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richard vA


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About richard vA

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    patient advocate and safety campaigner-involved HSIB Citizens partnership and previously NHSE/O patient voice

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  1. Content Article Comment
    the complaint framework is completely and by definition , i believe ,inadequate to the task to get learning-wrong people, wrong skills and goals. learning and action is needed. yet there is no route for families to pursue apart from complaints system that is widely shared. hence i wrote my blog, there are potential routes for all but they have to be fought for
  2. Content Article Comment
    important issues, my reflections on issues that need more exploration: 1. building back trust after harm events-one challenge-screen people for that challenge 2. safety netting and red flag issues so important with serious, changeable and particularly terminal conditions 3. how to recognise the power differential recognising the expertise patients and family carers may have in their wishes, values, condition, management issues around condition from past experiences, and then respecting and addressing. one of many aspects of shared decision making 4. transitions in and out o
  3. Content Article Comment
    So sorry to hear . I would like to be connected with 'Susan' as I am about to enter the process of learning from a palliative care investigation and one element was a late diagnosis of metastatic spread where if this had occurred earlier, more valuable vital support could have been offered . Services are still grappling with this issue and in covid times with massive backlogs the danger is growing without better safety netting systems and also systems able to honestly listen to and learn from patients and families feedback
  4. Content Article
    I love and support the NHS. But when things go wrong for patients and service users, the system is often too slow to change or respond effectively. I have been through complaints, the Ombudsman and Inquest processes around the poor end of life care of my late mother. Those processes took years and were almost as stressful as those last few days of my mother’s life. I would not do it again. At the time, I reported the incident in detail to the CQC (inspectors), to the CCG (commissioners), to Healthwatch (local and national), but I noted no evidence of change. In fact, the CQC continued for
  5. Content Article Comment
    I would like to add one thing not adequately addressed. Where is the patient voice? What rights do they have in how care is delivered and the best way to respond to harmful events they report. My story and call for action is one clear example , where the expertise and values of patients are surely paramount or cannot easily be trumped?
  6. Content Article Comment
    Very useful to know. My story is around the risk of chronic pain management being undermined at a crucial time, without consent and how that could be learned from and minimised
  7. Content Article Comment
    Great session on shared decision making here , a real avenue for patient voices to be heard right from the beginning and ultimately with good guidance may help prevent harm described above
  8. Content Article Comment
    This was a really good event , lots of information. NICE have developed general guidance and guidance for particular conditions is now a focus. I think dealing with needs of patients admitted to A&E needs attention, one being when they are on long established essential medication as I argue here https://www.pslhub.org/learn/patient-safety-in-health-and-care/patient-management/pain-management/please-don%E2%80%99t-undermine-my-pain-relief-a-call-for-learning-and-respect-for-patients-with-long-term-needs-r5699/ please read and share.
  9. Content Article
    My mother, 87 years, was admitted to hospital with a suspected heart attack. At the time, she was on a strong dose of a GP-prescribed opioid (fentanyl) to manage her growing lung cancer. The Duty doctor in the hospital seemed panicked as she was so unwell and used a drug to totally reverse her morphine as they thought she had overdosed. This caused excruciating pain for most of the last 60 hours of her life. They hadn’t properly assessed the history of her prescription or asked me, her documented health advocate, about the drug or my mother’s end of life wishes. After a 2-year long traumatic j