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Patient Safety Learning

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  1. Patient Safety Learning
    NHS guidance ‘too long to read,’ say hospital staff as safety watchdog exposes systemic risks to patients.
    The Healthcare Safety Investigation Branch (HSIB) revealed some NHS staff had admitted not reading official guidance on how to avoid the ‘never event’ error as part of a new report identifying deeper systemic problems that it said left patients at an increased risk.
    The independent body warned patients across the NHS remained vulnerable to being injured or even killed by the error that keeps happening in hospitals despite warnings and safety alerts over the last 15 years.
    HSIB launched a national investigation into the problem of misplaced nasogastric (NG) tubes after a 26-year-old man had 1,450ml of liquid feed fed into his lungs in December 2018 after a bike accident.
    The patient recovered but the error was not spotted, even after an X-ray.
    Read full story
    Source: The Independent, 17 December 2020
  2. Patient Safety Learning
    Almost half (47%) of patients with cancer do not think that they have been sufficiently involved in deciding which treatment option is best for them, a new survey shows. The survey of nearly 4000 patients across 10 countries also found that around four in 10 (39%) said that they were never or only sometimes given enough support to deal with symptoms and side effects.
    Read full story (paywalled)
    Source: BMJ, 25 July 2019
  3. Patient Safety Learning
    NHS England has shelved priorities on Long Covid and diversity and inclusion – as well as a wide range of other areas – in its latest slimmed down operational planning guidance, HSJ analysis shows.
    NHSE published its planning guidance for 2023-24, which sets the national “must do” asks of trust and integrated care systems, shortly before Christmas.
    HSJ has analysed objectives, targets and asks from the 2022-23 planning guidance which do not appear in the 2023-24 document.
    The measures on which trusts and systems will no longer be held accountable for include improving the service’s black, Asian and minority ethnic disparity ratio by “delivering the six high-impact actions to overhaul recruitment and promotion practices”.
    Another omission from the 2023-24 guidance compared to 2022-23 is a target to increase the number of patients referred to post-Covid services, who are then seen within six weeks of their referral.
    Several requirements on staff have been removed, including to ”continue to support the health and wellbeing of our staff, including through effective health and wellbeing conversations” and ”continued funding of mental health hubs to enable staff access to enhanced occupational health and wellbeing and psychological support”. 
    Read full story (paywalled)
    Source: HSJ, 4 January 2022
  4. Patient Safety Learning
    NHS leaders have urged Boris Johnson’s government to build 100 new hospitals and give the service an extra £7bn a year for new facilities and equipment. They want the Prime Minister to commit to far more than the 40 new hospitals over the next decade that the Conservatives pledged during the general election.
    So many hospitals, clinics and mental health units are dilapidated after years of underinvestment in the NHS’s capital budget that a spending splurge on new buildings is needed, bosses say. Too many facilities are cramped and growing numbers are unsafe for patients and staff, they claim.
    Johnson has promised £2.7bn to rebuild six existing hospitals and pledged to build 40 in total and upgrade 20 others, although has been criticised for a lack of detail on the latter two pledges.
    The call has come from NHS Providers, which represents the bosses of the 240 NHS trusts in England that provide acute, mental health, ambulance and community-based services.
    Read full story
    Source: The Guardian, 3 February 2020
  5. Patient Safety Learning
    Doctors from black, Asian and minority ethnic backgrounds have been hindered in their search for senior roles because of widespread “racial discrimination” in the NHS, according to a report from the Royal College of Physicians.
    The RCP, which represents 30,000 of the UK’s hospital doctors, found that ingrained “bias” in the NHS made it much harder for BAME doctors to become a consultant compared with their white counterparts.
    “It is clear from the results of this survey that racial discrimination is still a major issue within the NHS,” said Dr Andrew Goddard, the RCP’s president. “It’s a travesty that any healthcare appointment would be based on anything other than ability.”
    Read full story
    Source: The Guardian, 21 October 2020
  6. Patient Safety Learning
    Women who are operated on by a male surgeon are much more likely to die, experience complications and be readmitted to hospital than when a woman performs the procedure, research reveals.
    Women are 15% more liable to suffer a bad outcome, and 32% more likely to die, when a man rather than a woman carries out the surgery, according to a study of 1.3 million patients.
    The findings have sparked a debate about the fact that surgery in the UK remains a hugely male-dominated area of medicine and claims that “implicit sex biases” among male surgeons may help explain why women are at such greater risk when they have an operation.
    “In our 1.3 million patient sample involving nearly 3,000 surgeons we found that female patients treated by male surgeons had 15% greater odds of worse outcomes than female patients treated by female surgeons,” said Dr Angela Jerath, an associate professor and clinical epidemiologist at the University of Toronto in Canada and a co-author of the findings.
    “This result has real-world medical consequences for female patients and manifests itself in more complications, readmissions to hospital and death for females compared with males.
    “We have demonstrated in our paper that we are failing some female patients and that some are unnecessarily falling through the cracks with adverse, and sometimes fatal, consequences.”
    Read full story
    Source: The Guardian, 4 January 2022
  7. Patient Safety Learning
    The British Medical A has outlined its vision for an ‘unsafe’ NHS with a culture of bullying.  
    According to the BMA, doctors are working in hospitals and GP Practices that are hugely understaffed, where bullying and a culture of blame is the norm and where patient care is often unsafe. These are the findings of a year-long study – ‘Caring Supportive Collaborative: Doctors Vision for Change‘ – into the state of the NHS.
    The chair of the BMA Council, Dr Chaand Nagpaul said: “Nine in 10 doctors tell us that staffing levels are inadequate and that they work in environments where they fear the toxic combination of ever-increasing demand for services and lack of staff capacity will lead to mistakes."
    “They tell us there is a persistent culture of fear across the NHS, where blame stifles learning, contributing to the vicious cycle of low morale so staff leave and then there’s a problem of recruitment."
    “This unsafe, underfunded environment is as damaging for patients as it is for doctors. Radical change is clearly needed.”
    From the report comes a manifesto, which has today been sent to MPs, as well as the secretary of state for health and social care.
    Read full story
    Source: Practice Business, 17 September 2019
  8. Patient Safety Learning
    The NHS plans to treat up to 25,000 hospital patients at home in “virtual wards” to help clear the backlog caused by the pandemic, the “living with Covid” plan has revealed.
    Patients will be offered acute clinical care at home, including remote monitoring and treatment, as an alternative to hospital stays.
    Consultants or GPs will review patients daily via digital platforms and phone calls. In some cases, patients will be provided with a wearable device to continuously monitor and report their vital signs.
    The NHS has set a national target of 40 to 50 virtual beds per 100,000 population, which equates to about 25,000 beds across England, according to the “living with Covid” plan published this week.
    The document said: “The use of ‘virtual wards’ and ‘hospital at home’ models of care have ensured that patients can be safely cared for in their own homes and that additional bed capacity can be freed up in hospitals.” 
    Commenting on the initial rollout of virtual wards, Dr Tim Cooksley, the president of the Society for Acute Medicine, warned a “hasty” rollout could risk patient safety.
    He said: “Virtual wards do have the potential to be a model of the future. However, it is essential they are appropriately planned, resourced and staffed so they simply cannot be seen as a short-term mitigation measure which can be hastily rolled out mid-pandemic. Incorrect implementation could risk patient safety and significantly impact clinician and patient confidence.”
    Read full story (paywalled)
    Source: The Telegraph, 22 February 2022
  9. Patient Safety Learning
    With a focus on pharmaceutical supply chain regulation, Bonafi is one of the latest companies to launch within the regtech startup sector.
    “Companies operating in the global pharma industry must verify that those they are buying from and selling to are authorised to handle medicinal products for human use in their own countries,” explains its founder, Katarina Antill. “At present, this verification process is manual. Companies are using screenshots as proof and relying on spreadsheets to track verification activities, which increases the risk of errors.”
    “Manual processes are very labour intensive not least because companies must deal with multiple registries across multiple countries,” she says. “Most pharma manufacturers and wholesalers don’t have the resources to reverify their trading partners more than once a year, which is the current minimum legal requirement, and this too creates a potential vulnerability that can ultimately have an impact on patient safety and increase corporate risk.
     “I could see that this huge volume of manual work was a threat to patient-safety and extremely inefficient,” she adds. “Our solution gives companies much greater control over their compliance activities because they no longer have to rely on manual processes. It can also retrieve and aggregate data from multiple registers across multiple countries and has a constant monitoring and alert system, quality management dashboards, electronic signatures and workflows and will strengthen the attributes of traceability, transparency and security. It is all designed to help companies to be pro-active in their compliance activities, enabling them to go beyond compliance alone to reduce corporate risk and patient risk.”
    Read full story
    Source: The Irish Times, 13 February 2020
  10. Patient Safety Learning
    We have been coughed on and shouted at by people refusing to wear face masks. We need more protection, says NHS paramedic Jake Jones.
    The outpouring of appreciation for NHS staff during the COVID-19 crisis has been extraordinary. Yet reports of a recent rise in attacks on emergency workers, including ambulance crews, in England and Wales suggests the Thursday evening applause was hiding a less positive reality. Abuse of emergency workers is a growing issue: a 2018 survey found that 72% of ambulance staff have been attacked on duty, and figures have repeatedly pointed to an upward trend. As an NHS paramedic for 10 years, this aligns with Jake's own experience.
    The consultation on increasing sentences for assaults on emergency workers seeks to discourage attacks on them. Jake's hope is that it will also challenge what has become an ingrained view – that being abused and assaulted somehow goes with the territory.
    Read full story
    Source: The Guardian, 1 September 2020
    Read Jake's book 'Can you hear me? An NHS paramedics encounters with life and death'
  11. Patient Safety Learning
    A lot has been written about the workforce crisis in health and social care. 43,000 registered nurse vacancies, a 48% drop in district nurses in eight years and not enough GPs to meet demand.
    When we talk about workforce, the focus is always on numbers. There are campaigns for safe staffing ratios and government ministers like to tell us how many more nurses we have. But safety is not just about numbers. Recent workforce policy decisions have promoted a more-hands-for-less-money approach to staffing in healthcare. More lower-paid workers mean something in the equation has to give. In this case, it’s skill and expertise.
    In this article in The Independent, Patient Safety Learning's Trustee Alison Leary  discusses how healthcare has failed to keep frontline expertise in clinical areas due to archaic attitudes to the value of the experienced workforce.
    Read full story
    Source: The Independent, 15 December 2019
  12. Patient Safety Learning
    A shortage of skilled staff, coupled with rising demand, has created a “perfect storm” for patients using mental health and learning disability services, England’s healthcare regulator has warned.
    In its annual State of Care report for 2018-19, the Care Quality Commission said that although quality ratings across health and social care, including community mental health services, had been maintained overall, this masked “a real deterioration” in some specialist inpatient services over the past 12 months.
    Read full story (paywalled)
    Source: BMJ, 14 October 2019
  13. Patient Safety Learning
    Theresa May has urged the government to consider “redress” for the victims of a hormone pregnancy test blamed for causing serious birth defects.
    The former prime minister said that while Primodos victims had received an apology, “lives have suffered as a result” of the drug’s use.
    In an interview for a Sky News documentary, she praised campaigners who had been “beating their head against a brick wall of the state” which tried to “stop them in their tracks”.
    A review in 2017 found that scientific evidence did “not support a causal association” between the use of hormone pregnancy tests such as Primodos and birth defects or miscarriage. But Ms May ordered a second review in 2018, because, she said, she felt that it “wasn’t the slam-dunk answer that people said it was”.
    “At one point it says that they could not find a causal association between Primodos and congenital anomalies, but neither could they categorically say that there was no causal link,” she said.
    The second review concluded last month that there had been “avoidable harm” caused by Primodos and two other products – sodium valproate and vaginal mesh.
    An interview for Bitter Pill: Primodos, which will air on Sky Documentaries, Ms May said: “I think it’s important that the government looks at the whole question of redress and about how that redress can be brought up for people.
    Read full story
    Source: The Independent, 28 August 2020
  14. Patient Safety Learning
    A new private ambulance service will offer faster travel to A&E for those caught out by half-day waits for NHS ambulances, The Independent can reveal, in a sign of a growing “two-tier” health service.
    MET Medical ambulance service will begin by charging £99 for a call-out, and could serve thousands of people a week, its chief executive Dave Hawkins has said.
    Mr Hawkins, who is a paramedic himself, said he launched the service after seeing his elderly relatives wait too long for NHS ambulance services following falls.
    It comes as waiting times for ambulance service reached a crisis point in the last year, with frail and vulnerable people waiting hours for an ambulance.
    Ambulance response times hit record highs over 2022-23, with people who should have an ambulance within 20 minutes waiting an hour and 30 minutes in December 2023.
    According to estimates from the Association of Ambulance Chief Executives, 34,000 patients were likely to have suffered harm due to these delays – this hit a high of more than 60,000 in December 2022.
    MET Medical will still have to wait to deliver patients if they are seen as a priority, but it said its patients are likely to be lower priority and can be dropped at A&E without waiting for a handover.
    Mr Hawkins said vulnerable patients waiting for an ambulance can wait up to 12 hours.
    “It’s that moment when you’re out of options, it’s really a horrible place to be, particularly if it’s a loved one … It is a shame, like we’ve seen from the stats and everything, that the health service is failing us."
    Read full story
    Source: The Independent, 3 April 2024
  15. Patient Safety Learning
    The first new hospital cleaning standards for 14 years have been outlined by regulators, including confirmation of new food hygiene-style star ratings.
    Wards and theatres will be given ratings from one to five stars – based on audits which score the cleanliness of areas against safe standards – and these ratings will be made visible to patients.
    The plans for the new star ratings, which are expected to be easier for patients to understand than the current cleanliness percentage scores, were first revealed by HSJ in 2019.
    The ratings are also designed to encourage a more collaborative approach, by reflecting the cleanliness score for whole areas, as opposed to the performance of individual parties responsible for cleaning certain elements.
    Areas rated one to three stars would require improvement plans and be automatically placed under review, with “immediate action” being required in one-star rated areas.
    Read full story (paywalled)
    Source: HSJ, 6 May 2021
  16. Patient Safety Learning
    A policy ‘at the heart’ of NHS England’s efforts to improve maternity care is under question after being sharply criticised by an independent inquiry, and is the subject of major tensions within NHSE and midwifery, HSJ understands.
    The Ockenden report into major care failings at Shrewsbury and Telford Hospital Trust included 15 “immediate actions” for all maternity services in England, which government has accepted and said it would begin implementation.
    However, one of these relates to the “continuity of carer” model, which NHS England has championed since 2017, when it was described as “at the heart of” its national plans for improving maternity care and outcomes.
    The model intends to give women “dedicated support” from the same midwifery team throughout their pregnancy, with claimed benefits including improved outcomes, with a particular focus on some minority groups.
    However, Ms Ockenden indicated its implementation in recent years had stretched staffing, and therefore harmed quality and safety overall, and also appeared to question whether the model was evidenced.
    Some midwifery leaders are advocates for the model, but others have described how it can result in awful working patterns, with concerns it is causing some staff to leave the profession.
    Royal College of Midwives director for professional midwifery Mary Ross-Davie told HSJ: “With the right resources and the right number of midwives, CoC can have a positive impact on maternity care – but in too many trusts and boards this is simply not the situation. We are really pleased, therefore, to see that the review team has echoed the RCM’s recommendations around the suspension of continuity of carer where too few staff puts safe deployment at risk.”
    She said the model was “something to which many maternity services aspire, particularly for women who need enhanced monitoring throughout their pregnancy to deliver better outcomes for them and their baby”.
    Helen Hughes, chief executive of Patient Safety Learning charity, said that although it had heard positive feedback that the model can improve outcomes, there must also be a “robust assessment of the safety impact of implementing such changes and the sources and staffing in place to deliver this”.
    “Otherwise the core intentions and benefits will be lost,” Ms Hughes said.
    Read full story (paywalled)
    Source: HSJ, 31 March 2022
    Further reading
    Midwifery Continuity of Carer: What does good look like? Midwifery Continuity of Carer: Frontline insights The benefits of Continuity of Carer: a midwife’s personal reflection
  17. Patient Safety Learning
    The aftercare of COVID-19 patients will have significant financial implications for ‘understaffed’ community services, NHS England has been warned.
    This month the national commissioner released guidance for the care of patients once they have recovered from an immediate covid infection and been discharged from hospital.
    It said community health services will need to provide “ongoing health support that rehabilitates [covid patients] both physically and mentally”. The document said this would result in increased demand for home oxygen services, pulmonary rehabilitation, diagnostics and for many therapies such as speech and language, occupational, physio, dieticians and mental health support.
    One GP heavily involved in community rehab told HSJ: “There is a lot detailed information about what people might experience in recovery, but it doesn’t say what should actually happen.
    “We have seen people discharged from hospital that don’t know anything about their follow-up and the community [health sector] hasn’t got any instructions of what they should be doing or what services have even reopened. This guidance needs to go a step further and rapidly say what is expected so local commissioners can put that in place.”
    Read full story
    Source: HSJ, 10 June 2020
  18. Patient Safety Learning
    Women can be left in severe pain and at risk of infection if swabs and tampons used after childbirth are accidentally left in the vagina. That’s the safety risk the Healthcare Safety Investigation Branch highlight in their new report published yesterday.
    Vaginal swabs and surgical tampons (larger than tampons used by women during their menstrual cycle) are used to absorb bodily fluids in a number of procedures both in delivery suites and surgical theatres on maternity wards. They are intended to be removed once a procedure is complete.
    The report sets out the case of Christine, a 30-year-old woman who had a surgical tampon inserted after the birth of her first child. It was left in and not discovered until five days after leaving hospital. Whilst being in immense pain throughout, Christine saw the community midwife and GP twice before going back to hospital where the swab was found.
    Sandy Lewis, HSIB’s Maternity Investigation Programme Director, said: “Although measures have been put in place to reduce the chance of swabs and tampons being left in, it continues to happen, leaving women in pain and distress when they may have already gone through a traumatic labour.
    “There are numerous physical effects; pain, bleeding and possible infection, but we can’t forget about the psychological impact as there was in Christine’s case – she had to seek private counselling and felt that what happened affected her ability to bond with her baby."
    Read full story
    Source: Healthcare Safety Investigation Branch, 18 December 2019
  19. Patient Safety Learning
    Australia needs to “get real on medicine safety”, Federal Parliament heard this week.
    Speaking in the House of Representatives, Julian Hill (ALP, Vic) said “too many Australians are being seriously injured, sometimes with lifelong impacts or dying, because of the weakness in our pharmacovigilance system”.
    Mr Hill, Deputy Chair of the Parliamentary Joint Committee of Public Accounts and Audit, referred to a recent study by the Pharmaceutical Society of Australia which “estimated the extent of the problem at 250,000 annual hospital admissions as a result of medication related problems and 400,000 additional presentations to emergency departments, likely because of medicine related problems.
    There’s an annual cost of $1.4 billion, and yet 50 per cent of this harm is estimated to be preventable,” he said.
    “I have spoken before about my concerns in this area, and so have many other advocates, but the  government is still not taking these issues seriously. Every day of inaction means Australians are at risk of death or serious harm from medicines when it could be avoided”.
    Read full story
    Source: AJP.com.au, 28 November 2019
  20. Patient Safety Learning
    Five months after being infected with the coronavirus, Nicole Murphy’s pulse rate is going berserk. Normally in the 70s, which is ideal, it has been jumping to 160, 170 and sometimes 210 beats per minute even when she is at rest — putting her at risk of a heart attack, heart failure or stroke.
    No one seems to be able to pinpoint why. She’s only 44, never had heart issues, and when a cardiologist near her hometown of Wellsville, Ohio, USA, ran all of the standard tests, “he literally threw up his hands when he saw the results,” she recalled. Her blood pressure was perfect, there were no signs of clogged arteries, and her heart was expanding and contracting well.
    Murphy’s boomeranging heart rate is one of a number of mysterious conditions afflicting Americans weeks or months after coronavirus infections that suggest the potential of a looming cardiac crisis.
    A pivotal study that looked at health records of more than 153,000 U.S. veterans published this month in Nature Medicine found that their risk of cardiovascular disease of all types increased substantially in the year following infection, even when they had mild cases. The population studied was mostly White and male, but the patterns held even when the researchers analyzed women and people of color separately. When experts factor in the heart damage probably suffered by people who put off medical care, more sedentary lifestyles and eating changes, not to mention the stress of the pandemic, they estimate there may be millions of new onset cardiac cases related to the virus, plus a worsening of disease for many already affected.
    “We are expecting a tidal wave of cardiovascular events in the coming years from direct and indirect causes of covid,” said Donald M. Lloyd-Jones, president of the American Heart Association.
    Read full story (paywalled)
    Source: Washington Post, 21 February 2022
  21. Patient Safety Learning
    Obesity may double the risk of falling seriously ill with Covid-19 and increase the chances of dying by almost 50 per cent, according to researchers, who also warned any future vaccine may be less effective for the clinically overweight.
    Health issues caused by obesity include a number of pre-existing conditions known to exacerbate a Covid-19 infection – including heart disease, diabetes and high blood pressure.
    Now a global assessment of health data gathered since the start of the the pandemic by researchers at the University of North Carolina has found people with a Body Mass Index (BMI) of more than 30 were 113 per cent more likely to be hospitalised.
    Those admitted to hospital were found to be 74% more likely to be admitted to an intensive care unit, while the risk of death among obese patients increased by 48%.
    Read full story
    Source: The Independent, 26 August 2020
  22. Patient Safety Learning
    Only 15% of healthcare apps meet minimum safety standards, highlighting a “desperate need” for a proper review process, new research has concluded.
    Health app evaluation organisation ORCHA evaluated more than 5,000 apps against 260 performance and compliance factors and found that majority do not meet the minimum safety requirements.
    Liz Ashall-Payne, ORCHA’s Chief Executive, said: “We believe that digital health apps are one of the most important tools available to help tackle health issues in an ageing population that’s facing more complex, long-term problems. The fact that only 15% of apps that we review meet the minimum standards show there is a desperate need to regularly and properly assess the apps available to ensure that people are protected against the serious risks associated with downloading ineffective or even harmful apps.”
    Helen Hughes, Chief Executive of Patient Safety Learning, which is working with ORCHA to improve the safety of apps, said the research reiterated the need for consistent regulatory standards and accreditation frameworks to be applied to healthcare apps.
    “One of the areas we are beginning to explore with ORCHA is whether or not we can consider what patient safety would be in part of the review process,” she said. “Essentially what we want is patient safety embedded in all of the review processes so that we can inform and guide clinicians and inform and guide patients."
    “And that there is appropriate research on their use and their impact so that information can feed the improvement of standards.”
    Read full story
    Source: Digital Health. 9 October 2019
     
  23. Patient Safety Learning
    A low secure unit for people with learning disabilities and autism has been put into special measures after inspectors found the use of restraint and segregation affected the quality of life for some patients.
    Cedar House, in Barham near Canterbury, houses up to 39 people and had been rated “good” by the Care Quality Commission early last year.
    But at an inspection in February this year inspectors rated the service – run by the Huntercombe Group — “inadequate,” saying it was not able to meet the needs of many of the patients at the unit. It was issued with three requirement notices.
    One patient had been subject to prolonged restraint 65 times between September and February. Each time he was restrained by between two and 19 staff, for an average of nearly two hours. On one occasion, this restraint lasted for eight hours.
    But the inspectors were told that in the six months before the inspection 29 staff had been injured during these restraints, and the hospital had been trying to refer the patients to a more secure environment.
    “The impact of this inappropriately placed patient was considerable for both the patients and the hospital,” the report said. “The staff who were regularly involved in restraining the patient were tired and concerned about the welfare and dignity of the patient.”
    Read full story (paywalled)
    Source: HSJ, 21 July 2020
  24. Patient Safety Learning
    Medical examiners are doctors who look at every hospital death with a fresh pair of eyes to make an independent judgement about what took place. It is impossible to overestimate the importance of their role, and it is vital that NHS hospitals now get on with appointing them as a matter of urgency, says Jeremy Hunt, former Foreign Secretary, in an article in the Independent newspaper.
    The big issue is not that bad things happen (sadly in an organisation of 1.4 million people there will inevitably be things that go wrong) but that they take so long to identify and put right. Mid Staffs took four years, Morecambe Bay took nine years and it now looks like the problems at Shrewsbury and Telford could have taken place over 40 years.
    Anyone who has spoken to brave patient-safety campaigners who lost loved ones because of poor care will know that their motivation is never money, simply the desire to stop other families having to go through what they have suffered.
    That is why they and other patient groups all campaign for medical examiners – a process through which every death is examined by a second, independent doctor. It was first recommended following the Shipman inquiry but has taken a long time to implement – inevitably for cost reasons. 
    Where they have been introduced, medical examiners have been transformational. 
    The main pilot sites in Sheffield and Gloucester, which scrutinised over 23,000 deaths, found that “medical examiners have triggered investigations that identified problems with post-operative infections faster than other audit procedures, based on surprisingly few cases”. Doctors also felt confident in raising concerns, as they were protected and supported by the independent medical examiner. Remarkably, pilot studies found that 25% of hospital death certificates were inaccurate and 20% of causes of death were wrong.
    Read full story
    Source: The Independent, 16 January 2020
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