mental illness, whose physical needs they say are “all too often ignored”, while experts at think tank the Centre for Mental Health have warned that patients with mental illness are dying too young as the system “still separates mental and physical health”.
    Read full story
    Source: The Independent, January 2022
  17. Patient Safety Learning
    An independent provider’s NHS contract has been suspended, and a harm review is to be carried out on patients who have faced a long wait.
    Kent and Medway Clinical Commissioning Group suspended DMC Healthcare’s contract to provide dermatology services in north Kent “to ensure patient safety” on Friday. It said it had showing some patients had been on waiting lists longer than they should have been.
    It is unable to say how many patients are likely to be involved in the harm review, but it is expected to focus on those who have waited longer than they should or where harm is suspected.
    Read full story (paywalled)
    Source: HSJ, 24 June 2020
  18. Patient Safety Learning
    Senior doctors repeatedly raised concerns over safety and staffing problems at a mental health trust before a cluster of 12 deaths, an HSJ investigation has found.
    The deaths all happened over the course of a year, starting in June 2018, involving patients under the care of the crisis home treatment services at Birmingham and Solihull Mental Health Trust. The causes of the deaths included suicides, drug overdoses, and hanging.
    Coroners found several common failings surrounding the deaths and have previously warned of a lack of resources for mental health services in the city.
    HSJ has now seen internal documents which reveal senior clinicians had raised repeated internal concerns about the trust’s crisis home treatment teams during 2017 and early 2018. The clinicians warned of inadequate staffing levels, long waiting lists, and a lack of inpatient bed capacity.
    In the minutes of one meeting in February 2018, just two months before the first of the 12 deaths, a consultant is recorded as saying he had “grave concerns over safety in [the home treatment teams]”.
    Read full story
    Source: HSJ, 9 June 2020
  19. Patient Safety Learning
    A woman whose father died in a care home has launched a judicial review case in the High Court over the government’s “litany of failures” in protecting the vulnerable elderly residents who were most at risk from COVID-19.
    Cathy Gardner accuses England’s health and social care secretary, Matt Hancock, NHS England, and Public Health England of acting unlawfully in breaching statutory duties to safeguard health and obligations under the European Convention on Human Rights, including the right to life.
    Her father, Michael Gibson, who had Alzheimer’s disease, died aged 88 of probable COVID-19 related causes on 3 April at Cherwood House Care Centre, near Bicester, Oxfordshire. She claims that before his death the care home had been pressured into taking a hospital patient who had tested positive for the virus but had not had a raised temperature for about 72 hours.
    “I am appalled that Matt Hancock can give the impression that the government has sought to cast a protective ring over elderly residents of care homes, and right from the start,” Gardner said. “The truth is that there has been at best a casual approach to protecting the residents of care homes. At worst the government has adopted a policy that has caused the death of the most vulnerable in our society.”
    Read full story
    Source: BMJ, 15 June 2020
  20. Patient Safety Learning
    The NHS should expect a “huge number” of legal challenges relating to decisions made during the coronavirus pandemic, healthcare lawyers have warned.
    The specialists said legal challenges against clinical commissioning groups and NHS providers would be inevitable, around issues such as breaches of human rights and clinical negligence claims.
    Francesca Burfield, a barrister specialising in children’s health and social care, told HSJ’s Healthcheck podcast: “I think there is going to be huge number of challenges. If and when we move through this there will not only be a public enquiry, [but] I anticipate judicial reviews, civil actions in relation to negligence claims and breach[es] of human rights….”
    She said criminal proceedings by the Care Quality Commission or Crown Prosecution Service would also be a possibility, around issues such as deprivation of liberty, neglect, safeguarding, and potential gross negligence manslaughter.
    Read full story
    Source: HSJ, 20 April 2020
  21. Patient Safety Learning
    Government will pick five or six ‘integration frontrunner’ areas ‘to lead the way in developing and testing radical new approaches’ to speeding up discharge from acute hospitals.
    Along with NHS England, ministers today wrote to local NHS and council directors asking for bids to take part by 30 June.
    They said there was “a need to take a more fundamental look at [how the] system currently manages the discharge of patients, their post-acute care, and their access to high-quality social care”.
    The “discharge integration frontrunner sites” will focus on exploring “new service models, such as the delivery of a more integrated model for intermediate care across existing health and social care”, and “designing and testing new enabling arrangements, which might include new funding models, more integrated workforce models, or the deployment of new technologies”, their letter said.
    They said speeding up hospital discharge was “just one” potential benefit from integration and indicated that “future phases” of frontrunners may focus elsewhere.
    But delayed discharge has been a major pressure on the system over the past year, particularly last winter, and the letter says: “Delayed discharges are one very visible signal that the health and care system remains fragmented and too often fails to deliver joined-up services that meet people’s needs.”
    Read full story (paywalled)
    Source: HSJ, 21 June 2022
  22. Patient Safety Learning
    A senior medic has won a whistleblowing case after judges ruled she was dismissed after raising concerns about a new procedure her department was using.
    An employment tribunal found consultant nephrologist Jasna Macanovic was fired from Portsmouth Hospitals University Trust in March 2018 after telling bosses a dialysis technique called “buttonholing”, which had been “championed” there, was potentially dangerous.
    The trust’s case was that the way she had gone about raising concerns had made for an untenable working environment in the Wessex Kidney Centre.
    The process saw a Care Quality Commission complaint, an independent investigation and multiple referrals to the General Medical Council.
    Employment Judge Fowell said: “The plain fact is that after over twenty years of excellent service in the NHS, Dr Macanovic was dismissed from her post shortly after raising a series of protected disclosures about this one issue. It is no answer to a claim of whistleblowing to say that feelings ran so high that working relationships broke down completely, and so the whistleblower had to be dismissed.”
    Dr Macanovic resigned from the regional renal transplant team in July 2016 when she discovered two incidents had occurred that “had not been reported by either surgeon” and felt that one of the surgeons had misled the medical director over the issue, the tribunal heard.
    In an email sent after the resignation meeting, Dr Macanovic said the practice was considered inappropriate by the vast majority of experts in the field and that no other renal unit in England was using it. 
    The case exposes some worrying governance, both within the trust and between it and the Care Quality Commission, with which the issues were raised in 2016.
    When the CQC asked the trust for more information the unit’s clinical director responded that in his view that the deaths and infections were not due to the buttonholing.
    The CQC made no further enquiries and wrote back saying “they were satisfied that there were no safety concerns and that appropriate governance had been followed”.
    Read full story
    Source: HSJ, 24 March 2022
  23. Patient Safety Learning
    The safety of maternity services at a major north London hospital has been criticised by the care watchdog after an inspection prompted by the death of a woman.
    The Care Quality Commission (CQC) has issued the Royal Free Hospital, in Hampstead with a warning notice after inspectors identified serious safety failings in its maternity unit.
    An unannounced inspection of the hospital’s maternity service took place in October, following the death of Malyun Karama, in February this year.
    The 34-year-old died while giving birth to her stillborn baby. She suffered a ruptured uterus after being given an overdose of misoprostol to induce her labour.
    In a report following an inquest into her death Coroner Mary Hassell said: “Abnormal observations were relayed by a midwife to a senior registrar, but the doctor failed to attend Ms Karama and instead ordered fluids. The uterine rupture would have been life threatening whatever the care rendered to Ms Karama, but if the doctor had attended immediately and had reviewed and treated appropriately, the likelihood is that Ms Karama’s life would have been saved.”
    The CQC has yet to publish a full report on its inspection of the hospital but confirmed it had taken enforcement action and issued the trust with a warning notice.
    The concerns relate to the trust being too slow to investigate and make changes after incidents of harm. It’s understood a panel to investigate Ms Karama’s death did not meet until June this year.
    Read full story
    Source: The Independent, 1 December 2020
  24. Patient Safety Learning
    In an email to staff today (9 May 2023) NHS England (NHSE) have confirmed that to meet the deadline for implementing the new Learn From Patient Safety Events (LFPSE) service, Trusts will only need to ensure this is underway by the 30 September 2023, rather than fully implemented.
    LFPSE is a new central national service for recording and analysing patient safety events that occur in healthcare. Some NHS organisations are now using this system, instead of the National Reporting and Learning System (NRLS), and all organisations will be expected to transition to this.
    The original date for Trusts to implement LFPSE was the 31 March 2023. However, in response to concerns about the achievability of this deadline, on the 18 October NHSE announced an optional six-month extension, meaning that Trusts needed to deploy the new system by the 30 September 2023.
    Today’s email to NHS staff noted that some Trusts “are still anticipating challenges with the time scales”. Responding to this, NHSE clarified that provided the LFPSE transition within organisations Local Risk Management Systems was underway by the end of September, and that application of the guidance to configure formals and fields was being actively worked on, this milestone should be considered as having been met.
    Commenting on this Helen Hughes, Chief Executive of charity Patient Safety Learning, said:
    “This is a welcome announcement by NHS England, reducing the immediate pressure on staff who had raised serious concerns on the ability to have LFPSE configured and ready to submit events by the 30 September deadline. This flexibility will ensure that the new LFPSE service has a stronger chance of successful transition and to enable patient safety improvement”.
  25. Patient Safety Learning
    A nurse in the US sued Louisville, Ky.-based Kindred Healthcare this week, alleging the organisation fired him in retaliation for raising patient safety concerns.
    Sean Kinnie worked as an intensive care unit nurse at Kindred Hospital-San Antonio. Mr Kinnie claims he was suspended twice and then fired after leaders at the 59-bed transitional care hospital learned he anonymously reported patient safety concerns to The Joint Commission in November 2019 and January. 
    Mr Kinnie said issues related to inadequate staffing and unsanitary care environments put patients in "grave danger," according to the lawsuit. He also said the hospital created a culture in which employees were afraid to stand up for patients for fear of retaliation from management. 
    In January, Mr Kinnie told the hospital's chief clinical officer Sharon Danieliewicz that he was the staff member who reported the patient safety concerns to The Joint Commission. Mr. Kinnie claims he faced increased scrutiny after this disclosure and was ultimately fired Feb. 24 for violating facility policy.
    Read full story
    Source: Becker's Hospital Review, 24 August 2020
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