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Patient Safety Learning

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  1. Patient Safety Learning
    Great Ormond Street Hospital (GOSH) failed to properly investigate child deaths, suggests evidence uncovered by the BBC.
    The source of one fatal infection was never examined and in another case GOSH concealed internal doubts over care. Amid claims GOSH put reputation above patient care, former Health Secretary Jeremy Hunt urged it to consider a possible "profound cultural problem".
    Responding, the central London hospital said it rejected all suggestions that it treated any child's death lightly.
    BBC Radio 4's File on 4 programme has spoken to several families whose children were treated at the world-famous hospital. All said that while care at one point had been excellent, when things went wrong GOSH appeared to have little interest in fully understanding what had happened.
    The concerns over how Great Ormond Street is run are shared by staff. A staff survey, published last month, made grim reading for management.
    On two aspects, including whether there is a safety culture, it received the lowest score of all trusts in its category, while on three other questions, including how bad bullying and harassment were, and how good the quality of care was, its own staff rated it as among the worst.
    "If we want the NHS to offer the highest quality care in the world, then we have to change a blame culture and sometimes a bullying culture, for a learning and an improvement culture," the former Health Secretary Jeremy Hunt told File on 4.
    "That staff survey would indicate they don't have that culture at Great Ormond Street."
    Read full story
    Source: BBC News, 17 March 2020
    Read Joanne Hughes' response to this news in her blog shared on the hub.
  2. Patient Safety Learning
    An 88-year-old woman with dementia was physically and mentally abused at a luxury care home charging residents close to £100,000 a year, the Guardian can reveal.
    Staff misconduct was exposed by secret filming inside the home run by Signature Senior Lifestyle, which operates 36 luxury facilities mostly in the south of England.
    It has admitted that Ann King was mistreated at Reigate Grange in Surrey earlier this year.
    Distressing footage from a covert camera inside her room shows:
     Care staff handling King roughly, causing her to cry out in distress. On one occasion she was left on the floor for 50 minutes.  King being taunted, mocked and sworn at when she was confused and frightened.  The retired nurse being assaulted by a cleaner, who hits her with a rag used to clean a toilet while she is lying in bed.  The cleaner threatening to empty a bin on the pensioner’s head and making indecent sexual gestures in her face. The abuse was exposed by King’s children, Richard Last and Clare Miller. They became so concerned about her wellbeing at the care home, where she lived from January 2021 to March 2022, that they installed a hidden camera on her bedside table.
    They have shared the footage because they fear what happened to their mother may not be an isolated incident, and because: “She has always been horrified by this type of thing and we felt she would have wanted us to show this is going on.”
    Read full story
    Source: The Guardian, 13 October 2022
  3. Patient Safety Learning
    The chief executive of one of England’s most prestigious private hospitals has lost her employment tribunal claim that she was dismissed for whistle blowing over patient safety issues.
    Aida Yousefi ran the Portland Hospital in central London from January 2017 until her dismissal in December 2019 on two counts of gross misconduct. She was also in charge of The Harley Street Clinic and a specialist cancer centre. 
    Ms Yousefi’s argument that she was removed after raising concerns about the patient safety was rejected by central London employment tribunal in a judgment published last week.
    The judge instead ruled that while other senior staff had raised patient safety concerns over cost-cutting, there was no evidence that Ms Yousefi had done so.
    In their judgment the tribunal panel said: “In oral evidence the claimant further accepted that, as CQC-registered manager, if patient safety concerns were not being dealt with she should have raised it with CQC. She did not do so at any point during her employment.”
    Staffing concerns were raised by The Harley Street Centre chief nursing officer Claire Champion and others. However, the tribunal heard evidence that doing so could be frowned upon by senior management at HCA International.
    The tribunal was shown an email from then vice president of financial operations at THSC and the Portland Enda O’Meara saying “Frankly – we are starting to piss some very senior people off in appearing that we can’t [make savings]. We can’t always cite patient safety. Because the response will always be other facilities are doing it”. 
    Another email from Mr O’Meara said: “Please don’t cite ’patient safety’ unless you truly believe it to be the case. This term is particularly sensitive and nothing winds them up more”.
    Read full story (paywalled)
    Source: HSJ, 28 March 2022
  4. Patient Safety Learning
    A new high of 6.4 million people in England were waiting for routine NHS treatment in March 2022, as 12 hours waits in A&E hit an all time high last month and ambulance services continued to struggle.
    This is up from 6.2 million in February and is the highest number since records began in August 2007.
    A new record of 24,138 people had to wait more than 12 hours in A&E after a decision to admit them had been made in April.
    The figure is up from 22,506 in March, and is the highest for any calendar month in records going back to August 2010.
    However the number of patients being seen within four hours in April improved compared to March, with 72.3% of patients seen in this time compared to 71.6%.
    Professor Stephen Powis, national medical director for NHS England, said: “Today’s figures show our hardworking teams across the NHS are making good progress in tackling the backlogs that have built up with record numbers of diagnostic tests and cancer checks taking place in March, as part of the most ambitious catch up plan in NHS history.
    “We always knew the waiting list would initially continue to grow as more people come forward for care who may have held off during the pandemic, but today’s data show the number of people waiting more than two years has fallen for the second month in a row, and the number waiting more than 18 months has gone down for the first time."
    Read full story
    Source: The Independent, 12 May 2022
  5. Patient Safety Learning
    An NHS mental health trust that has been the worst performing in England has been warned it must improve after failing another inspection.
    Norfolk and Suffolk NHS Foundation Trust (NSFT) has been rated "inadequate" in the latest Care Quality Commission (CQC) report.
    The CQC said it had served the trust with a warning notice that it had to act on to improve patient care.
    The trust has been rated "inadequate" on three previous occasions by the health watchdog, as well as being the only one currently within the NHS's improvement regime for not meeting standards.
    Following the latest inspection, its overall rating was downgraded from "requires improvement" - and three out of five measures assessed by the CQC, for safety, leadership and effectiveness, met its lowest grading.
    The report said two wards were immediately closed to new patients following a CQC visit in November, after the trust was threatened with enforcement action if urgent measures were not taken.
    Significant staffing problems, including an annual nurse vacancy rate of more than 17%, were also highlighted.
    Staff at an adult long stay ward did not complete regular checks on patients supposed to happen every 30 to 60 minutes, which meant they were unaware if somebody needed help for periods of up to seven hours.
    Inspectors also said there had been a severe deterioration on the trust's inpatient ward for children and young people - the Dragonfly Unit in Carlton Colville, Suffolk.
    They found it was reliant on agency workers and lacked a permanent doctor.
    Read full story
    Source: BBC News, 27 April 2022
  6. Patient Safety Learning
    Patient safety campaigners have said ‘too many women’ are still not being offered a general anaesthetic for a diagnostic test because of staff shortages, leaving them in severe pain.
    A survey by the Campaign Against Painful Hysteroscopies found around 240 women – which equates to 80 per cent of respondents – who had a hysteroscopy since the start of 2021 said they were not told they could have a general anaesthetic prior to the procedure.
    This suggests the situation has only improved marginally since 2019, when the campaign group first started collecting data. A spokeswoman from the campaign group called the pain being endured by women “barbaric” and said staffing shortages need to be addressed.
    Guidance from the Royal College of Obstetricians and Gynaecologists said all pain relief options, including general anaesthetic, should be discussed.
    Helen Hughes, chief executive of Patient Safety Learning, said: “We are hearing from too many women that they are not being given the full information about the procedure. It damages their trust and makes them worry about accessing future services.”
    She said: “It’s distressing that despite what we know, [the guidance] is not being implemented properly. Informed consent is essential for patient safety as well as a legal requirement.”
    Read full story (paywalled)
    Source: HSJ, 7 June 2022
    What is your experience of having a hysteroscopy? Share your experiences on the hub in our community forum.
    Further reading:
    House of Commons Debate - NHS Hysteroscopy Treatment Through the hysteroscope: Reflections of a gynaecologist Minister acknowledges patients’ concerns about painful hysteroscopies; but will action be taken? Improving hysteroscopy safety: Patient Safety Learning blog Outpatient hysteroscopy: RCOG patient leaflet
  7. Patient Safety Learning
    People suffering 'Long Covid’ symptoms will be offered specialist help at clinics across England, the head of the NHS announced today.
    Respiratory consultants, physiotherapists, other specialists and GPs will all help assess, diagnose and treat thousands of sufferers who have reported symptoms ranging from breathlessness, chronic fatigue, 'brain fog', anxiety and stress.
    Speaking at the NHS Providers conference today (Wednesday), NHS chief executive Sir Simon Stevens will announce that £10 million is be invested this year in additional local funding to help kick start and designate Long Covid clinics in every area across England, to complement existing primary, community and rehabilitation care.
    Sir Simon said new network will be a core element of a five-part package of measures to boost NHS support for Long Covid patients:
    New guidance commissioned by NHS England from NICE by the end of October on the medical ‘case definition’ of Long Covid. This will include patients who have had covid who may not have had a hospital admission or a previous positive test. It will be followed by evidence-based NICE clinical guidelines in November on the support that Long Covid patients should receive, enabling NHS doctors, therapists and staff to provide a clear and personalised treatment plan. This will include education materials for GPs and other health professionals to help them refer and signpost patients to the right support. The ‘Your Covid Recovery’ – an online rehab service to provide personalised support to patients. Over 100,000 people have used the online hub since it launched in July, which gives people general information and advice on living with Long Covid. Phase 2 of the digital platform will see people able to access a tailored rehabilitation plan. This service will be available to anyone suffering symptoms that are likely due to COVID-19, regardless of location or whether they have spent time in hospital.  Designated Long Covid clinics, as announced today. This will involve each part of the country designating expert one-stop services in line with an agreed national specification. Post-covid services will provide joined up care for physical and mental health, with patients having access to a physical assessment, a cognitive assessment and a psychological assessment. Patients could also then be referred from designated clinics into specialist lung disease services, sleep clinics, cardiac services, rehabilitation services, or signposted into IAPT and other mental health services. NIHR- funded research on Long Covid which is working with 10,000 patients to better understand the condition and refine appropriate treatment. The NHS’s support will be overseen by a new NHS England Long Covid taskforce which will include Long Covid patients, medical specialists and researchers. Read full story
    Source: NHS England, 7 October 2020
    Read Patient Safety Learning's response to this news
    Please share your thoughts with us on the support that is needed on our patient safety platform, the hub.
  8. Patient Safety Learning
    An NHS England review into the behaviour of high-profile senior leaders who took over a Midlands trust has concluded that the interim CEO “behaved poorly and inappropriately” while its chair was “complicit with” and failed to address problems.
    NHS England had commissioned an independent probe into allegations about the behaviour of new executives, who had recently been appointed to the board of Walsall Healthcare Trust.
    David Loughton and Professor Steve Field, who hold the same roles at the Royal Wolverhampton Trust, were brought in as interim chief executive and chair respectively in spring 2021.
    Walsall has faced care quality concerns for some years and it was hoped the pair from neighbouring Wolverhampton would bring improvements. 
    Dr McLean wrote in her review: “Leadership changes can, understandably, represent a period of anxiety for those affected but this can be minimised if changes are made in line with appropriate values and processes. 
    “Whilst I conclude that the joint chair and interim CEO were motivated to act in the best interests of patients, I was saddened by much of what I heard.
    ”In the narratives I heard, there was a consistent lack of compassion or respect for people.”
    She concluded: “The interim CEO, while motivated by the safety and care of patients, has behaved poorly and inappropriately … the joint chair has been complicit with and failed to address this behaviour.”
    Read full story (paywalled)
    Source: HSJ, 2 February 2022
  9. Patient Safety Learning
    Hundreds of women have said they’ve undergone “distressing” diagnostic tests at NHS hospitals which were not carried out in line with recommended practice.
    Around 520 women who attended NHS hospitals in England to undergo hysteroscopies — a procedure which uses narrow telescopes to examine the womb to diagnose the cause of heavy or abnormal bleeding — have told a survey their doctors carried on with their procedures even when they were in severe pain.
    This is despite the Royal College of Obstetricians and Gynaecologists advising clinicians should offer to reschedule with the use of general anaesthetic, epidural or sedation if the pain becomes unbearable. 
    The Campaign Against Painful Hysteroscopy patient group has surveyed 860 women who had had the procedure at an English NHS hospital, and shared the results with HSJ. Of them, 750 said they were left distressed, tearful or shaken by the procedure, with around 466 of them saying that feeling remained for longer than a day.
    Many of the women said their painful hysteroscopies damaged their trust in healthcare professionals, had made cervical smears more painful and had a negative impact on sexual relationships.
    Patient Safety Learning have connected with the campaigning group 'Hysteroscopy Action' on this issue. We have seen stories and comments posted on the hub from patients who have suffered similar distressing experiences. We are using this feedback and evidence to help campaign for safer, harm-free care. We welcome others to join in the conversation.
    Read full story (paywalled)
    Source: HSJ, 2 March 2020
  10. Patient Safety Learning
    A hospital has made changes after two patients were accidentally given medical air instead of oxygen.
    The two incidents, which took place at the Norfolk and Norwich University Hospital (NNUH), were classed as "never events" meaning they were serious but preventable.
    They happened to patients in November who were being handed over to the hospital by the East of England Ambulance Service.
    The patients should have been given oxygen but were given medical air instead which only contains 20pc oxygen.
    The ambulance service said in a message to staff: "Severe harm or death can occur, if medical air is accidentally administered to patients instead of oxygen. As per NNUH's request, with immediate effect, when handing over at the NNUH, all medical equipment and oxygen should be swapped only by an emergency department doctor or registered nurse."
    Read full story
    Source: Eastern Daily Press, 2 December 2019
  11. Patient Safety Learning
    The NHS 111 helpline for urgent medical care is facing calls for an investigation after poor decision-making was linked to more than 20 deaths.
    Experts say that inexperienced call handlers and the software used to highlight life-threatening emergencies may not always be safe for young children. At least five have died in potentially avoidable incidents.
    Professor Carrie MacEwen, Chairwoman of the Academy of Medical Royal Colleges, said: “These distressing reports suggest that existing processes did not safeguard the needs of the children in these instances.”
    Since 2014 coroners have written 15 reports involving NHS 111 to try to prevent further deaths. There have been five other cases where inquests heard of missed chances to save lives by NHS 111 staff; two other cases are continuing and one was subject to an NHS England investigation.
    Read full story (paywalled)
    Source: The Times, 5 January 2020
  12. Patient Safety Learning
    ‘Unprofessional’ behaviours, a lack of compassion, and tension among staff and managers are all contributing to pockets of ‘poor culture’ at an acute trust.
    A Freedom to Speak Up report presented to the board of Buckinghamshire Healthcare Trust found there had been an increase in bullying and reports of staff members being “humiliated” during the last three months.
    The report, which covers the first two quarters of 2021-22, highlighted a “lack of compassion, kindness, and understanding” between colleagues and noted “increasing levels of frustration” that people are not being held to account for “unprofessional” poor behaviours.
    The report added the findings were not surprising due to the pressures of the pandemic experienced by staff.
    It found: “There appears to be an increase in the proportion of concerns around interpersonal behaviours and communication issues as well as levels of frustration and tension amongst staff and managers.”
    Read full story (paywalled)
    Source: HSJ, 24 November 2021
  13. Patient Safety Learning
    Leaving the EU means the UK has greater control over the training of healthcare professionals. The Department of Health and Social Care (DHSC) has announced that nurses and other allied healthcare professionals will be able to retrain as doctors ‘more quickly’ now the UK has left the EU.
    Under training standards set by the EU, existing healthcare professionals wishing to move into another area would have to complete a set standard of training, regardless of any existing health background or qualifications. Under the potential new system, a nurse who has been in the job for 10 years could benefit from training standards based upon experience and qualifications, rather than strict time-frames.
    Health Secretary Matt Hancock said: “Our incredible NHS is full of highly-qualified and dedicated professionals – and I want to do everything I can to help them fulfil their ambitions and provide the best possible care for patients. Without being bound by EU regulations, we can focus on ensuring our workforce has the necessary training which is best suited to them and their experience, without ever compromising on our high standards of care or on patient safety. The plans we are setting out today mean that we can retrain healthcare workers and get them back to the frontline faster. This is good for patients, and good for our NHS."
    Nursing leaders warn that the move needs to come without compromising patient care. Andrea Sutcliffe CBE, Chief Executive and Registrar at the Nursing and Midwifery Council (NMC) said: “Having enough health and care professionals with the right knowledge, skills and values is vital to meet the individual needs of people across all four countries of the UK now and in the future."
    “The NMC supports the wish to explore how education and training for registered nurses and midwives may be achieved in more flexible ways while ensuring our high standards are maintained and not compromised. Every nursing and midwifery professional must be safe and competent to provide the best care and support possible."
    Read full story
    Source: Nursing Notes, 9 February 2020
  14. Patient Safety Learning
    Today is Global Handwashing Day, a global advocacy day dedicated to increasing awareness and understanding about the importance of handwashing with soap as an effective and affordable way to prevent diseases and save lives.
    hub content on handwashing:
    WHO: Guidance on engaging patients and patient organisations in hand hygiene initiatives
    Safety and Health Practitioner: Tips for hand hygiene 
    Hand washing dance - this is how we do it
    What initiatives are in your hospital to ensure "clean hands for all"? Share your tips on the hub.
  15. Patient Safety Learning
    ‘Disparity ratios’ highlighting how staff with minority ethnic backgrounds are represented at different levels in each trust have been created by the national workforce race equality standard programme to help tackle ‘racist practice’ in the NHS.
    NHS England head of WRES Professor Anton Emmanuel said the data had been created to indicate the differences in progression between white people and those from an ethnic minority background through the ranks of each organisation.
    Detail of the methodology used to calculate the ratios has not been published, but it appears they have been determined by comparing the share of staff by ethnicity in different bands. 
    Speaking at the Ambulance Leadership Forum last week, professor Emmanuel, said: “We have gone through each of the seven regions of the country and presented to them the local disparity ratios for each trust and put that into a heatmap…The whole point is to make that data digestible and actable on.”
    The data can be adapted to look at different points in a trust’s progression routes and can also be used with other groups, such as disabled staff. 
    Read full story (paywalled)
    Source: HSJ, 24 May 2021
  16. Patient Safety Learning
    People with learning disabilities have been given do not resuscitate orders during the second wave of the pandemic, in spite of widespread condemnation of the practice last year and an urgent investigation by the care watchdog.
    Mencap said it had received reports in January from people with learning disabilities that they had been told they would not be resuscitated if they were taken ill with COVID-19.
    The Care Quality Commission (CQC) said in December that inappropriate Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) notices had caused potentially avoidable deaths last year.
    DNACPRs are usually made for people who are too frail to benefit from CPR, but Mencap said some seem to have been issued for people simply because they had a learning disability. The CQC is due to publish a report on the practice within weeks.
    The disclosure comes as campaigners put growing pressure on ministers to reconsider a decision not to give people with learning disabilities priority for vaccinations. There is growing evidence that even those with a mild disability are more likely to die if they contract the coronavirus.
    Read full story
    Source: The Guardian, 13 February 2021
  17. Patient Safety Learning
    A survey of an area’s GPs and other primary care staff found those from a minority ethnic background feel they are less involved in decision making and less respected by their colleagues, according to results shared with HSJ.
    The survey, instigated by GPs in Doncaster, South Yorkshire, also found more staff from a minority ethnic background said they had experienced some form of bullying or harassment, including “instances of physical violence”.
    The work is thought to be unusual in primary care — annual “workforce race equality standard” surveys are required by NHS England for NHS trusts and, in the past year, clinical commissioning groups, but not in primary care. 
    The survey in October was instigated by Doncaster Primary Care BAME Network and facilitated by Doncaster clinical commissioning group. It was sent to GPs and practice staff, community pharmacy staff, and other “healthcare professionals” in primary care. There were 136 respondents.
    The report of the results said minority ethnic staff felt they were less able to make decisions to improve the work of primary care, less involved in decisions regarding their area of work and less respected by their colleagues compared with their white colleagues.
    Read full story (paywalled)
    Source: HSJ, 9 March 2021
  18. Patient Safety Learning
    A hernia mesh lawsuit recently filed by a Washington woman alleges that a Strattice “pig skin” mesh product used during her hernia repair was defective and failed, resulting in the need for two additional revision surgeries.
    The Strattice Reconstructive Tissue Matrix is a hernia repair mesh introduced in 2008, which is constructed from porcine, or pig skin. The mesh is then preserved in a phosphate buffered aqueous solution. It is marketed as a cross-linked graft device, which is intended to chemically link the proteins in the tissue together. However, a growing number of lawsuits allege that the design actually increases the risk of foreign body responses, infections and other complications.
    Hundreds of injuries and several deaths have been linked to the Strattice hernia mesh made from pig skin, according to the lawsuit.
    Read full story
    Source: About Lawsuits.com, 20 January 2023
  19. Patient Safety Learning
    NHS bosses have attacked the country’s leading private mental healthcare chain for failing to keep patients safe, The Times has learnt, as an investigation reveals the Priory Group has been criticised for failings in the care of 30 patients who have died.
    An investigation by this newspaper reveals that the company, which earns at least £400 million a year from public sector contracts for looking after mentally ill patients, has been repeatedly criticised for the same failures of care over the past decade.
    This week the Priory was criticised in the inquest of Eliana Hanton, 20, who died after hanging herself using a ligature point that had been highlighted as a risk in an internal audit four months earlier.
    An inquest in Birmingham last week concluded that neglect by the Woodbourne Priory Hospital contributed to the death of Matthew Caseby, 23.
    The company has repeatedly been criticised for the same failings in relation to patient deaths, leading to questions about whether it is learning from its mistakes, including inadequate or inaccurate risk assessments, staff's lack of training or expertise, a failure to address known ligature points or escape routes and materials which could be used to self-harm, and poor record keeping.
    Read full story (paywalled)
    Source: The Times, 29 April 2022
  20. Patient Safety Learning
    A struggling ambulance trust could face a ‘Titanic moment’ and collapse entirely this summer if the region’s worsening problems with hospital handover delays are not taken more seriously, its nursing director has told HSJ.
    Mark Docherty, of West Midlands Ambulance Service (WMAS), said patients were “dying every day” from avoidable causes created by ambulance delays and that he could not understand why NHS England and the Care Quality Commission were “not all over” the issue.
    He revealed that handover delays at the region’s hospitals were the worst ever recorded, that rising numbers of people were waiting in the back of ambulances for 24 hours, and that serious incidents have quadrupled in the past year, largely due to severe delays.
    More than 100 serious incidents recorded at WMAS relate to patient deaths where the service has been unable to respond because its ambulances are held outside hospitals, according to the minutes of the trust’s March quality and safety committee.
    "Around 17 August is the day I think it will all fail,” he said. “I’ve been asked how I can be so specific, but that date is when a third of our resource [will be] lost to delays, and that will mean we just can’t respond. Mathematically it will be a bit like a Titanic moment.
    ”It will be a mathematical certain that this thing is sinking, and it will be pretty much beyond the tipping point by then.”
    Read full story (paywalled)
    Source: HSJ, 25 May 2022
  21. Patient Safety Learning
    A serious coronavirus-related syndrome may be emerging in the UK, according to an “urgent alert” issued to doctors, following a rise in cases in the last two to three weeks, HSJ has learned.
    An alert to GPs and seen by HSJ says that in the “last three weeks, there has been an apparent rise in the number of children of all ages presenting with a multisystem inflammatory state requiring intensive care across London and also in other regions of the UK”.
    It adds: “There is a growing concern that a [covid-19] related inflammatory syndrome is emerging in children in the UK, or that there may be another, as yet unidentified, infectious pathogen associated with these cases.”
    Little is known so far about the issue, nor how widespread it has been, but the absolute number of children affected is thought to be very small, according to paediatrics sources. The syndrome has the characteristics of serious COVID-19, but there have otherwise been relatively few cases of serious effects or deaths from coronavirus in children. Some of the children have tested positive for COVID-19, and some appear to have had the virus in the past, but some have not.
    Read full story
    Source: HSJ, 27 April 2020
    Do you work in paediatrics? Have you seen similar trends emerging? What are your thoughts on the concerns raised? Join the conversation in the hub community area: 
     
  22. Patient Safety Learning
    Six directors will lead the different units of NHS England’s new transformation directorate created by merging NHS Digital and NHSX into the organisation.
    Documents obtained by HSJ show how the transformation directorate’s senior team will be structured in the interim period until NHSD and NHSX are fully merged with NHSE.
    The new directorate is led by Tim Ferris, who was appointed last year as NHSE sought to speed up the digital transformation of NHS services.
    The directorate has outlined 10 draft priorities for the next few years, including ambitious proposals to install electronic patient records at every NHS trust, make electronic clinical decision support systems “the norm” for clinicians, and a huge expansion of virtual wards.
    The remaining seven priorities are:
    Expanding the functions and uptake of the NHS App; Increase diagnostics capacity; Data architecture and infrastructure for population health, planning and research; Population health and personalised prevention; Exploiting the NHS’s purchasing power; NHS as a platform for rapid cycle research and innovation; and Redesign pathways using digital tools. Read full story (paywalled)
    Source: HSJ, 8 February 2022
  23. Patient Safety Learning
    A children’s nurse who raised legitimate concerns over racial discrimination at a major London trust was suspended and victimised by her managers for doing so, an employment tribunal has ruled.
    Jeyran Panahian-Jand, who worked on a children’s ward at Whipps Cross Hospital, parts of Barts Health Trust, had raised concerns with her manager in 2019 that staff were divided on “racial lines”, with an “unfair allocation of work”, as well as bullying of two junior staff.
    Her manager Heather Roberts, as well as other superiors, told Ms Panahian-Jand she should raise a formal complaint, without offering to look at the issues raised and keep the complaint informal, which the tribunal said they should have done under whistleblowing policies.
    Ms Roberts later accused Ms Panahian-Jand, who identified as white, of continuing to talk about her allegations on the ward, and with the agreement of Ghislaine Stephenson, the associate director of nursing for children, Ms Panahian-Jand was suspended for the “disruption” and “upset” she was causing, the tribunal judgment said.
    Ms Panahnian-Jand then lodged a formal complaint over race discrimination, as well as accusing two other bank nurses of making “racially abusive” remarks. A subsequent internal investigation supported three allegations of race discrimination made by Ms Panahian-Jand, while a separate probe into her own alleged misconduct found there was no case to answer.
    Read full story (paywalled)
    Source: HSJ, 23 February 2021
  24. Patient Safety Learning
    The NHS is currently rolling out services on NHS sites to test people for coronavirus, including a new service now in action in west London, offering ‘drive through’ coronavirus testing.
    The new service, provided by Central London Community Healthcare NHS Trust in Parsons Green, is only accessed through a referral from NHS 111, and means people worried about the virus can safely and quickly get checked close to home.
    The model is one of the ways in which community testing and home testing are being rolled out nationwide, with the NHS’ strategic incident director for coronavirus, asking health services in every part of England to set up home and community testing.
    After being referred through NHS 111, people are invited to an appointment in their car, during which two community nurses carry out a swab in the nose and mouth, which are checked and assessed within 72 hours.
    People are asked to self-isolate while checks are completed, to prevent any potential onward transmission of the virus.
    Dr Joanne Medhurst, medical director for Central London Community Healthcare NHS Trust, said: “Anyone who is worried about coronavirus should call NHS 111 for up to date advice. We’ve set up the ‘drive through’ service to make sure people in our community can get safe, convenient and quick checks for coronavirus, as part of NHS efforts to keep everyone safe."
    “It’s crucial that, as a community service, we help residents in our area to get accurate, timely advice while managing extra pressure on the NHS, and so far this week we’ve had good feedback from people that the swabbing service offers reassurance at what can be a difficult time.”
    Read full story
    Source: NHS England, 28 February 2020
  25. Patient Safety Learning
    Today, we are proud to announce the official launch of the hub, our shared learning platform for patient safety.
    We have been hard at work since launching the hub in beta in July, continuing to develop and improve the platform. Now, the hub is officially ready to be used by everyone committed to improving safety – patients and their families, clinicians, patient safety experts, and health and social care organisations.
    the hub has been designed with clinicians, patient safety experts and patients following research by Carl Macrae, Professor of Organisational Behaviour and Psychology at Nottingham University Business School and a renowned specialist on patient safety.
    the hub will be a crucial online repository for sharing different experiences and perspectives of what has worked well, as well as case studies, research papers, blogs, investigation reports, policy guidance and toolkits. It will provide a platform where people can ask questions, seek advice and share ideas to improve patient safety.
    Registration and use of the hub are free.
    Help us work towards the patient-safe future by joining the hub, sharing your learning and hearing valuable insight from others in health and social care.
    Join the hub today
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