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Steve Turner

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Everything posted by Steve Turner

  1. Content Article Comment
    I find it shocking that the proposed reforms, listed below, are not already in place: patient involvement in complaints investigations the establishment of independent investigation bodies more meaningful data analysis strategies to uncover and address systemic causes behind recurring complaints. Perhaps people who are involved with complaints handling, and those who have made complaints can share their experiences? Good or bad experiences - all will contribute to further learning and help deliver real change.
  2. Content Article
    "The inestimable, magnificent, Will Powell speaking on Radio Ombudsman about the long struggle to discover the truth about his son's death and the subsequent failure of accountability mechanisms" - Rob Behrens, Parliamentary and Health Service Ombudsman UK, Vice-President IOI Europe, Visiting Professor UCL. MCFC.
  3. Article Comment
    Another important article behind a paywall, which is linked to longstanding problems. This article needs to be opened up to the public. I hope the mainstream media and the regional and local media pick this up.
  4. Content Article Comment
    I am so saddened to read yet another report on failings that, if seen and acted on in isolation, will not lead to the systemic changes that are needed. I agree with the conclusion. The approach to patient safety needs to change. This is the 'modernisation' our health and social care services desperately need. No more 'lessons will be learned' statements without follow up, and no more 'sorry-not-sorry' apologies, we need radical patient-led change, transparency, and accountability.
  5. Community Post
    This potentially looks very helpful. Preventable deaths tracker:
  6. Content Article
    The UK Government has opened a consultation on changes to the Mental Capacity Act (MCA) 2005 Code of Practice, and implementation of Liberty Protection Safeguards (LPS). This consultation is also seeking views on the LPS regulations, which will underpin the new system. This consultation applies to England and Wales and is open until 7 July 2022.
  7. Article Comment
    It's a pity this article is behind a paywall. In my experience, both professional and personal, CQC reports can bear little or no relationship to the patient care and the culture of organisations. The system is riddled with cronyism. See: https://on.ft.com/3GVIIgX (sorry this is also behind a paywall). We need a pro-active, independent, patient-led system to monitor quality & look at outcomes, starting with commissioning, in my view.
  8. Community Post
    This work has so much potential for improvements in patient safety. Will it link to Coroners prevention of future deaths reports? It's such a complex area, with so many threads and possibilities for learning. I used to work in a Mental Health Assertive Outreach Team and was greatly saddened by the high mortality rate from deaths through neglect or undetected (and treatable) physical illnesses.
  9. Content Article Comment
    Thank you for posting this. The actions resulting from Coroners' prevention of future deaths are vital for patient safety. I look through these reports when preparing clinical education sessions, and have included this link in my medicines and prescribing teaching resource page: https://www.judiciary.uk/subject/alcohol-drug-and-medication-related-deaths/
  10. Content Article Comment
    Thank you for posting this. Coroners' prevention of future deaths reports are important, and the actions resulting from them are vital for patient safety. I look through these reports when preparing clinical education sessions, and have included this link in my teaching resources: https://www.judiciary.uk/subject/prevention-of-future-deaths/ Unfortunately, I believe there is an inconsistency in when Coroners make these reports. For example, in the case of the death of Oliver McGowan, where no such report was made. This is a case study I use in my medicines and prescribing teaching work. I've also come across a press reports of a trust putting pressure on a Coroner not to make a prevention of future deaths report. I'm interested in people's views on this. Am I right in thinking that there is an inconsistency in how Coroners use their powers to make prevention of future deaths reports? Are there any other reported examples of trust's trying to put pressure on Coroners?
  11. Content Article
    In this study, 156 participants were recruited and randomised to placebo (n=83) or ketamine (n=73), stratified by centre and diagnosis: bipolar, depressive, or other disorders. Two 40-minute intravenous infusions of ketamine (0.5 mg/kg) or placebo (saline) were administered at baseline and 24 hours, in addition to usual treatment. The primary outcome was the rate of patients in full suicidal remission at day 3, according to the scale for suicidal ideation total score ≤3. Analyses were conducted on an intention-to-treat basis. The findings indicate that ketamine is rapid, safe in the short term, and has persistent benefits for acute care in suicidal patients. Comorbid mental disorders appear to be important moderators. An analgesic effect on mental pain might explain the anti-suicidal effects of ketamine. There are also some useful and thought-provoking comments on this research, and a helpful visual aid.
  12. Article Comment
    Anyone who is familiar with what happened to Dr Raj Mattu, and who was in charge at the time, will know why this story is important. I believe leaders who behave badly and display a 'consistent lack of compassion or respect for people' should be held to account, not allowed to move freely within the NHS. Dr Raj Mattu (Cardiologist): Dr Raj Mattu is an internationally recognised cardiologist who worked at University Hospitals of Coventry and Warwickshire NHS Trust (UCHWT). In 2001 he raised patient safety concerns including when five patients were routinely put in a ward designed for four, which on one occasion this led to the death of a patient. Following this, over 200 false allegations were made against Mr Mattu. These ranged from questions over his qualifications to charges of serious criminal conduct outside of work. They were sent to the GMC, CQC, the Strategic Health Authority and three different police forces. All of these have been investigated and found to be false. In 2010, ill and suffering from depression, he was finally sacked by managers who questioned the validity of his ailments and found him “unmanageable”. 14 years after first being suspended from his job Dr Mattu won a £1.22 million unfair dismissal case against UCHWT. It is estimated that the full cost of Dr Mattu’s case exceeds £10million. In 2016 Dr Mattu was awarded the UK Whistleblowing Prize from free speech charity Blueprint.
  13. Content Article Comment
    An important message here. Knowing the reason for the use of a medicine (i.e. its 'indication') is vital for patient safety. It's not just pharmacists who need to know the indication for a medicine. In my clinical practice I've seen problems caused by misunderstandings of what a medicine was prescribed for. Including patients who have been prescribed antipsychotic drugs which they did not know the reason for & which could be making their condition worse. Also, I've come across people who were prescribed antidepressants for pain rather than depression (e.g., amitriptyline which is indicated for both things) who believed they were taking an antidepressant and that it 'wasn't working', not knowing that the dose prescribed for pain is lower than that for depression. Many medicines have several different indications, also some medicines are used 'off label' (i.e. for purposes that they are not licensed for). This can be confusing to both patients and clinicians alike, especially when trying to build up a list of previous medicines and what they were prescribed for. I've seen prescribing mistakes made as a result.
  14. Content Article Comment
    An insightful piece, written with objectivity and empathy, highlighting the need for a deeper understanding of why people speak up in healthcare and the consequences for us all when patient safety concerns are dismissed. All healthcare leaders should read this and reflect on how effective current measures are, and what actions are needed.
  15. Article Comment
    Interesting. Time to rethink I believe. Although I work in a vaccination clinic I am against mandatory vaccination, except for international travel where it links to the need to vaccinate as many people as possible across the world. Some people cannot have the vaccines for clinical reasons, and I've sympathy for those few who have had severe side-effects and say 'can I not have my immunity level checked instead? Other things that concern me are when people say (or imply) that those unvaccinated don't deserve treatment. That appalls me. Us clinicians are not here to judge, although I can appreciate people's frustration & why this hurts if you have lost someone close. Also, I get cross when people in positions of power (especially clinicians) demand to know why individuals are exempt for wearing a mask (often asking them in non-private spaces). This is because while some are just anti-mask and could wear one, some people have deep rooted problems that mean they can't wear a mask, this may be due to past abuse. Mandatory vaccination for NHS staff feeds into people's prejudices, in my view.
  16. Community Post
    The West Suffolk Independent Review published yesterday indicates that safety concerns were ignored and the hunt for an anonymous whistleblower was "flawed" and "ill-judged". https://www.england.nhs.uk/east-of-england/wp-content/uploads/sites/47/2021/12/west-suffolk-review-081221.pdf This Review was commissioned following widely reported events arising from an anonymous letter that was sent in October 2018 to the relative of a patient who had died at the West Suffolk NHS Foundation Trust (the Trust). The 225 page report contains important learning and highlights the need for an open culture in the NHS and an end to a culture of avoidance, denial and victimisation of those who speak out for patient safety. This report highlights the need for cultural change and raises several key points: The importance of real and empowered clinical leadership. The importance of NHS leaders being self-questioning, open to criticism and to listen to staff. The importance of leaders understand the value of dissent and disagreement. Where concerns and criticisms appear or do turn out to be misguided, the need for NHS leaders to avoid jumping to any conclusion that the individual raising them is simply making trouble.
  17. Community Post
    I am so sorry to hear of your experience Dom. As a mental health nurse who trained in the 1980s I have witnessed a shocking decline in the NHS. The NHS being an institution which, like you, I support and want to see thrive and become world class. The NHS, and indeed all services commissioned by health & social care, has fallen victim to a culture of avoidance, a rise of cronyism (based on self-interest) and exclusion of those who speak out. That includes appalling treatment of patients and relatives who speak out. This has to change. In order to change this problem has to be fully recognised, independently scrutinised, and spoken about openly at the top, not avoided and skirted around, as is currently happening for example through the weak implementation of the Francis Review recommendations and stigmatisation of many who who speak out.
  18. Article Comment
    My experience, which echoes that of many others, indicates that the National Guardian Office us a very bad idea. #FTSU Guardians operate under a conflict of interest as they report to the employer. Also the National Guardian office is impossible to engage with, unless you agree with them. This means the initiative has potential to do harm as well as good. The #FTSU Guardians in some organisations can be helpful. I know some #FTSU Guardians who are genuine & who work for organisations that listen & want to change. Unfortunately other organisations use the Guardians to maintain the status quo. So speaking up to them is like putting your own name on a blacklist, & any #patientsafety issues will be ignored. I believe in the principle of 'do no harm' which is why I speak out. If you are looking at this from a healthcare organisation outside the UK and thinking of adopting this approach I'd urge you to study the evidence closely, and look at this from all angles.
  19. Content Article
    In this video of a plenary session from the Guidelines International Network (GIN) Conference on 26 October 2021, James McCormack, Professor at the Faculty of Pharmaceutical Science, University of British Columbia, discusses issues with clinical practice guidelines and ways to overcome them.
  20. Content Article
    The Global Drug Policy Index provides a score and ranking for each country to show how much their drug policies and their implementation align with the UN principles of human rights, health and development. It offers an important accountability and evaluation mechanism in the field of drug policy.
  21. Content Article Comment
    Excellent poster. Good to see scientific rigour applied to this safety critical topic. In my view, this provides and important and stark contrast to the pseudo-science and waffle produced by the National Guardian Office.
  22. Content Article Comment
    In my blog there is broken link to the Turn Up The Volume! web page. This is no longer updated, (as I am retiring soon) , however some of the materials may be helpful. Here's the link: https://www.carerightnow.co.uk/turn-up-the-volume-resources-2/
  23. Content Article
    It's that time again. 'Speak Up Month' in the NHS. In this blog, I discuss the definition of 'whistelblowing' and why this is important. I believe that although the Francis Report has stimulated some positive changes, the only way to successfully move forward on this is to celebrate and promote genuine whistleblowers. This includes using the word 'whistleblowing', not a euphemism. It also needs us to involve everyone, including patients, in the changes. "Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. The more we move away for labelling and stereotyping the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and reconciliation." What is whistleblowing? "In the UK, NHS bodies have been guilty of muddying the waters. Sometimes implying that whistleblowers are people who fail to use the proper channels, or are troublemakers, especially when they go outside their organisation with their concerns. In fact, the Public Interest Disclosure Act makes no distinction between ‘internal’ and ‘external’ whistle-blowers..."
  24. Article Comment
    Is this a signal that the old system of GPs acting as gatekeepers needs changing? Ref: https://bjgp.org/content/69/682/e294
  25. Community Post
    That would be good. I wonder how common experiences of bouncing, delayed or lost referrals are are. There is so much learning to be had. Including simple changes that can be made right now to improve communication and the safety of referral processes. Thank you.
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