Mark Hughes
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Content ArticleTrust 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.
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Content ArticleWhile 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.
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Content ArticleThe 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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Content ArticleIn this article Sir Bernard Jenkin, Member of Parliament for Harwich and North Essex, considers the role of new statutory body to investigate patient safety concerns across England to improve NHS care at a national level, the Health Services Safety Investigations Body (HSSIB). He talks about the new “safe space” powers of the organisation and its intended role in the healthcare system.
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Content ArticleThe 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 document sets out the terms of reference for this inquiry, following an engagement process led by the inquiry’s independent chair, Lady Justice Thirlwall, with the affected families and other stakeholders.
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Content ArticleAs part of the development of the new Learn from Patient Safety Events (LFPSE) service, this report from NHS England summarises the outcome of Discovery Phase research which considered how best patients, service users and their families can give their views on safety incidents, for the whole NHS to learn from.
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Content ArticleThis is an oral statement given to the House of Commons by the Secretary of State for Health and Social Care, Steve Barclay MP, to update on the Lucy Letby statutory inquiry.
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Content ArticleIn this letter, Rob Behrens, the Parliamentary and Health Service Ombudsman, calls on the Secretary of State for Health and Social Care, Steve Barclay MP, to prioritise improving patient safety in the wake of the Lucy Letby trial.
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Content ArticleThis summary guide pulls together best practice to support NHS clinicians to better meet the Faster Diagnosis Standard for cancer. Getting It Right First Time (GIRFT) and NHS England’s Cancer Programme have worked in partnership to produce this guidance, which outlines how cancer alliances and local organisations can implement NHS England’s best practice timed diagnostic pathways for cancer. The guidance includes advice for all stages of a cancer diagnosis, from early identification of patients to onward referral, as well as useful insights from the relevant GIRFT national clinical leads and links to best practice case studies. This edition has a particular focus on colorectal cancer, prostate cancer and skin cancer.
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Content ArticlePeri-operative medication safety is complex. Avoidance of medication errors is both system- and practitioner-based, and many departments within the hospital contribute to safe and effective systems. For the individual anaesthetist, drawing up, labelling and then the correct administration of medications are key components in a patient's peri-operative journey. These guidelines from the Association of Anaesthetists aim to provide pragmatic safety steps for the practitioner and other individuals within the operative environment, as well as short- to long-term goals for development of a collaborative approach to reducing errors.
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Content ArticleWhile there is much potential and promise for the use of artificial intelligence in improving the safety and efficiency of health systems, this can at times be weakened by a narrow technology focus and by a lack of independent real-world evaluation. It should be expected that when AI is integrated into health systems, challenges to safety will emerge, some old, and some novel. In this chapter of the book Safety in the Digital Age: Sociotechnical Perspectives on Algorithms and Machine Learning, Mark Sujan argues that to address these issues, a systems approach is needed for the design of AI from the outset. He draws on two examples to help illustrate these issues: Design of an autonomous infusion pump and Implementation of AI in an ambulance service call centre to detect out-of-hospital cardiac arrest.
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Content ArticleThis guide is intended for people caring for people living with Alzheimer’s Disease and other forms of dementia, to help facilitate conversations that can help to make health care decisions as the need arises. It has been produced as part of the Conversation Project, a public engagement initiative of the Institute for Healthcare Improvement (IHI). The Project’s goal is to help everyone talk about their wishes for care through the end of life, so those wishes can be understood and respected.
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Content ArticleDelayed discharges, where a patient is medically fit to leave hospital but is not discharged, were a particular problem in England in the winter of 2022/23. In this article, Camille Oung from the Nuffield Trust highlights some possible solutions to help better prepare health and care services for discharge pressures next winter.
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Content ArticleThis annual report looks back at the work undertaken by NHS Resolution in 2022-23. NHS Resolution is an arm’s-length body of the Department of Health and Social Care, responsible for providing expertise to the NHS on resolving concerns and disputes fairly, sharing learning for improvement and preserving resources for patient care.
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Content ArticleAll aspects of the diagnostic process are potentially vulnerable to error and this can occur in all healthcare settings and services. The Agency for Healthcare Research and Quality (AHRQ) is the lead Federal agency investing in research to improve diagnostic safety and reduce diagnostic error in the United States. On this webpage they collate a range of different research, tools and resources related to improving diagnostic safety.
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Content ArticleThe Maternity Survey 2022, run by Ipsos on behalf of the Care Quality Commission, looked at the experiences of women and other pregnant people who had a live birth in early 2022. In this article Anita Jefferson from Ipsos looks at the results of this and considers what they tell us about experiences of maternity services.
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Content ArticleIn June 2023 the AHSN Network published a refreshed Patient Safety Plan, reflecting progress made across focus areas including managing deterioration in care homes; maternity and neonatal health; medicines safety; mental health; and system safety. In this podcast episode, Caroline Kenyon talks to four leaders responsible for delivering the plan across the country, Tasha Swinscoe, Alison White, Katie Whittle and Jodie Mazar.
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Content ArticleReflecting on the impact of restrictions placed on families and visitors to hospitals and care homes during the Covid-19 pandemic, this article, published in the BMJ, argues that families must be recognised and valued as partners in patient care.
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Content ArticleThis report provides a review of the Healthcare Safety Investigation Branch (HSIB) maternity investigation programme during 2022/23. During this period HSIB completed 702 reports and made more than 1,380 safety recommendations.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) Annual Review 2022/23 looks back at its work over this period, during which HSIB published 16 investigation reports and issued 36 safety recommendations to 13 different organisation.
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Content ArticleOn Monday 10 July 2023 the Centre for Perioperative Care (CPOC) and Patient Safety Learning jointly hosted a webinar on the new National Safety Standards for Invasive Procedures 2 (NatSSIPs 2). This article contains links to video recordings of this webinar.
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Content ArticleThis article provides an overview of a Parliamentary reception, hosted by Carolyn Harris MP, as part of the Safety for All campaign. The event was attended by over 50 guests including MPs, Peers, frontline healthcare professionals, patients and representatives from NHS organisations, regulators, charities, unions and industry.
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Content ArticleOn the 18 April 2023 the Women and Equalities Select Committee published a report on Black maternal health. This analysed Government and NHS activities to date in this area and made a number of recommendations for further action needed to end disparities in maternal deaths. This paper sets out the UK Government’s response to the recommendations in this report.
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Content ArticleOn the 23 January 2023 the Minister for Mental Health and Women’s Health Strategy, Maria Caulfield MP, announced the commencement of a rapid review into patient safety in mental health inpatient settings in England. The review Chair, Dr Geraldine Strathdee, was asked to consider how improvements could be made to the way that data and information is used in relation to patient safety in mental health inpatient care settings and pathways, including for people with a learning disability and autistic people. This report contains the findings of this review and an associated set of recommendations.
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Content ArticleThis is the transcript of an oral statement to the House of Commons by Steve Barclay MP, Secretary of State for Health and Social Care, on improving safety in mental health in-patient services across England.
