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Patient Safety Learning

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  1. Event
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    This Westminster conference will discuss next steps for improving health outcomes for children and young people in England. Delegates will assess the future of the new network of Family Hubs, with discussion on improving the coordination and accessibility of children’s care, as well as shifting focus towards early intervention and prevention, and improving the provision of support to families. It will be an opportunity to review progress on and next steps for The best start for life: a vision for the 1,001 critical days, which looks at providing support for local authorities in addressing the needs of children and their families, and consider the future of children’s health data. Further sessions will examine measures that were included in the Plan for Patients, which sets out to improve access to children’s mental health services, and enhance funding and regulation to reduce care backlogs. Overall, areas for discussion include: Family Hubs: progress made so far in implementation - addressing challenges in the transition to the family hub service model the role of community support - delivering long-term improvements to the lives of families - improving engagement and communication with families utilising the Family Hubs to improve coordination across support services - developing and sharing best practice across local authorities. Impact of poverty and cost of living pressures: latest thinking on approaches to mitigating the impact of poverty on child development understanding the economic pressures on families - addressing their impact children’s health implementing early intervention and prevention programmes - applying lessons learnt from the Surestart programme. Developing child health services: addressing waiting times and care backlogs - returning service provision to pre-pandemic levels. next steps for regulation and funding - the role of integrated care systems in supporting local needs. Mental health support: developing the community-based offer for mental health support - enabling service coordination meeting the increased demand for services - evaluating resource allocation early years development: progress made following publication of the final Leadsom Review - acting on the recommendations - the future for health visiting and child development checks. Digital health and data sharing: opportunities and issues arising from the use and sharing of child health data - increasing the quality of NHS records to improve outcomes - faster identification of health and social concerns latest thinking on data sharing practices - evaluating digital security provisions, Register
  2. Content Article
    The NHS Staff Survey is one of the largest workforce surveys in the world and is carried out every year to improve staff experiences across the NHS. It asks staff in England about their experiences of working for their respective NHS organisations. 636,384 staff responded to the survey in 2022. The full results of the 2022 NHS Staff Survey are published on the NHS Staff Survey website.
  3. News Article
    Progress being made on tackling the hospital waiting backlog will be put at risk by next week's junior doctors' strike, NHS bosses are warning. NHS England medical director Prof Sir Stephen Powis said there had been huge achievements over the winter. But he said it was inevitable the 72-hour walkout in England, which starts on Monday, would have an impact. It comes as the annual NHS staff survey shows a falling number happy to recommend the care at their service. The poll found 63% would be happy to see a friend or relative treated - down by five percentage points in the past year and 11 over two years. Meanwhile, latest performance data shows NHS emergency services are continuing to miss their targets, although the situation is not getting worse. Dr Tim Cooksley, president of the Society for Acute Medicine, said despite the situation not getting worse it still presented a "damning" picture, and warned it was "increasingly causing harm to patients". Read full story Source: BBC News, 9 March 2023
  4. News Article
    Nine care home workers are facing trial for neglecting, verbally abusing and deliberately antagonising extremely vulnerable patients in care described as “devoid of kindness and respect” but also criminal. The six men and three women, aged 25-54, are being prosecuted after a reporter went undercover and filmed the behaviour for a BBC Panorama documentary. Opening the case at Teesside crown court in Middlesbrough, the prosecuting barrister, Anne Richardson, said the patients all resided at Whorlton Hall, a 17-bed independent specialist hospital unit near Barnard Castle, County Durham, operated by Cygnet Health Care. Richardson said caring for such residents was a “hard, demanding job, and that carers can face complex, difficult, obstreperous, and sometimes violent people who sadly do not realise what they are doing and cannot help their actions.” But they deserved to be treated with “kindness, respect and patience.” Richardson said the jury would hear evidence of ill-treatment which was “cruel and abusive”. It was “not only devoid of the respect and kindness that those residents deserved but was also a criminal offence”. It included care workers repeatedly saying words they knew to be triggers to patients, belittling those in their care and deliberately antagonising them. Read full story Source: The Independent, 8 March 2023
  5. News Article
    A staffing crisis in children’s dentistry has prompted the urgent removal of junior doctors from Great Ormond Street Hospital NHS Foundation Trust (GOSH. GOSH has struggled to recruit consultants for its paediatric dentistry services for at least two years, which has led to trainee doctors going unsupervised, according to a new report by regulator Health Education England. A report seen by The Independent said the service was running with just one part-time consultant but needed at least two. The news comes amid a national “crisis” in dentistry, with the latest data from the government showing that half of all children’s tooth extractions in 2021-22 were due to “preventable tooth decay”. GOSH told The Independent it was struggling with a “limited pool” of paediatric dentists and, as a result of shortages, many patients were waiting longer than the 18-week standard. Read full story Source: The Independent, 8 February 2023
  6. News Article
    Covid-19 may not have taken as great a toll on the mental health of most people as earlier research has indicated, a new study suggests. The pandemic resulted in “minimal” changes in mental health symptoms among the general population, according to a review of 137 studies from around the world led by researchers at McGill University in Canada, and published in the British Medical Journal. Brett Thombs, a psychiatry professor at McGill University and senior author, said some of the public narrative around the mental health impacts of Covid-19 were based on “poor-quality studies and anecdotes”, which became “self-fulfilling prophecies”, adding that there was a need for more “rigorous science”. However, some experts disputed this, warning such readings could obscure the impact on individual groups such as children, women and people with low incomes or pre-existing mental health problems. They also said other robust studies had reached different conclusions. Read full story Source: The Guardian, 8 March 2023
  7. Content Article
    Concerns about Covid-19 related mental health are substantial, but the sheer volume of low quality evidence has posed a barrier to evidence synthesis and decision making. In this systematic review,  Thombs et al. synthesised results of mental health outcomes in cohorts before and during the Covid-19 pandemic. The authors compared general mental health, anxiety symptoms, and depression symptoms in the general population and other groups during covid-19 with outcomes from the same cohorts before Covid-19. The study found high risk of bias in many studies and substantial heterogeneity suggest caution in interpreting results. Nonetheless, most symptom change estimates for general mental health, anxiety symptoms, and depression symptoms were close to zero and not statistically significant, and significant changes were of minimal to small magnitudes. Small negative changes occurred for women or female participants in all domains. The authors will update the results of this systematic review as more evidence accrues.
  8. News Article
    England’s care regulator has been accused of failing to keep private nursing home residents safe after a family alleged a delay in exposing serious risks led to a loved one’s painful premature death. Relatives of Bernard Chatting, 89, said they relied on a “good” rating from the Care Quality Commission when they moved him into a £1,200-a-week home in Dorset. But after he experienced care so unsafe he ended up in hospital and died a few weeks later, it emerged the CQC already knew the home was failing badly. The case comes as CQC’s traffic light ratings become increasingly important for people looking to place relatives in England’s 17,000 care homes amid a staffing and funding crisis which experts fear could increase the risk of maltreatment of the most vulnerable citizens. The ratings from inadequate to outstanding are one of the few ways that families can check care standards. “We wouldn’t have sent Dad there if we knew,” said Chatting’s son-in-law, Phil Davenport. “It is beyond my understanding how the CQC inspect, have serious concerns, and yet not advise the public more quickly. Read full story Source: The Guardian, 8 March 2023
  9. Content Article
    To mark International Women’s Day, host Helen McKenna speaks with Professor Dame Lesley Regan and Dr Janine Austin Clayton about women’s health journeys from start to finish. They explore why women can struggle to get medical professionals to listen to them and the impact this has on diagnosis and treatment, as well as the mental and physical effects on women themselves.
  10. News Article
    Lisa Hague, 38, was diagnosed with endometriosis at the age of 17 after being in such severe pain that she resorted to taking a powerful painkiller, dihydrocodeine, that had been prescribed to her partner for a sports injury. She had an allergic reaction to the codeine and was taken to hospital. After speaking to a doctor about why she had taken such a risk, she was referred for a laparoscopy and diagnosed. “I’d never heard of endometriosis before and didn’t know anyone that had it,” she says. The diagnosis was a relief, but there were few treatment options available and she has had to manage intense pain and very heavy bleeding for a few days each month. At times, she has resorted to sitting against hot radiators or taking scalding baths to “as a distraction from the internal pain”. “It is very dismissed still at the doctors,” she says. Hague says there is a “desperate need” for better treatments so that her teenage daughter’s generation do not face the same struggle. “Things have got to have changed since I was 17,” she says. Read full story Source: The Guardian, 8 March 2023
  11. News Article
    A trust spent £460,000 on legal fees trying to fight a patient safety whistleblowing case that it lost, it can be revealed. An employment tribunal judge rejected the idea that a consultant nephrologist had done anything to bring about her dismissal from Portsmouth Hospitals University Trust. Jasna Macanovic was subjected to what the tribunal earlier this year called “a campaign of harassment”, after she warned colleagues that a procedure they were using was harming patients. After relationships broke down in the Wessex Kidney Unit, she was referred to a disciplinary panel at which two board members – the former nursing director and the current medical director – offered her a good reference if she would resign. She refused and was dismissed in March 2018. The judge noted the offer was clear evidence that the disciplinary process was a foregone conclusion. Read full story Source: HSJ, 8 March 2023
  12. News Article
    Five women who say they were denied abortions in Texas despite facing life-threatening health risks have sued the state over its abortion ban. Texas bars abortions except for medical emergencies, with doctors facing punishment of up to 99 years in jail. According to the lawsuit, doctors are refusing the procedure even in extreme cases out of fear of prosecution. The Center for Reproductive Justice has filed the legal action on behalf of the five women and two healthcare providers that are also plaintiffs. "It is now dangerous to be pregnant in Texas," said Nancy Northup, the centre's president. One of the women, Amanda Zurawski, said she had become pregnant after 18 months of fertility treatments. She had just entered her second trimester when she was told she had dilated prematurely and that the loss of her foetus, whom she and her husband had named Willow, was "inevitable". "But even though we would, with complete certainty, lose Willow, my doctor could not intervene while her heart was still beating or until I was sick enough for the ethics board at the hospital to consider my life at risk," Ms Zurawski said. For three days, trapped in a "bizarre and avoidable hell", Ms Zurawski was forced to wait until her body entered sepsis - also known as blood poisoning - and doctors were allowed to perform an abortion, according to the lawsuit. Ms Zurawski spent three days in intensive care, leaving the hospital after a week, the legal action says. The ordeal has made it harder for her to conceive in future, she said. Read full story Source: BBC News, 8 March 2023
  13. Event
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    This intensive two day masterclass will provide Root Cause Analysis training in line with the 2019 Patient Safety Strategy and subsequent guidance. The course will offer a practical guide to conducting RCA with a focus on systems-based patient safety investigation as proposed within the latest guidance released by NHS England and NHS Improvement. The course provides insights into how RCA is evolving and gives detailed information on what standards RCA investigations are expected to reach following the detailed recent reviews of patient safety work across the NHS and healthcare. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/root-cause-analysis-2-day-masterclass or email: kate@hc-uk.org.uk. hub members receive 20% discount. Email info@pslhub.org for discount code.
  14. Event
    This national conference looks at the practicalities of serious incident investigation and learning from deaths in mental health services and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework). The Patient Safety Incident Response Framework (PSIRF) was published on 16th August 2022 and replaces the Serious Incident Framework. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement, and updates from PSIRF early adopter sites in mental health. The conference will also examine how the new framework will fit with the Royal College of Psychiatrists Care Review Tool for mortality review. The conference is particularly timely considering the current Essex Mental Health Independent Inquiry which has National Implications. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-of-deaths-serious-incidents-in-mental-health-services or email: frida@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow this conference on Twitter @HCUK_Clare #SIMental
  15. Event
    This conference focuses on recognising and responding to the deteriorating patient and ensuring best practice in the use of NEWS2. The conference will include National Developments including the recommendations on NEWS2 and Covid-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The day will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, the role of human factors in responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis and Covid-19, involving patients and families in recognising deterioration, using clinical judgement, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. The Recording of NEWS2 score, escalation time and response time for unplanned critical care admissions is now an NHS CQUIN goal. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit or email kate@hc-uk.org.uk. hub members receive a 20% discount. Email: info@pslhub.org Follow on Twitter @HCUK_Clare #DeterioratingPatient
  16. Event
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    Despite decades of attention to safety, the 2023 New England Journal of Medicine article titled "The Safety of Inpatient Health Care" ushers in a stark reminder that patients continue to experience unacceptably frequent, and often serious, harms while receiving care. This 2023 IHI Patient Safety Awareness Week free webinar features lead author and globally renown safety expert, Dr. David Bates, who will share perspective on the history of harm in health care, key findings, and insights from this recent publication, associated opportunities to improve identification and measurement of events, and methods for anticipating and preventing harm. Whether you’re a health care leader, safety or quality professional, direct care provider, or work in any setting or role in health care, you’ll leave this illuminating discussion with refreshed thinking about what’s essential for a radical reboot of safety and the role that you and your organizations can take to eliminate and prevent harm. Register
  17. Event
    Gender health inequalities have long been an issue. Women often struggle to be heard and to have their health and wellbeing needs met. There have been, and continue to be, many missed opportunities for health services to improve the health and wellbeing of all women. The event from the King's Fund will bring together those working in the health and care system to find practical solutions to the experiences women have, both in terms of their access to and experience of the health and care system, and disparities in outcomes. Join partners across the voluntary, community and social enterprise (VCSE) sector, local government, and organisations across the health and care system to discuss and explore opportunities embed women’s voices more deeply in the system. Register
  18. News Article
    Nearly three-quarters of children detained under the mental health act are girls, a new report has found, amid warnings youngsters face a “postcode lottery” in their wait for treatment. Average waiting times between children being referred to mental health services and starting treatment have increased for the first time since 2017 with the children’s commissioner describing support across the country as “patchy”. In the annual report on children’s mental health services, the watchdog warned that, although the average wait is 40 days, some children are waiting as long as 80 days for treatment after being referred in 2021-22. The analysis, published on International Women’s day, also says young girls represented the highest proportion of children detained under the mental health act last year, highlighting “stark and worrying” gender inequalities. Read full story Source: The Independent, 7 March 2023 Further reading on the hub: Top picks: Women's health inequity
  19. Content Article
    This is an annual report by the Children’s Commissioner review in children’s mental health services in England during 2021-22. It considers key trends in children’s access to mental health services and considers the current state of care provided to children who are admitted to inpatient mental health settings.
  20. News Article
    A two-month-old baby died after doctors mistook symptoms of a suspected perforated bowel for a cow’s milk intolerance. Nailah Ally was diagnosed with a hole in the heart before she was born and necrotising enterocolitis (NEC) shortly after her birth in October 2019. Nailah died from multiple organ failure after she was sent home from hospital and went into septic shock A consultant believed Nailah might have an intolerance to cow’s milk and changed the formula she was being fed. A spokesman for the family said: “Nailah’s case not only vividly highlights the dangers of sepsis, but the potential consequences of poor communication between doctors as well as between doctors and families.” Read full story (paywalled) Source: The Telegraph, 7 March 2023
  21. News Article
    Former patients of a surgeon who has been struck off say their lives have been ruined by his misconduct. The number of people harmed by Jeremy Parker is unknown but at least 123 are taking legal action. Their lawyer said the scale of harm caused by his malpractice "could be huge". A total of 53 allegations against him were found "proved" including dishonestly adding to the case notes of 14 patients, botching operations, not diagnosing infections, failing to consult colleagues and not obtaining patient consent. The General Medical Council also confirmed a patient had a leg amputated below the right knee after a procedure carried out by Mr Parker went awry. Christian Beadell from Fletchers Solicitors, which is representing former patients in a class action, said East Suffolk and North Essex NHS Trust (ESNEFT) had not answered questions over whether it had initiated a recall process to determine the number patients harmed. "It's difficult to say how many patients have been injured by him," Mr Beadell said. Read full story Source: BBC News, 8 March 2023
  22. Content Article
    Sex and gender bias in health and social care results in poor outcomes for patients and has a negative impact on safety during care and treatment. For the last two International Women’s Days, Patient Safety Learning has highlighted patient safety concerns on this topic, considering the broader risk to safety posed by this bias and the impact on outcomes and safety of women being historically underrepresented in clinical trials and medication research.[1] [2] The theme of this year’s International Women’s Day is #EmbraceEquity. In support of this aim, there are seven different missions which have been identified to help forge a gender-equal world, including one focused specifically on health: “To assist women to be in a position of power to make informed decisions about their health”[3] This year we will focus on this mission, considering the relationship between women’s health, informed consent and patient safety. We will first set out what we mean by informed consent, before discussing how failures in consent can have a negative impact on women’s health. Then we will consider the UK Women’s Health Strategy in relation to these issues, and discuss what is needed to improve patient safety.
  23. News Article
    The government’s response to the East Kent maternity scandal inquiry has been condemned as ‘very disappointing’ by its chair. More than four months on from the inquiry report, ministers this morning issued what they called an “initial response” to it, as a brief written statement to Parliament. It contained few specific proposals, instead saying government was kicking off a series of other reviews, and “working” with various other agencies. Inquiry chair Bill Kirkup, the well-regarded former medic and expert in care failures, told HSJ the response was poor and should have been “wider and deeper”. Dr Kirkup said the response showed government had “not grasped how fundamental” some of the issues outlined in his report were, and “what sort of initiative” was needed to address them. Read full story (paywalled) Source: HSJ, 7 March 2023
  24. News Article
    More than three years into the Covid pandemic, there are a host of important unanswered questions about Long Covid, which significantly limit healthcare providers’ ability to treat patients with the condition, according to US physicians and scientists. That vacuum of information remains as much of the US has moved on from the pandemic, while Covid long-haulers continue to face stigma and questions over whether their symptoms are real, providers say. “We don’t quite have our finger on the pulse of what’s wrong, what biologically is causing it, and that’s a big problem,” said Dr Marc Sala, co-director of the Northwestern Medicine Comprehensive Covid-19 Center. “It’s hard to direct drugs or treatments without having the biological underpinnings for why someone is feeling so fatigued with exercise.” In addition to the ambiguity around the root causes of Long Covid, there are also challenges in research because of how Covid can produce so many different symptoms. The Centers for Disease Control and Prevention list includes fatigue, respiratory issues and difficulty thinking or concentrating but also states that “post-Covid conditions may not affect everyone the same way”. “Everyone has a different constellation of symptoms,” said Dr Steven Deeks, an infectious disease specialist at the University of California, San Francisco. “Some people get better over time, some people wax and wane, some people get worse,” and so it is difficult for researchers to determine when a study should end and compare a drug versus a placebo. Read full story Source: The Guardian, 6 March 2023
  25. Content Article
    Statement from Maria Caulfield, Parliamentary Under Secretary of State (Minister for Mental Health and Women's Health Strategy) on the Government’s initial response to the report of the independent review into the maternity and neonatal services at East Kent University NHS Foundation Trust that was published on the 19 October 2022. NHS England commissioned Dr Bill Kirkup to undertake this review following concerns about the quality and outcomes of care.
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