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Sam

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  2. Sam
    A trust saw nearly 1,000 safety reports filed after introducing a new electronic patient record (EPR) – including one where a patient died and 30 others where they suffered harm.
    The Royal Surrey Foundation Trust and Ashford and St Peter’s Hospital Foundation Trust installed a new joint EPR system in the middle of last year.
    But Royal Surrey’s board was told there had been 927 Datix reports — which are used to raise safety concerns — related to the introduction of the “Surrey Safe Care” system, running up until mid September this year.
    The catastrophic harm involved a patient death which the trust says was not “directly linked to technical problems” with the EPR, as “human factors” were involved, including inexperience or unfamiliarity with the electronic prescribing system.
    Louise Stead, chief executive of Royal Surrey, said: “Implementing an electronic patient record is a huge shift for any workforce and we experienced some issues with the functionality of the system and getting users sufficiently trained and confident in using it correctly. We have worked hard to address these issues as quickly and responsibly as possible.
    “Our fundamental aim is for ‘zero harm’ and any harm caused to a patient is taken extremely seriously and investigated. In the case of these Datix incidents the vast majority (over 99%) resulted in low or no harm to patients.
    “However, one case resulted in the tragic death of a patient and we have been working closely with their family to be transparent and learn every possible lesson. This case was not directly linked to technical problems with the electronic patient record system and human factors did contribute. We are sincerely sorry for the failure in their care and devastating impact upon this person’s family.”
    Read full story (paywalled)
    Source: HSJ, 11 October 2023
     
  3. Sam
    Patient Safety Learning Press Release
    10th December 2020
    Today the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust published its first report on its findings.[1] The report made recommendations for actions to be implemented by the Trust and “immediate and essential actions” for both the Trust and the wider NHS.
    The Review was formally commissioned in 2017 to assess “the quality of investigations relating to new-born, infant and maternal harm at The Shrewsbury and Telford Hospital NHS Trust”.[2] Initially it was focused on 23 cases but has been significantly expanded as families have subsequently contacted the review team with their concerns about maternity care and treatment at the Trust. The total number of families to be included in the final report is 1,862. These initial findings are drawn from 250 cases reviewed to date.
    This is another shocking report into avoidable harm.
    We welcome the publication of these interim findings and the sharing of early actions that have been identified to make improvements to patient safety in NHS maternity services. We commend the ambition for immediate responses and action.
    Reflecting on the report, there are a number of broad patient safety themes, many of which have been made time and time again in other reports and inquiries.
    A failure to listen to patients
    The report outlines serious concerns about how the Trust engaged and involved women both in their care and after harm had occurred. This was particularly notable in the example of the option of having a caesarean section, where there was an impression that the Trust had a culture of wanting to keep the numbers of these low, regardless of patients’ wishes. They commented:
    “The Review Team observed that women who accessed the Trust’s maternity service appeared to have little or no freedom to express a preference for caesarean section or exercise any choice on their mode of deliver.”
    It also noted a theme in common with both Paterson Inquiry and Cumberlege Review relating to the Trusts’ poor response to patients raising concerns.[3] The report noted that “there have also been cases where women and their families raised concerns about their care and were dismissed or not listened to at all”.
    The need for better investigations
    Concerns about the quality of investigations into patient safety incidents at the Trust is another theme that emerges. The review reflected that in some cases no investigation happened at all, while in others these did take place but “no learning appears to have been identified and the cases were subsequently closed with it deemed that no further action was required”.
    One of the most valuable sources for learning is the investigation of serious incidents and near misses. If these processes are absent or inadequate, then organisations will be unable to learn lessons and prevent future harm reoccurring. Patient Safety Learning believes it is vital that Trusts have the commitment, resources, and frameworks in place to support investigations and that the investigators themselves have the right skills and training so that these are done well and to a consistently high standard. This has not formed part of the Report’s recommendations and we hope that this is included in their final report.
    Lack of leadership for patient safety
    Another key issue highlighted by the report is the failure at a leadership level to identify and tackle the patient safety issues. Related to this one issue it notes is high levels of turnover in the roles of Chief Executive, executive directors and non-executive directors. As part of its wider recommendations, the Report suggests trust boards should identify a non-executive director who has oversight of maternity services.
    Good leadership plays a key role in shaping an organisations culture. Patient Safety Leadership believes that leaders need to drive patient safety performance, support learning from unsafe care and put in place clear governance processes to enable this. Leaders need to be accountable for patient safety.
    There are questions we hope will be answered in the final report that relate to whether leaders knew about patients’ safety concerns and the avoidable harm to women and their babies. If they did not know, why not? If they did know but did not act, why not?
    Informed Consent and shared decision-making
    The NHS defines informed consent as “the person must be given all of the information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead”.[4] The report highlights concerns around the absence of this, particularly on the issue of where women choose as a place of birth, noting:
    “In many cases reviewed there appears to have been little or no discussion and limited evidence of joint decision making and informed consent concerning place of birth. There is evidence from interviews with women and their families, that it was not explained to them in case of a complication during childbirth, what the anticipated transfer time to the obstetric-led unit might be.”
    Again this is another area of common ground with other recent patient safety reports such as the Cumberlege Review.[5] Patient Safety Learning believes it is important that patients are not simply treated as passive participants in the process of their care. Informed consent and shared decision making are vital to respecting the rights of patients, maintaining trust in the patient-clinician relationship, and ensuring safe care.
    Implementation for action and improved patient safety
    In its introduction, the report states:
    “Having listened to families we state that there must be an end to investigations, reviews and reports that do not lead to lasting meaningful change. This is our call to action.”
    Responding with an official statement in the House of Commons today, Nadine Dorries MP, Minister for Mental Health, Suicide Prevention and Patient Safety, did not outline a timetable for the implementation of this report’s recommendations.
    In 2020 we have seen significant patient safety reports whose findings have been welcomed by the Department of Health and Social Care but where there has subsequently been no formal response nor clear timetable for the implementation of recommendations, most notably the Paterson Inquiry and Cumberlege Review.
    Patient Safety Learning believes there is an urgent need to set out a plan for implementing the recommendations of the Ockenden Report and these other patient safety reports. Patients must be listened to and action taken to ensure patient safety.
    [1] Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Emerging findings and recommendations form the independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, 10 December 2020. https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2020/12/ockenden-report.pdf
    [2] Ibid.
    [3] The Right Reverend Graham Jones, Report of the Independent Inquiry into the Issues raised by Paterson, 2020. https://assets.publishing.serv...; The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020. https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf
    [4] NHS England, Consent to treatment, Last Accessed 16 July 2020. https://www.nhs.uk/conditions/consent-to-treatment/
    [5] Patient Safety Learning, Findings of the Cumberlege Review: informed consent, Patient Safety Learning’s the hub, 24 July 2020. https://www.pslhub.org/learn/patient-engagement/consent-and-privacy/consent-issues/findings-of-the-cumberlege-review-informed-consent-july-2020-r2683/
  4. Sam
    A patient flow model which involves moving A&E patients to wards “irrespective” of whether there are beds available, is under review for wider rollout by NHS England and is being endorsed by senior clinicians, despite safety fears, HSJ has learned. 
    The Royal College of Emergency Medicine has said it would be “unethical” for leaders not to at least consider implementing some form of “continuous flow” model for emergency patients.
    The approach has been been trialled recently by North Bristol Trust and at several London trusts. HSJ understands NHS England is considering the wider implementation of the continuous flow model, although no final decision has yet been made.
    The calls come despite patient safety concerns about the model being raised by the Nuffield Trust think tank, who said the evidence for the model is “poor” and could spread risk to other parts of the hospital.
    Read full story (paywalled)
    Source: HSJ, 21 October 2022
  5. Sam
    The government has been warned it is throwing “a lit match into a haystack” by discharging Covid-positive patients to care homes, with politicians demanding that the safety of residents and staff is guaranteed under the new policy.
    During the first wave of the pandemic, approximately 25,000 hospital patients were sent to care homes – many of whom were not tested – which helped spread the virus among residents. Around 16,000 care home deaths have been linked to COVID-19 since the start of the crisis.
    The strategy was one of the government’s “biggest and most devastating mistakes” of the crisis, says Amnesty International, and questions have been raised over the decision to introduce a similar policy as the UK’s second wave intensifies.
    As part of the 2020 adult social care winter plan, the government has called on local authorities and care providers to establish “stand-alone units” – so-called “hot homes” – that would be able to receive and treat Covid hospital patients while they recover from the disease.
    There is also an expectation that, due to housing pressures and a shortage of suitable facilities, some patients may be discharged to “zoned accommodation” within a home, before being allowed to return to normal living settings once they test negative for the virus.
    Councils have been told to start identifying and notifying the Care Quality Commission of appropriate accommodation, and to ensure high infection prevention standards are met.
    Under the requirements outlined by the government, discharged patients “must have a reported Covid test result". However, The Independent revealed on Monday that these rules have not been followed in some cases, with a recent British Red Cross survey finding that 26 per cent of respondents had not been tested before being discharged to a care home.
    There is also concern whether care homes possess enough adequate personal protective equipment to prevent outbreaks, with the CQC revealing last month that PPE was still not being worn in some sites.
    Read full story
    Source: The Independent, 27 0ctober 2020
  6. Sam
    Hospital chiefs in the South West have warned the region will not avoid the extreme pressures felt by other parts of the NHS amid rapidly rising numbers of COVID-19 inpatients.
    The region was the least affected area of England during the pandemic’s first wave, but the medical director of two acute trusts yesterday predicted a “tidal wave” of COVID-19 coming to the West Country.
    Adrian Harris, medical director at Royal Devon and Exeter Foundation Trust and Northern Devon Healthcare Trust (NDHT), said the region faced an “absolute crisis” and individual trusts would be “hanging on by their fingernails”.
    His comments, made at NDHT’s board meeting, came on the same day HSJ revealed the South West region now has the fastest growth in COVID-19 inpatients. Although the region is England’s least densely populated, it also has the lowest hospital capacity per capita in the country.
    Dr Harris said: “We hope and we pray that the lockdown has come in time for Devon. My personal view — and of my colleagues around the country — is that there’s a tidal wave of COVID-19 coming to the West Country."
    “We are preparing to be hit as hard as the East of England. If we are hit as hard, we will be hanging on by our fingernails and we are planning accordingly.”
    Read full story (paywalled)
    Source: HSJ, 8 January 2021
  7. Sam
    GPs are failing to urgently refer patients with “red flag” signs of suspected cancer to a specialist, research suggests.
    Six out of 10 patients in England with key symptoms indicating possible cancer did not receive an urgent referral for specialist assessment within two weeks, as recommended in clinical guidelines, according to a new study.
    Nearly 4% of these patients were subsequently diagnosed with cancer within the next 12 months. The findings were published in the journal BMJ Quality & Safety.
    In the study, researchers analysed records from almost 49,000 patients who consulted their GP with one of the warning signs for cancer that should warrant referral under clinical guidelines. Of the 29,045 patients not referred, 1,047 developed cancer within a year (3.6%).
    Early diagnosis and prompt treatment is crucial to survival chances. Every four-week delay in cancer treatment increases the risk of death by 10%.
    Read full story
    Source: The Guardian, 5 October 2021
  8. Sam
    The staff-side committee of a major hospital trust has stopped working with its leadership, with its chair alleging an ‘endemic’ culture of ‘racism, discrimination and bullying’.
    Irene Pilia, staff-side committee chair at King’s College Hospital Foundation Trust, told colleagues that the decision was taken “in the interests of staff”, especially black, Asian and minority ethnic workers, and expressed concerns about the organisation’s disciplinary procedures. She said the decision had the backing of staff committee officers and delegates.
    Ms Pilia, who is also the senior KCHFT Unite representative, said she was open to resuming partnership working again, but told trust executives: “I have lost trust and confidence in the ability of [KCHFT] to conduct fair, impartial and no-blame investigations.
    “Until there is tangible and credible evidence that racist behaviour at all levels is proactively eliminated, such that perpetrators face real consequences (including to the detriment of their careers) for their actions and are no longer allowed to behave in racist ways with impunity, I take a stand for the hundreds, possibly thousands of KCHFT staff whose voices are not being heard."
    Read full story (paywalled)
    Source: HSJ, 22 October 2020
  9. Sam
    Oversight failures, a fearful workplace culture and lax quality standards for years at a Veterans Affairs hospital in Arkansas, USA, allowed a pathologist who was routinely drunk on the job to misdiagnose thousands of veterans — sometimes with dire or deadly consequences, a new investigation has found.
    Hospital leaders “failed to promote a culture of accountability” that would have led more of the doctor’s colleagues to come forward with accounts that his behavior was putting patients at risk, according to the report released Wednesday by VA’s Office of Inspector General. But the staff members at the Veterans Health Care System of the Ozarks in Fayetteville feared that reporting their concerns would lead to retaliation from their bosses.
    “Any one of these breakdowns could cause harmful results,” Inspector General Michael Missal’s staff wrote in an 86-page report about the failures to stop the pathologist, Robert Morris Levy. “Together and over an extended period of time, the consequences were devastating, tragic, and deadly.”
    Read full story
    Source: The Washington Post, 2 June 2021
  10. Sam
    A privately run child and adolescent mental health unit has been closed permanently, with its residents moved elsewhere, after concerns were raised about their safety.
    The Care Quality Commission (CQC) said it had taken “urgent action to ensure the provider makes immediate and significant improvements” at the Cygnet Hospital in Godden Green, outside Sevenoaks in Kent, after a series of unannounced inspections last month and this month.
    The hospital had a CAMHs unit with up to 23 beds – details of which have been removed from the company’s website. However, only a small number of beds were occupied and these patients were either discharged or transferred to other hospitals before the unit closed on Monday.
    Last year Cygnet Health Care also launched a 12 bed female psychiatric intensive care unit on the site. Some of these beds have been commissioned by Kent and Medway NHS and Social Care Partnership Trust since early this year, as there are no NHS female PICU sites in the county. This unit remains open, although the CQC said the concerns raised with it related to the safety of both PICU and CAMHs patients.
    Karen Bennett-Wilson, the CQC’s head of hospital inspection and lead for mental health in the south, said: “CQC has also worked closely with NHSE/I, Cygnet Healthcare and other local partners who have taken the decision to close the CAMHS unit and move the young people in the service to other care appropriate to their needs."
    Read full story (paywalled)
    Source: HSJ, 20 October 2020
  11. Sam
    The Care Quality Commission may in future be notified when ‘secretive’ external reviews have looked at patient safety issues within trusts.
    Last summer, HSJ revealed guidance for trusts to publish summaries of royal colleges’ reviews was being widely ignored, with some even failing to inform the CQC.
    A recent BBC Panorama programme has again raised the issue, with Academy of Medical Royal Colleges chair Helen Stokes-Lampard saying she was “dismayed” the body’s guidance was not being followed.
    But she has now told HSJ of “advanced discussions” with the CQC about changes which would see the royal colleges routinely inform the regulator when reviews raise patient safety issues.
    Read full story (paywalled)
    Source: HSJ, 3 June 2021
  12. Sam
    NHS leaders are being encouraged to have ‘difficult discussions’ about inequalities, after a trust found its BAME staff reported being ‘systematically… bullied and harassed’, along with other signs of discrimination.
    A report published by Newcastle Hospitals Foundation Trust found the trust’s black, Asian and minority ethnic staff are more likely than white staff to be bullied or harassed by colleagues, less likely to reach top jobs, and experience higher rates of discrimination from managers.
    It claims to be the first in-depth review into pay gaps and career progression among BAME workforce at a single trust.
    The new report revealed that, in a trust survey carried out last year, some BAME staff described being subjected to verbal abuse and racial slurs by colleagues; had left departments after being given no chance of progression; and been “systematically… bullied and harassed”.
    Read full story (paywalled)
    Source: HSJ, 22 September 2020
  13. Sam
    After many months of development and several user workshops, we are delighted and proud to present the hub at Patient Safety Congress 2019.
    the hub is one of the actions proposed by Patient Safety Learning's A Blueprint for Action. The report identifies six foundations of safe care: shared learning, leadership, professionalising patient safety, patient engagement, data and insight, and culture, and proposes a range of actions to address these foundations. the hub is Patient Safety Learning's share online learning platform, which encourages and facilitates knowledge sharing, collaboration and conversation in patient safety across the whole of health and social care. It is a platform for health and social professionals, patients and their families to share and learn from one another.
    the hub is free for everyone to use. Have a browse and you will find the latest news, research, resources and events in patient safety, and lively conversations and debates. Members can share content, comment on posts and start conversations in our communities. Please use the hub, share content and let us know what you think and how we can continue to develop it.
    We would like to take the opportunity to thank everyone who has contributed this far in the development of the hub. Your thoughts, ideas and critique have been invaluable. the hub is still in development and we continue to seek out user testing and feedback. Please contact us at feedback@pslhub.org with your ideas or if you would like to be a part of our user testing group.  
  14. Sam
    Children's services could be forced to close at a hospital that is accused of leaving young patients traumatised and sick through poor care.
    The care regulator said it had taken action to "ensure people are safe" on Skylark ward at Kettering General Hospital (KGH) in Northamptonshire.
    Thirteen parents with serious concerns after their children died or became seriously ill have spoken to the BBC.
    A BBC Look East investigation has heard allegations spanning more than 20 years about the treatment of patients on Skylark ward, a 26-bed children's unit.
    The BBC discovered:
    An independent report found staff left a 12-year-old boy - who died at KGH in December 2019 - for four hours suffering seizures, and suggests little effort was made to obtain critical care support. In April 2019, nurses allegedly dragged a "traumatised" four-year-old girl down a corridor in agony, insisting that she could walk. Medics are accused of refusing to carry out an MRI scan, which would have detected a dangerous cyst on her spine. Mothers claim to have been threatened with safeguarding referrals, with one stating a referral was made against her after she complained her son was struggling to breathe, while another likened it to blackmail. Read full story
    Source: BBC News, 20 February 2023
  15. Sam
    Hospitals throughout the NHS are in such a poor state of repair that patient safety and care is being put at risk, according to an investigation by the Labour Party. A freedom of information requests sent to every hospital trust in England highlighted problems such as sewage and water leaking on to hospital wards, broken lifts and ceilings collapsing. The incidents have affected patient care, often leading to the cancellation of appointments and leaving people waiting longer for vital treatment. It is speculated that these issues are not just confined to secondary care.
    Read full story
    Source: Nursing Notes, 5 July 2019
  16. Sam
    Old age and having a wide range of initial symptoms increase the risk of "long Covid", say scientists. 
    The study estimates one in 20 people are sick for least eight weeks. The research at King's College London also showed being female, excess weight and asthma raised the risk.
    The aim is to develop an early warning signal that can identify patients who need extra care or who might benefit from early treatment.
    The findings come from an analysis of people entering their symptoms and test results into the COVID Symptom Study app.
    Scientists scoured the data for patterns that could predict who would get long-lasting illness.
    "Having more than five different symptoms in the first week was one of the key risk factors," Dr Claire Steves, from Kings College London, told BBC News.
    COVID-19 is more than just a cough - and the virus that causes it can affect organs throughout the body. Somebody who had a cough, fatigue, headache and diarrhoea, and lost their sense of smell, which are all potential symptoms,- would be at higher risk than somebody who had a cough alone. The risk also rises with age, particularly over 50, as did being female.
    Dr Steves said: "We've seen from the early data coming out that men were at much more risk of very severe disease and sadly of dying from Covid, it appears that women are more at risk of long Covid."
    No previous medical conditions were linked to long Covid except asthma and lung disease.
    Read full story
    Source: BBC News, 21 October 2020
  17. Sam
    An external review has been launched at a leading children’s hospital after a series of “never events”.
    According to local commissioners, a review by the Association for Perioperative Practitioners will look into seven incidents at Alder Hey Children’s Foundation Trust over the last two years. The probe had been delayed by the pandemic and began this month.  
    Great Ormond Street Hospital for Children FT and Sheffield Children’s FT, the two other dedicated children’s trusts in England, reported one and four never events respectively, between April 2018 and July 2020, according to national data.
    In a statement, Alder Hey claimed it could not provide further details of the incidents. But most have been described in its board papers over the past year. They include a 15-year-old who had the wrong tooth removed by the surgical division, a patient who had the wrong eye operated on, a swab that was left inside a patient having their adenoids and tonsils removed, and an incorrect implant being inserted into an orthopaedics patient.
    Liverpool Clinical Commissioning’s group’s board papers for September said: “The trust has had a series of seven never events and there is a plan to undertake an external review that has been delayed due to the pandemic response. The trust has approached the Association for Perioperative Practitioners and have agreed the process."
    “The trust also plans to work with Imperial College London on a peer review and bespoke human factors training to include simulation training and coaching. The trust also plans to produce an overarching action plan to bring together the themes and learning from the seven never events. This work is still underway and NHSE/I and CCG had requested a copy of this plan.”
    Read full story (paywalled)
    Source: HSJ, 24 September 2020
  18. Sam
    The toxicity of a commonly prescribed beta blocker needs better recognition across the NHS to prevent deaths from overdose, a new report warns today.
    The Healthcare and Safety Investigation Branch (HSIB) report focuses on propranolol, a cardiac drug that is now predominately used to treat migraine and anxiety symptoms. It is highly toxic when taken in large quantities and patients deteriorate quickly, making it difficult to treat. The investigation highlighted that these risks aren’t known widely enough by medical staff across the health service, whether issuing prescriptions to at risk patients, responding to overdose calls or carrying out emergency treatment.
    Dr Stephen Drage, ICU consultant and HSIB’s Director of Investigations, said: “Propranolol is a powerful and safe drug, benefitting patients across the country. However, what our investigation has highlighted is just how potent it can be in overdose. This safety risk spans every area of healthcare – from the GPs that initially prescribe the drug, to ambulance staff who respond to those urgent calls and the clinicians that administer emergency treatment."
    The report also emphasises that there is a link between anxiety, depression and migraine, and that more research is needed to understand the interactions between antidepressants and propranolol in overdose.
    Read full story
    Source: HSIB, 6 February 2020
  19. Sam
    In a recent interview in The Times, former Chief Medical Officer, Professor Sir Harry Burns considers the symptoms of the country’s drug deaths epidemic. The total of 1,187 fatalities in 2018 represents 218 drug deaths per million of the population and a 27% year-on-year rise. The death rate is three times higher than in the UK as a whole and worse than that of the United States. Politicians should listen to people working on the front line to tackle rising deaths, according to Sir Harry. The trouble is, he says, “public policy tends to be made because someone has a clever idea which then gets picked up by a politician. Very few outcomes in society are determined by one thing.” He believes that health and social benefit on a national scale comes with incremental change over an extended period of time. 
    When asked what one thing would you do to improve the health of the nation, Sir Harry said "Scotland has made enormous strides in improving patient safety using the concepts of improvement science in which front line staff have tested many different ideas and applied at scale the changes which they have seen work. It’s the principle of marginal gains that has been successful in sport. I would use this approach to improve wellbeing across society."
    Read full interview
    Source: The Times, 20 July 2019
  20. Sam
    Wards at a trust facing an inquiry over the deaths of vulnerable patients have been downgraded to ‘inadequate’ over fresh patient safety concerns. 
    The Care Quality Commission said five adult and intensive wards across three hospitals run by Tees, Esk and Wear Valleys (TEWV) Foundation Trust “did not manage patient safety incidents well”. It also criticised the trust’s leaders for failing to make sure staff knew how to assess patient risk.
    The watchdog rated the trust’s acute wards for adults of working age and psychiatric intensive care units as “inadequate” overall as well as for safety and leadership. The trust was also served a warning notice threatening more enforcement action if the patient safety issues are not urgently addressed. At the previous inspection in March 2020, the service was rated “good”.
    TEWV said it has taken “immediate action” to address the issues, including a rapid improvement event for staff and daily safety briefings, and will also spend £3.6m to recruit 80 more staff. The trust’s overall rating of “requires improvement” remains unchanged after this inspection.
    Brian Cranna, CQC’s head of hospital inspection for the North (mental health and community health services), said: “We found these five wards were providing a service where risks were not assessed effectively or managed well enough to keep people safe from harm."
    “Staff did not fully understand the complex risk assessment process and what was expected of them. The lack of robust documentation put people at direct risk of harm, as staff did not have access to the information they needed to provide safe care."
    Read full story (paywall)
    Source: HSJ, 26 March 2021
  21. Sam
    The Care Quality Commission (CQC) has been found guilty of maladministration over its handling of a fit and proper person test complaint which led to a £200,000 investigation by an NHS trust. A Parliamentary and Health Service Ombudsman (PHSO) investigation identified “several instances of maladministration” in the CQC’s handling of a complaint by former consultant paediatrician David Drew. 
    Ombudsman Rob Behrens has now written to the Health Secretary, NHS England, Chair of the Commons Health Committee Sarah Wollaston, and Chair of the Parliamentary and Constitutional Affairs Committee Bernard Jenkin with a copy of the PHSO investigation. In his letter. Mr Behrens said: “I believe this case exemplifies the damaging impact that poor handling of allegations can have on people’s faith in the ability of the CQC to identify and act on misconduct when whistleblowers come forward. This underlines the need for reform to the [fit and proper person] system and the recommendations from the Kark review to be swiftly implemented.”
    Read full story (paywalled)
    Source: HSJ, 24 July 2019
  22. Sam
    Royal College of Nursing (RCN) member Tara Matare has won the coveted title of RCN Nurse of the Year 2019. She scooped the leadership category at the RCNi Nurse Awards before being crowned the overall winner. Tara has tackled short staffing, improved workplace culture and enhanced patient care at her ophthalmology unit at Whipps Cross Hospital in London. Over a 14-year mission to overhaul the unit, there have been a steady stream of challenges, including fighting ophthalmology’s corner to ensure it wasn’t overlooked in favour of higher-profile inpatient services and tackling an ingrained culture of bullying.  
    Read full story
    Source: Royal College of Nursing, 4 July 2019
  23. Sam
    Self-harm among the over-65s must receive greater focus because of the increased risks associated with the pandemic, a leading expert has said.
    Loneliness, bereavement and reluctance to access GPs can all be causes in older adults, said Prof Nav Kapur, who has produced guidelines on the subject.
    He warned that in over-65s, without the right help, self-harm can also be a predictor of later suicide attempts.
    The NHS's mental health director said it had expanded its community support.
    Claire Murdoch added that its services, including face-to-face appointments, had "continued for all who needed them", and 24/7 crisis lines had been established.
    Over-65s are hospitalised more than 5,000 times a year in England because of self-harm and self-poisoning, figures obtained from NHS Digital show.
    Read full story
    Source: BBC News, 3 June 2021
  24. Sam
    A second “mutilated” patient left with life-changing injuries after botched hospital surgery has described how she was left in urine-soaked bed sheets for days by nurses who called her lazy when she was unable to get out of bed.
    Lucy Wilson told The Independent she believes she would have been better looked after at a veterinary practice compared to the level of care she received from nurses at Norfolk and Norwich Hospital Trust in January last year.
    She was one of three patients harmed by surgeon Camilo Valero in the same week and almost died after Dr Valero and other staff failed to recognise her life-threatening injuries following the operation to remove her gall bladder.
    Dr Valero is under investigation by the General Medical Council but is still practising under supervision at the trust, which has refused to say whether the third patient survived their ordeal.
    After requests by The Independent, bosses at the NHS trust have now committed to publishing details of a secret review carried out by the Royal College of Surgeons into Dr Valero’s work and the wider surgical services at the trust.
    Read full story
    Source: The Independent, 31 May 2021
  25. Sam
    Dr Max Pemberton, columnist for the Daily Mail, gives his opinion of the app that offers patients a GP consultation via their mobile phone. In theory, it sounds great: the patient can dial up, speak to and (via phone camera) see a doctor, who could be anywhere. However, how effective can such consultations be?  "I have been able to test this service for myself — and what I have experienced left me worried", says Dr Pemberton.
    Read full story
    Source: The Spectator, 20 July 2019
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