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Mark Hughes

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  1. Content Article
    The Lampard Inquiry will seek to understand the events that led to the tragic deaths of mental health inpatients under the care of NHS trusts in Essex between 2000 and 2023. This document outlines the terms of reference set following consultation with the chair of the inquiry, Baroness Lampard.
  2. Content Article
    In this episode, Dr Paul Grime, Chairman of the Safer Healthcare and Biosafety Network, speaks to Jonathan Pearce, Chief Executive of Antibiotic Research UK. Jonathan has nearly 20 years’ experience as a CEO in the UK charity sector and has led a number of national organisations, including DKMS UK, Lymphoma Action and Adoption UK. Safety Talks is a podcast series as part of the Safety for All Campaign, launched to shine a light on the symbiotic relationship and benefits of integrating the approach to deliver healthcare worker safety and patient safety.
  3. Content Article
    This is the report of a review conducted by the Health and Social Care Select Committee’s Independent Expert Panel, examining progress the UK Government has made against accepted recommendations from public inquiries and reviews on patient safety. It focuses on five recommendations, giving the Government for each a rating in the style used by national bodies such as the Care Quality Commission. The overall rating across all recommendations is ‘requires improvement’.
  4. Content Article
    The National Safety Standards for Invasive Procedures (NatSSIPs) 2 are intended to help share learning and best practice to support multidisciplinary teams and organisations to deliver safer care. This two-page summary document, published by the Centre for Perioperative Care, provides a concise overview of NatSSIPs for anyone who does interventional procedures and the teams who support them.
  5. Content Article
    In this episode Dr Paul Grime, Chairman of the Safer Healthcare Biosafety Network, speaks to Dr Shriti Pattani, an accredited specialist in Occupational Health working for London North West University Hospitals NHS Trust as their Clinical Director. She also works as a GP and was recently awarded an OBE for her outstanding work in occupational health. Her particular interests include the mental health of Doctors, education of GPs and other physicians on the importance of work on health and how best to use the ‘fit note’ and opportunities for fast tracking NHS staff to promote their health and wellbeing. Safety Talks is a podcast series as part of the Safety for All Campaign, launched to shine a light on the symbiotic relationship and benefits of integrating the approach to deliver healthcare worker safety and patient safety.
  6. Content Article
    In late 2023, the Minister for Mental Health and Women’s Health Strategy, Maria Caulfield MP, asked the Patient Safety Commissioner for England to explore redress options for those who have been harmed by pelvic mesh and sodium valproate. This report sets out the outcome of this project and is designed to help the government understand the options available for providing redress to those patients harmed by pelvic mesh and valproate.
  7. Content Article
    On 26 January 2023, University Hospitals Sussex NHS Foundation Trust contacted the Royal College of Surgeons of England to request an invited service review of the Trust’s general surgery department, with a specific focus on upper gastrointestinal surgery, lower GI surgery and emergency general surgery. The request highlighted that the general surgery department was a service which had been under scrutiny for many years, with a history of internal reviews, and concerns being raised by consultant surgeons as well as other members of staff within the department. This report sets out the findings of this review.
  8. Content Article
    On the 24 October 2023 the Health and Social Care Select Committee announced that its independent Expert Panel would be undertaking an evaluation of government progress on implementing accepted recommendations to improve patient safety. As part of this review, the Committee wrote to the Secretary of State for Health and Social Care requesting a list of key independent public inquiry and review recommendations pertaining to patient safety and whistleblowing in the NHS that that the Government has accepted since 2010. This letter sets out the response to this request from Maria Caulfield MP, Parliamentary Under Secretary of State.
  9. Content Article
    In this article, Claire Brader summarises the recent findings on the performance of NHS maternity services in England, as well as recent government and NHS policies aimed at improving the quality of maternity care.
  10. Content Article
    Elizabeth Roberts was severely frail and bedbound, supported by visits from care agency carers four times per day and her local District Nursing Team. She had ischaemic and hypertensive heart disease and developed a large sacral sore with associated sepsis. She was admitted to Tameside General Hospital on 19 May 2023 where despite treatment, she died the same day of Sepsis with congestive cardiac failure. In this report the Coroner notes concerns about the her case and the capacity of the District Nursing Team providing here care.
  11. Content Article
    Pressure ulcers are a significant challenge for the patients who develop them and the healthcare professionals involved in their prevention and management. They can result in serious complications and avoidable harm, with patients with mobility difficulties at particularly risk from this. This guidance is designed to help practitioners and managers across health and care organisations to provide caring and quick responses to people at risk of developing pressure ulcers.
  12. Content Article
    Morgan-Rose Hart died after she was found unresponsive while being detained under section 3 of the Mental Health Act at the Derwent Centre at the Princess Alexandra Hospital in Essex. Morgan-Rose was last clinically observed at 14.06 on 6 July 2022 and in between the last observation and when Morgan-Rose was discovered the Coroner notes that multiple failings in her care took place, including consecutive hours observations being incorrect and falsified.
  13. Content Article
    Andrew Guillaume was admitted to Warwick Hospital on the 6 June 2023. Following a review, it was agreed that the likely diagnosis was severe aortic stenosis requiring an urgent Consultant to Consultant referral to University Hospitals Coventry and Warwickshire (UHCW) cardiology team. However, no referral was made as the Consultant was unable to get through to the switchboard at UHCW, so Mr Guillaume remained at Warwick Hospital. Subsequently his condition worsened and on the 16 June 2023 a plan was made to update the cardiothoracic surgery team at UHCW to expedite his surgery, but again they were unable to reach the team through the switchboard. Mr Guillaume was admitted to the unit on 19 June 2023, but sadly died on 20 June 2023 due to a further sudden deterioration in his condition.
  14. Content Article
    In this article for the Journal of Eating Disorders, Alykhan Asaria considers the criteria used in a paper by Guadiani et al. (J Eat Disord 10:23, 2022) to define ‘terminal anorexia nervosa’ and outlines concerns about this new term from a lived experience perspective. The author highlights issues about the ambiguities around how the criteria can be applied safely and the impact of labelling anorexia nervosa sufferers with terms. Further articles on the hub from Alykhan Asaria: ‘Terminal anorexia’: a lived experience perspective
  15. Content Article
    Produced by the Institute of Global Health Innovation at Imperial College London, and commissioned by the charity Patient Safety Watch, this report considers the current state of patient safety around the world, through analysis of publicly available data from the last two decades. It includes an interactive data dashboard, case studies of patient safety excellence and a ranking of patient safety in OECD countries.
  16. Content Article
    The review into the statutory duty of candour has been established by the Department of Health and Social Care to consider the design of operation of this requirement, assess its effectiveness and make advisory recommendations. The duty of candour is about people’s right to openness and transparency from their health or care provider. It means that when something goes wrong during the provision of health and care services, patients and families have a right to receive explanations for what happened as soon as possible and a meaningful apology.
  17. Content Article
    The Thirlwall Inquiry has been set up to examine events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital. This website provides information about inquiry team, terms of reference and publications relating to this.
  18. Content Article
    This report summarises the findings arising from a comprehensive study of antibiotic ‘line flushing’ and disposal practices in NHS organisations across Great Britain. It argues that is a need for concerted, UK-wide action on antibiotic line flushing policies.
  19. Content Article
    Homecare medicines services deliver medicines and provide medicine-related care to patients in their homes, for example, teaching them to self-inject, and delivering medicine that might need special transport. In this report, the House of Lords Public Services Committee highlights concerns about multiple reports of delays and errors by homecare providers, resulting in patients receiving care later than scheduled. The report states that this key service is not working the way it should and, in some cases, is causing patients serious harm.
  20. Content Article
    Christina Ruse was admitted to the Spire Hospital on 14 December 2021 and underwent a total left hip replacement. Her condition deteriorated and observations were commenced at five minute intervals. Mrs Ruse was reviewed and on further deterioration in her condition it was decided to transfer her to the High Dependency Unit, Norfolk and Norwich University Hospital. On arrival of the ambulance Mrs Ruse was undergoing a further investigatory procedure. On this being completed Mrs Ruse was taken to the Norfolk and Norwich University Hospital, where her condition continued to deteriorate and she died on 15 December 2021.
  21. Content Article
    Barbara Hollis underwent a total left knee replacement operation on 22 February 2022. The surgery was uneventful with no complications, however after her return to the ward Mrs Hollis became restless and confused. Following a review of her deteriorating condition the decision was made to transfer her to the High Dependency Unit at the Norfolk and Norwich University Hospital. Arrangements were made for the transfer and the ambulance service was called at 19.51 and were told that immediate clinical intervention was needed, but the agreed hospital to hospital transfer pathway was not followed. There was a two hour delay in ambulance attendance, during which time Mrs Hollis continued to deteriorate. Mrs Hollis was subsequently taken to the High Dependency Unit at the Norfolk and Norwich University Hospital where her condition continued to deteriorate and she died in the early hours of the 23 February 2022.
  22. Content Article
    A pulmonary embolism happens when a blood clot breaks off and travels to the lungs where it blocks the flow of blood. Although life-threatening, when diagnosed promptly survival rates are good. This report from the Parliamentary and Health Service Ombudsman (PHSO) looks at the case of a man who died of a pulmonary embolism after doctors failed to test for deep vein thrombosis.
  23. Content Article
    Trust boards’ regular oversight of the quality and safety of maternity and neonatal services has been the subject of successive inquiries and reviews. In this report, the Sands and Tommy’s Joint Policy Unit review publicly available board papers and minutes for seven NHS Trusts in England. They analyse whether the information presented to boards, the process for review, and actions taken enabled boards to deliver effective oversight over the safety and quality of maternity and neonatal services.
  24. Content Article
    While at Amberley Hall Care Home for rehabilitation, Geoffrey Whatling’s family had raised concerns that he was unwell. He was scored as a 7 on the National Early Warning Score (NEWS2) system on the 8 April 2023. Such a score requires a 999 call to be made, however instead a 111 call was made. The 111 call taker was not made aware of his NEWS2 score. Further observations were carried out on 9 April 2023 (NEWS2 score 6), and 07.00 (NEWS2 score 5) and again on 10 April 2023 at 12.13 (NEWS2 score 9/10), when emergency services were called and Mr Whatling was admitted to Queen Elizabeth Hospital. Despite treatment his condition continued to deteriorate and he died on 26 April 2023.
  25. Content Article
    The Patient Safety Commissioner for England was asked by the UK Government to run a series of policy sprint meetings to set out what would make Martha’s Rule a success in England. Martha’s Rule would mean that if a patient, family member or carer suspected deterioration or a serious concern, they would have the right to easily call for a rapid review or second opinion from an doctor within the same hospital. In this letter to the Secretary of State for Health and Social Care, Steve Barclay MP, the Patient Safety Commissioner outlines the process and outcome of these meetings and a set of recommendations for the implementation of Martha’s Rule.
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