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Sam

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  1. News Article
    To new parents processing the shock of delivery and swimming in hormones, newborns can feel like a tiny, terrifying mystery; unexploded ordinance in a crib. “We were totally unprepared,” says Odilia. Neither she or her husband had ever changed a nappy and had no idea the baby needed feeding every three hours. “If you’re a new mum or dad, you have no idea,” recalls Anouk, a new mother. “I’m a doctor,” says Zarah, another new mother, incredulously. “So, you would expect that I’d know something, and I knew some things, but you really don’t have any clue.” The difference for these new parents, compared to the rest of us, is that they gave birth in the Netherlands. That meant help was instantly at hand in the form of the kraamzorg, or maternity carer. Everyone who gives birth in the Netherlands, regardless of their circumstances, has the legal right – covered by social insurance – to support from a maternity carer for the following week. These trained professionals come into your home daily, usually for eight days, providing advice, reassurance and practical help. It’s a different role to midwives, who continue to monitor women and babies after the birth in the Netherlands; the maternity carer updates the midwife on the mother and baby’s health and progress as well as supporting the parents as they come to terms with their new child. A maternity carer in the Netherlands, explains Betty de Vries of Kenniscentrum Kraamzorg, the organisation that registers maternity carers, “takes care of the woman the first week, advises her on breastfeeding and bottle feeding, hygiene, gives advice … everything to do with safe motherhood and a safe baby. She is there for the whole day most of the time so she can see how they are doing.” Her colleague, director Esther van der Zwan, adds: “It’s a lot of responsibility.” To prepare, maternity carers train for three years – a combination of academic and on-the-job placements – and have regular refresher training in everything from CPR to breastfeeding support.
  2. News Article
    Some care home residents may have been "neglected and left to starve" during the pandemic, Scotland's Covid Inquiry is expected to hear. Lawyers representing bereaved relatives said they also anticipate the inquiry will hear some people were forced into agreeing to "do not resuscitate" plans. Shelagh McCall KC told the inquiry that evidence to be led would "point to a systemic failure of the model of care". The public inquiry is investigating Scotland's response to the pandemic. Ms McCall is representing Bereaved Relatives Group Skye, a group of bereaved relatives and care workers from Skye and five other health board areas of Scotland. In her opening statement, she told the public inquiry that families wanted to know why Covid was allowed to enter care homes and "spread like wildfire" during the pandemic. She added: "As well as revealing the suffering of individuals and their families, we anticipate the evidence in these hearings will point to a systemic failure of the model for the delivery of care in Scotland, for its regulation and inspection. "We anticipate the inquiry will hear that people were pressured to agree to do not resuscitate notices, that people were not resuscitated even though no such notice was in place, that residents may have been neglected and left to starve and that families are not sure they were told the truth about their relative's death." Read full story Source: BBC News, 25 October 2023
  3. News Article
    No senior NHS England director is prepared to take responsibility for ADHD services — which are facing waits of up to a decade and severe medication shortages — HSJ has discovered. Despite soaring demand for assessments and widespread drug shortages recently triggering a national patient safety alert, responsibility for attention-deficit/hyperactivity disorder services does not sit within any NHS England directorate. HSJ understands that none of NHSE’s mental health, learning disability, or autism programmes have been given any resources for ADHD. It is also claimed that the medical and long-term conditions teams “are not very interested” in taking responsibility, and “assumed someone else was doing it”. A senior source, very close to the issue, told HSJ that no NHS senior director had taken “ownership” of the issue, and there was a widespread misapprehension that responsibility for ADHD services was part of the autism remit given to the mental health directorate. “We haven’t got the attention we need around ADHD,” said the source, “we need a [dedicated] neurodiversity programme.” Read full story (paywalled) Source: HSJ, 26 October 2023
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    With a strong national drive to standardise on a handful of EPR systems what are the risks of creating monopolies? What are the risks of vendor-lock in for future innovation, costs, choice and interoperability. Join our panellists as they debate this key industry topic. Find out more
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    This lecture will briefly outline challenges in quality and safety in healthcare, will identify the patchy history of attempts to make improvements, will emphasise the need to build and evidence base for improvement, and will outline some of the challenges and opportunities in evidence generation. Mary Dixon-Woods is Director of THIS Institute and The Health Foundation Professor of Healthcare Improvement Studies in the Department of Public Health and Primary Care at the University of Cambridge. Register
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    This conference focuses on priorities for improving urgent and emergency care services in England. It will be an opportunity to examine progress and next steps for: the Delivery plan for recovering urgent and emergency care services - published by NHS England in January 2023 the Re-envisioning urgent and emergency care report - published by the NHS Confederation in December 2022. Stakeholders and policymakers will assess key priorities, including implementation and investment of the delivery plan, and the way forward for reducing waiting times and improving patient outcomes. Further sessions look at issues surrounding the workforce and service capacity, speeding up patient discharge, next steps for the same day emergency care policy, and the future outlook for virtual wards. Includes keynote sessions with: Ashley McDougall, Director, Health Value for Money, National Audit Office; Dr Adrian Boyle, President, Royal College of Emergency Medicine; and a pre-recorded contribution from Miriam Deakin, Director of Policy, NHS Providers. Overall, areas for discussion include: the delivery plan: progress, trends and challenges in delivering sustainable recovery of urgent and emergency care in England - priorities for improving accessibility workforce: what will be needed to deliver aims of the NHS Long Term Workforce Plan for emergency care strategies for growing the emergency care workforce, as well as training, professional development and retention priorities for supporting staff and addressing challenges for the workforce that are specific to emergency care waiting times: enabling same day emergency care targets to be met - latest thinking and best practice in effective hospital design, and developing capacity and flow - priorities for funding hospital bed occupancy: addressing issues with speeding up patient discharge - the role of social care and options for expanding care in the community - progress in delivery of virtual wards capacity and accessibility: the role of Integrated Care Systems in developing effective pathways for improving capacity - involvement of the independent sector quality: next steps for driving up standards - enabling long-term sustainable system recovery - priorities for aligning needs in emergency care with wider policy developments and initiatives Register
  7. News Article
    Financial directors need to take responsibility for safety, which should be at the core of how the NHS runs services, the leadership of the Health Services Safety Investigations Body (HSSIB) said at its launch Wednesday. The Healthcare Safety Investigation Branch is now an independent body – and has been renamed HSSIB – although maternity investigations are hosted by the Care Quality Commission. Questioning how many finance directors across the NHS take responsibility for safety, HSSIB’s interim chief investigator Rosie Benneyworth said: “We need a position where finance directors in every organisation are as responsible for safety as the person leading the safety agenda and vice versa, the safety person works with the finance agenda to support them. “Often you see the finance director and safety lead don’t work effectively together and we need to change that.” Dr Benneyworth said progress will not be made unless operational delivery, financial delivery and safety are tackled “in the same breath”. HSSIB’s new chair Ted Baker also called for safety to become a core part of running services “in the way running the accounts is”, as it is currently still seen “as an add-on”. He stressed that safety “drives efficiencies, enables innovation and saves costs”. Read full story (paywalled) Source: HSJ, 19 October 2023
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    The Learn from Patient Safety Events (LFPSE) service is the NHS's new system for the recording and analysis of patient safety events. Very little research had been done before to understand the best ways to make sure patients, service users and their families can give their views on safety incidents, for the whole NHS to learn from. Learning from patients’ experiences and how they feel about the care they have received is known to be a very good way to make healthcare services better. However, getting the right information from people in the right way, and making sure the right NHS staff see it and can act on it, is difficult to do. This Show and Tell outlines the research completed to understand how we can do this better through the introduction of the LFPSE service. Audience: This is a publicly open event for anyone interested in understanding the work that NHS England has completed into understanding the best ways to make sure patients, service users and their families can give their views on safety incidents, for the whole NHS to learn from. Speakers: Lucie Mussett Patient Safety Lead & Senior Product Manager for the Learn from patient safety events (LFPSE) service Hope Bristow – Senior User Centred Designer (Informed Solutions) Natasha Hughes – User Researcher (Informed Solutions) Register
  9. Event
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    This two-day King's Fund conference aims to explore how the current strain on services makes listening to people more difficult but even more important, at a time when public satisfaction with the NHS is at an all-time low. Join us to hear about how you can make sure building in the user voice is routine and core to the business of the health and care system, not just ‘a nice to have’. Conference sessions will: discuss how the NHS and social care cannot deliver quality unless listening to patients and carers, and acting on their feedback, lies at the heart of its culture.   provide learning on how to listen well and what meaningful engagement with people and communities looks like. Gain insight into the findings from the Fund’s project on understanding integration with the HOPE (Heads of Patient Experience) network by working with six sites on an action learning piece. Learn about how health and social care decision-makers cannot overcome challenges and answer long-term questions alone - such as how the system will address the deep inequalities and how it can adapt to provide the joined-up, efficient care that people want and gives them more control – public input is crucial. Join peers to share learning on grasping this opportunity to finish building a culture where listening to patients, service-users, and communities is everyone's business.   Register
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    This free online event is an exciting opportunity to hear nursing workforce expert, Professor Alison Leary MBE, speak on the subjects of safe caseloads in community nursing. Professor Alison Leary PhD RN FRCN is Chair of Healthcare & Workforce Modelling at London South Bank University and Director of the QNI’s International Community Nursing Observatory. We will also hear from Cathy Woods and representatives of the software company Yarra, on the Use of E-CAT software for Monitoring Caseloads. The E-CAT product for district nursing is an electronic tool which supports caseload analysis and audit. Underpinned by a bespoke dependency tool and based on a methodology validated by the University of Ulster, the tool looks at caseload variables at all levels, from caseload holder to commissioner and facilitates caseload benchmarking and performance management. The tool has been implemented in all five health trusts in Northern Ireland providing a significant regional evidence base. We will be able to hear about the experience of using E-CAT in Northern Ireland from the NI Public Health Agency. Register
  11. News Article
    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
  12. News Article
    An NHS trust and ward manager have appeared in court charged with the manslaughter of a 22-year-old mental health patient who died in hospital in July 2015. Alice Figueiredo was found dead at Goodmayes Hospital in east London, and an investigation into her death was opened in April 2016. The Crown Prosecution Service (CPS) authorised the Met Police to charge North East London NHS Foundation Trust (NELFT) with corporate manslaughter last month following a five-year investigation. It is just the second NHS Trust to face manslaughter charges. The Trust is additionally charged with an offence under section three of the Health and Safety at Work Act in connection with mental health patient Ms Figueiredo's death. Ward manager Benjamin Aninakwa also faces a charge of gross negligence manslaughter and an offence under section seven of the Health and Safety at Work act. NELFT is just the second ever NHS Trust believed to have been charged with corporate manslaughter, after Maidstone and Tunbridge Wells Trust was charged over the death of a woman who underwent an emergency Caesarean in 2015. Read full story Source: Mail Online, 6 October 2023
  13. News Article
    ADHD patients around the UK are finding they can't get hold of medication since a national shortage was announced. Three different medicines are affected, and the government says some supply issues could last until December. The Department for Health and Social Care (DHSC) says "increased global demand and manufacturing issues" are behind the shortages. Medication helps to manage symptoms, which can include difficulty concentrating and focusing, hyperactivity and impulsiveness. Dr Saadia Arshad, a consultant psychiatrist, who specialises in diagnosing and treating people with ADHD. She says the shortage of medication is "not a new issue, but it's a recurring one". Dr Saadia says suddenly stopping meds can lead to patients "feeling jittery, finding it difficult to pay attention, staying focused and feeling restless". Even though she understands the shortage can be worrying, Dr Saadia says it's important that people don't take measures into their own hands. "These medicines can be quite potent and the response to medication for two individuals is not the same," she says. "So please do not take any action without discussing it with your clinician." Read full story Source: BBC News, 6 October 2023
  14. News Article
    Seven trusts have been added to NHS England’s list of providers with the worst elective and cancer problems, putting the number of organisations in the ‘tier 1’ group back into double figures – and five leaving it, HSJ has learned. Since last summer, NHS England has put trusts considered most “at risk” of missing recovery trajectories into “tiers” for either elective or cancer performance, or both. The list has changed significantly for quarter three of this year, despite only a few months passing since the last rankings were revealed in August. HSJ understands this is due to system-level agreements and some national factors, including the impact of ongoing industrial action on elective activity. The number of trusts in the most challenged “tier 1” group for both elective and cancer performance has increased from eight to 11, with seven new providers entering this tier and five leaving. Read full storySource: HSJ, 9 October 2023
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    Agenda and registration
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    Last year, our helpline advisers dealt with an average of two calls a day relating to complaints – could the caller complain about what had happened? How to complain? Who to complain to? This event is for patients and carers who would like answers to some basic questions about complaining about care. Solicitors Chris James and Josh Hughes from law firm Bolt Burdon Kemp will be joining our Chief Executive Rachel Power in this online event. Between them they’ll: Help people understand the NHS complaints process, including its limitations Describe how to get the most out of making a complaint Explain were the distinction can lie between poor service and a claim in negligence. Register
  17. News Article
    Police are investigating possible corporate manslaughter at the hospital where serial killer Lucy Letby worked. The former nurse, 33, was jailed in August for murdering seven babies and attempting to kill six others at the Countess of Chester Hospital. Cheshire Police said the latest investigation was in its early stages. Lawyers representing some of the victims' families said they were "reassured" steps were being taken to consider the actions of management. Organisations and companies can be found guilty of corporate manslaughter as a result of serious management failures resulting in a gross breach of a duty of care under The Corporate Manslaughter and Corporate Homicide Act 2007. Det Supt Simon Blackwell, of Cheshire Police, said the inquiry would focus on the indictment period of the charges for Letby from June 2015 to June 2016. He said the investigation would consider areas "including senior leadership and decision making to determine whether any criminality has taken place". "At this stage we are not investigating any individuals in relation to gross negligence manslaughter," he added. Read full story Source: BBC News, 4 October 2023
  18. News Article
    Trust leaders have been asked to “self-assess” the quality of their “improvement culture” as part of an initiative launched by NHS England chief executive Amanda Pritchard in the spring to lead the service's new improvement drive. The call came from NHS Impact, led by former Modernisation Agency chief David Fillingham, who along with NHS Impact’s deputy chair – University Hospitals Coventry and Warwickshire Foundation Trust CEO Andy Hardy – has written to service leaders, setting out the first stage in the improvement drive. They have asked the boards and CEOs of trusts and integerated care boards to “engage directly” with a new self-assessment tool and maturity matrix created by NHS Impact. This is designed to gauge their progress on adopting the five practices that NHS IMPACT claim “form the DNA of an improvement culture”. Those five practices are: A shared purpose and vision which are widely spread and guide all improvement effort. Investment in people and in building an improvement focused culture. Leaders at every level who understand improvement and practise it in their daily work. The consistent use of an appropriate suite of improvement methods. The embedding of improvement into management processes so that it becomes the way in which we lead and run our organisations and systems. Read full story (paywalled) Source: HSJ, 29 September 2023 .
  19. News Article
    More than 1 in 10 sexual harassment complaints against doctors are not investigated by the General Medical Council because of an “arbitary” rule, the Observer has revealed. According to data obtained under the Freedom of Information Act, 13% of sexual misconduct complaints made between the years 2017-18 and 2021-22 were closed without investigation because the GMC is prevented from considering alleged incidents more than five years after the event. As part of the council’s remit to protect patient safety and improve medical education and practice across the UK it investigates any kind of complaint against doctors. The figures show the GMC refused to investigate 170 complaints relating to sexual assault, attempted rape, and rape in the period analysed. In 22 of those cases the five-year rule was cited. It received 566 sexual harassment complaints in the same period. Anthony Omo, the GMC’s general counsel and director of fitness to practise, told the Observer: “We can and do waive the five-year rule where there are grave allegations involving sexual assault or rape. In many cases involving sexual allegations, the GMC’s position will be that such serious misconduct is incompatible with continued registration.” A government consultation in February heard that the five-year-rule was “arbitrary” and “a barrier to public protection” as it allowed doctors who may be guilty of inappropriate behaviour to continue practising. However, despite commitments from the Department of Health and Social Care to scrap the limitation as a “top priority”, no date has been set. Read full story Source: The Guardian, 30 September 2023
  20. News Article
    Brain surgery using artificial intelligence could be possible within two years, making it safer and more effective, a leading neurosurgeon says. Trainee surgeons are working with the new AI technology, to learn more precise keyhole brain surgery. Developed at University College London, it highlights small tumours and critical structures such as blood vessels at the centre of the brain. The government says it could be "a real game-changer" for healthcare in the UK. Brain surgery is precise and painstaking - straying a millimetre the wrong way could kill a patient instantly. Avoiding damaging the pituitary gland, the size of a grape, at the centre of the brain, is critical. It controls all the body's hormones - and any problems with it can cause blindness. Read full story Source: BBC News, 28 September 2023
  21. News Article
    Thousands of women are having induction of labour delayed because of a shortage of staff, raising concerns about the safety of them and their babies, HSJ has found. The issue has been highlighted at seven hospitals in Care Quality Commission reports over the past six months, and HSJ has identified a further three trusts declaring they are concerned about it in their own board papers over the same period. At University Hospitals of Leicester Trust, more than 1,300 “red flags” were raised in a five-month period due to delays in the induction of labour, linked to staffing levels, the CQC said earlier this month. Most were dealys in continuing inductions, and a smaller number were delays between admission and beginning an induction. UHL indicated it had set its own “red flag” bar locally, so all the delays did not represent a national alert. Carolyn Jenkinson, CQC deputy director of secondary and specialist healthcare, told HSJ: “At some maternity services we’ve found women having to wait long periods of time to be induced or for transfer to a labour ward once the induction process has started, and in some cases a lack of effective monitoring during periods of delay. “Where we have found concerns about delayed treatment – including induction of labour – we have made clear to those trusts that effective oversight of the issue is vital and that all action possible should be taken to mitigate any risk and keep people using the service safe.” Read full story (paywalled) Source: HSJ, 27 September 2023
  22. News Article
    The U.S. Department of Health and Human Services (HHS), through the Agency for Healthcare Research and Quality (AHRQ), announced nine grant awards of $1 million each for up to 5 years to support existing multidisciplinary Long COVID clinics across the country to expand access to comprehensive, coordinated, and person-centered care for people with Long COVID, particularly underserved, rural, vulnerable, and minority populations that are disproportionately impacted by the effects of Long COVID. The grants are a first of their kind. They are designed to expand access and care, develop, and implement new or improved care delivery models, foster best practices for Long COVID management, and support the primary care community in Long COVID education. This initiative is part of the Biden-Harris Administration's whole-government effort to accelerate scientific progress and provide individuals with Long COVID the support and services they need. “The Biden-Harris Administration is supporting patients, doctors and caregivers by providing science-based best practices for treating long COVID, maintaining access to insurance coverage, and protecting the rights of workers as they return to jobs while coping with the uncertainties of their illness,” said Secretary Xavier Becerra. “Treatment of Long COVID is a major focus for HHS, and AHRQ is helping lead the way through grants to investigate best practices and get useful guidance to doctors, hospitals, and patients.” Read full story Source: AHRQ, 20 September 2023
  23. Event
    The Safe Anaesthesia Liaison Group (SALG) Patient Safety Conference will be held virtually this year on Thursday 23 November 2023. The first session will include engaging lectures around the current work of SALG, and the second session will focus on topical issues in relation to a selected group or society (yet to be announced). There will be a prize session for accepted abstracts, with a poster section and oral presentations. This online conference is being organised by SALG co-chairs, Dr Peter Young from the Association of Anaesthetists, Dr Felicity Platt, Royal College of Anaesthetists The day will provide valuable knowledge for doctors engaged in clinical anaesthesia, pain management and intensive care medicine, and who have an interest in improving patient safety. Register
  24. Event
    This conference focuses on patient involvement and partnership for patient safety including implementing the New National Framework for involving patients in patient safety, and developing the role of the Patient Safety Partner (PSP) in your organisation or service. The conference will also cover engagement of patients and families in serious incidents, and patient involvement under the Patient Safety Incident Response Framework published in August 2022. This conference will enable you to: Network with colleagues who are working to involve patients in improving patient safety. Reflect on patient perspective. Understand the practicalities of recruiting Patient Safety Partners. Improve the way you recruit, work with and support Patient Safety Partners. Develop your skills in embedding compassion and empathy into patient partnership. Examine the role of patients under the new Patient Safety Incident Response Framework (PSIRF). Understand how you can improve patient partnership, family engagement and involvement after serious incidents. Identify key strategies for support patients, their families and carers to be directly involved in their own or their loved one’s safety. Learn from case studies demonstrating patient partnership for patients safety in action. Examine methods of involving patients to improve patient safety in high risk areas. Self assess and reflect on your own practice. Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register **Five free places for hub members. Email info@pslhub.org for code**
  25. News Article
    Hospitals are still promoting a “natural birth is best” philosophy – despite a succession of maternity scandals highlighting the dangers of the approach. A Telegraph investigation has found a number of trusts continuing to push women towards “normal” births – meaning that caesarean sections and other interventions are discouraged. On Saturday, the Health Secretary has expressed concern about the revelation, vowing to raise the matter with senior officials. Guidelines for the NHS make it categorically clear that a woman seeking a caesarean section should be supported in her choice, after “an informed discussion about the options”. Maternity services were last year warned by health chiefs to take care in the language they used, amid concern about “bias” towards natural births. The warning from maternity officials followed concern that women were being left in pain and fear, with their preferences routinely ignored. The findings come 18 months after Dame Donna Ockenden published a scathing report into maternity care at Shrewsbury and Telford NHS Trust, which warned that a focus on natural birth put women in danger. Read full story (paywalled) Source: The Telegraph, 23 September 2023
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