Patient_Safety_Learning

Parkinson’s is the fastest growing neurological condition in the world. Currently there is no cure for Parkinson’s, but medication plays a vital role in managing symptoms and preventing deterioration. In this blog, Joanne explains how delays to her mother’s time-critical medication in hospital led to her condition deteriorating.  I want to share my story about my mother’s treatment after she was admitted to hospital with a sore knee. She lived independently and walked with one stick prior to her admission. Her Parkinson’s was well managed with her medication. Right at the beginning of my mother’s inpatient stay she received the wrong amount of her time critical medication and her usual timings were not honoured, despite information given to medical staff on admission. My mother lost all her function which caused her to fall, she couldn’t sit up properly and was lying to the side and hunched over. She managed to feed herself a few times in this lying to the side/hunched over position. This in turn meant she aspirated and then took pneumonia. She also has heart failure, and the amount of antibiotics needed to shift the pneumonia then caused fluid overload which made her heart failure worse. We were not given much hope for her. She lost 4 stone of weight and was hospitalised for a total of 96 days. At times, she could not even coordinate her hand to mouth to eat. I was constantly having to chase the medical staff for her medication to be given at the correct times. I was made to feel like a pest. They even ran out at one stage, and the dosage was over 2 hours late. My mother was never incontinent on admission to hospital but that also soon changed. She deconditioned, was frail and then had trouble with orthostatic hypotension which restricted her rehab. She had several urinary tract infections which in turn caused delirium which was very upsetting. It is of my opinion that the medication delays caused the problems. I complained about the care and got her moved to a local hospital. She came on leaps and bounds, and they were bang on time constantly with her meds. No issues at all. Two physiotherapists had her up and walking. She was finally discharged from hospital on day 96 with a Zimmer frame with wheels and the assistance of two people. The physiotherapy team felt confident she wasn’t at her baseline and could improve to having the Zimmer and assistance of one. Things felt more positive. She then went to a rehab care centre where the physiotherapy input was minimal. The physiotherapist there reassessed her and told me that she would never walk again as it was too unsafe. Medical advice was to find a permanent nursing home for her. I then contacted a private neuro physiotherapist who specialises in Parkinson’s and he has hope for her and has had her up and walking again. I’m so very upset and traumatised by what has happened to my mother. It’s a very sad situation that we are currently faced with and I have no doubt that it all has been caused by an incorrect dosage and delays to the set timings of her Parkinson’s medication during her hospital admission. I do not feel the medical staff understood the importance of her time critical medication. There needs to be more awareness throughout health trusts and training for any staff involved in dispensing these medications. Guidelines or standards should be implemented and in place for time critical medication. It is not acceptable to follow general medication guidelines for time critical Parkinson’s medication. Share your story Have you or someone you care for been affected by any of the issues raised in Joanne's blog? Or perhaps you are a healthcare professional putting measures in in place to reduce errors around time-critical medication? You can comment below (sign up for free first) or email us at [email protected] to share your insights. Related reading Medication delays: A huge risk for inpatients with Parkinson’s Keeping patients with Parkinson’s safe in hospital: 4 key actions for staff Preparing to go into hospital – tips for people with Parkinson's and their carers Lightning Learning: Time Critical Medications ‘Every minute counts’: taking a national approach to time-critical medicines

Sex and gender-based inequities in health are widely recognised, with much work needed to improve care, treatment and outcomes for women. In this blog, we’ve selected 14 resources to highlight and evidence some of the key patient safety issues and the need for greater investment in this area. 1. Bias and Biology: How the gender gap in heart disease is costing women’s lives In this briefing the British Heart Foundation highlights the stark inequalities in awareness, diagnosis and treatment of heart attacks that are leading to women needlessly dying every day in the UK. 2. Medicines, research and female hormones: a dangerous knowledge gap In this blog, Patient Safety Learning takes a look at why women have been historically underrepresented in clinical trials and medical research, and the ongoing implications this has on medication safety for women. 3. Gender bias: A threat to women’s health Sarah Graham, award winning journalist, founder of Hysterical Women and author of Rebel Bodies, talks about gender bias within healthcare. Sarah draws on research, anecdotal evidence and the Cumberlege report to highlight how widespread mistreatment of women can have a negative impact on their safety as a patient. 4. Uncharted bodies: Why we’re exploring the gender health gap A series of articles from Refinery29 UK, focusing on the gender health gap. Looking at five distinct areas in reproductive and gynaecological health they highlight how a lack of research and data is directly affecting women’s health. 5. Miss Diagnosed: The health handbook every woman (and man) should read This handbook published by digital healthcare provider Livi looks at some of the evidence surrounding sex-based health inequalities and how they are affecting women in the UK. 6. RCOG video series: Tackling inequalities and disadvantage during pregnancy and birth This video series from the Royal College of Obstetricians and Gynaecologists (RCOG) discusses what actions are required to understand and work with vulnerable women and determine the best way to care for women who require complex intersecting services. 7. Empowering patients is key to improving gynaecology experiences In this opinion piece for the BMJ, Stephanie O’Donohue explains how a collaborative dialogue between clinician and patient can make a huge difference to patient experiences of gynaecology procedures. With a focus on pain, Stephanie draws on her own experiences, both positive and negative, to illustrate the value of shared-decision making. 8. Women and Equalities Committee: Women’s reproductive health conditions Women’s reproductive health conditions, such as endometriosis, adenomyosis and heavy menstrual bleeding are highly prevalent in the UK. This report looks at the experiences of care women with reproductive conditions get in England. It states that many women find their symptoms dismissed and normalised by those they turn to for help. 9. Woman of the North: Inequality, health and work Women in the North of England face unequal challenges and inequalities in their lives and health compared to those in the rest of the country according to a report from Health Equity North. They are more likely to work more hours for less pay and to be in worse health. On top of this, they are more likely to be an unpaid carer, live in poverty and to have fewer qualifications. The inequity between women living in the North of England and those in the rest of the country has grown over the past decade harming women’s quality of life, work, their families and communities. 10. How can reframing women’s health improve outcomes? An interview with Dr Marieke Bigg In an interview for the hub, sociologist Dr Marieke Bigg discusses how societal ideas about the female body have restricted the healthcare system’s approach to women’s health and describes the impact this has had on health outcomes. She also highlights areas where the health system is reframing its approach by listening to the needs of women and describes how simple changes can make a big difference. 11. Prioritizing women’s inclusion in clinical trials of medical devices In this JAMA Internal Medicine article, doctors Jessica Holtzman and Rita Redberg argue that for decades, women have been inadequately represented in clinical trials of drugs and devices evaluated by the US Food and Drug Administration (FDA). Looking at existing evidence on the issue, they identify barriers and improvements to women's representation in trials. They argue that the FDA needs to take action by declining to review medical devices and drugs if the representation of women does not reflect the intended use population. 12 Medical misogyny - things surgeons have said to women in Sling the Mesh Time and again members of the mesh community report facing a brick wall of institutional denial when seeking help for their pain and complications. This YouTube video highlights some of the outrageous, unacceptable and inappropriate comments that doctors have said to members of hashtag #slingthemesh support group in a pervasive culture of medical misogyny that should not still exist in modern medicine. 13 “It’s not menopause, you’re too young and don’t have the right symptoms"—the difficulties accessing menopause support and treatment Exactly 2 years ago, Clare hit rock bottom and took an extended break from work—not for a serious disease or major surgery, but because of something that all women experience but are often unable to access proper care or support for. In this blog for the hub, Clare shares her experience of trying to access menopause support and treatment in the NHS. 14 Women’s heart health - a patient safety priority Risa Mallory is a retired psychotherapist from Canada. After a serious cardiovascular event in 2018 she became a patient advocate, collaborating with organisations across the globe. In this blog Risa talks about her experience and the patient safety issues she's observed as a woman with a heart condition. "When I think about patient safety, I don’t just think about hospital infections or medication errors. For me, patient safety means something much more personal: whether my heart symptoms are taken seriously, and whether my care reflects the realities of being a woman." Read more in the women's health section of the hub. Share your insights Have you ever felt that your sex, gender or how you identify, has impacted your experience as a patient and led to less safe care? Or perhaps you are clinician or researcher with a perspective to share on health inequities? Please leave a comments below (sign up here first for free), or contact us directly at [email protected].

Navigating health and social care systems can be confusing and frustrating for patients and carers. In this blog Emma Sheffield, Communications and Marketing Manager at the Patients Association, explains how their free helpline is helping support people.  The Patients Association is a UK-wide charity dedicated to amplifying patient voices and improving healthcare experiences. We provide support, guidance, and advocacy to help people navigate the complex world of health and social care. Our free helpline offers specialist information and guidance to anyone, across all four UK nations. Whether you’re struggling to understand your healthcare options, need help resolving a concern, or just want to share your experience, our team is here to listen and assist. While we are not medically trained and cannot offer clinical or legal advice, we can help you make sense of the system and connect you with the right resources. What can you contact us about? The healthcare system can be overwhelming, and it’s not always clear where to turn for help. Our helpline is here to support you with a wide range of concerns, including: Care navigation – understanding how to access the right healthcare services, from GP appointments to specialist referrals. Your healthcare rights – how to get a second opinion, changing your GP or dentist, or accessing your medical records. Making a complaint – guidance on raising concerns about NHS or social care experiences, including who to contact and how to escalate issues. Accessibility and patient safety – ensuring you receive the support you need, such as interpreters or disability accommodations, and knowing what to do when care falls short. How the helpline has helped patients Ramona*, a concerned relative, reached out to our helpline after her Deaf family member faced barriers at their GP surgery. Despite requesting a British Sign Language (BSL) interpreter well in advance, the patient arrived at their appointment to find no interpreter arranged. The situation left them struggling to communicate effectively, leading to frustration and a lack of clarity about their care. When Ramona later contacted the GP practice, she was told there was "no budget" for BSL interpreters. Feeling this was unfair, she contacted us to speak to someone about it. Our helpline team explained that GP surgeries have a responsibility to provide accessible communication support. We guided her to contact the local Integrated Care Board (ICB) for clarity on funding policies and directed her to the Equality Advice and Support Service (EASS) for further support in raising a formal complaint. With this information, Ramona felt empowered to challenge the decision and advocate for her relative’s rights. Another caller, Arman*, contacted us after facing difficulties in managing their ADHD treatment. Following discharge from a specialist clinic, their GP continued prescribing their medication, but when it became less effective, they were told that only a specialist could approve a change. This meant starting the referral process again, leading to long delays and uncertainty. Feeling stuck, Arman contacted our helpline for guidance. We suggested asking their GP to clarify why specialist input was needed and whether any alternative medications could be prescribed in the meantime. We also explored ways to speed up the referral process, including requesting a referral back to their previous clinic or finding another specialist with a shorter wait time. With these options in mind, Arman felt more confident in approaching their GP and taking control of their care. Call or email the helpline You can call our helpline on 0800 345 7115 (freephone) between Monday to Friday, 9:30am to 5pm. You can also send us an email at: [email protected]. Your voice matters Calling the helpline doesn’t just help you, with your permission, your experiences contribute to wider improvements in patient care. Our partnership with the Care Quality Commission (CQC) means that your feedback can help inform changes in healthcare services, ensuring others don’t face the same challenges. If you have concerns about your healthcare, need help understanding your rights, or just need guidance on where to turn next, our helpline is here for you. You don’t have to navigate the system alone, speak to one of our friendly team members and we can help you find the answers you need. * Names have been changed. Related reading Lost in the system? NHS referrals "I love the NHS, BUT..." Preventing needless harms caused by poor communication in the NHS (DEMOS, November 2023) Robust collaborative practice must become the bedrock of modern healthcare Robbie: A homeless patient’s struggles with the system Digital-only prescription requests: An elderly woman sent round the houses Lost in the system: the need for better admin Digital-only prescription requests: An elderly woman sent round the houses

Patient Safety Learning stands with others around the world to celebrate International Women’s Day (8 March). The campaign theme for 2025 is ‘Accelerate Action’ and is a worldwide call to acknowledge strategies, resources and activity that positively impact women's advancement. In this blog, we explore four key areas of patient safety relating to women’s health, where we believe action needs to be accelerated: Pain management. Waiting times for elective gynaecology care. Redress for harmed patients. Disparities in maternal outcomes. Pain management Evidence shows that women are in pain more often and more severely than men.[1,2] They are also more likely to have their pain dismissed or underestimated[3], with racial biases leaving Black women particularly vulnerable.[4] These inequities can prolong women’s suffering of both acute and chronic pain, and can lead to delays in diagnoses and treatment. Women’s pain is dismissed in areas of healthcare relevant to both men and women, for example cardiology,[5] as well as in areas specific to the female body, for example gynaecology or maternity.[6] At Patient Safety Learning, we have heard too many accounts of patients attending gynaecology procedures where they have experienced unexpected high levels of pain that has not been managed or responded to appropriately.[7,8,9,10] In many cases, these experiences have led to an erosion of trust in the healthcare system and an increased anxiety in attending future appointments that may play a critical role in their outcomes. There is no nationally adopted, standardised patient feedback collection around pain experiences in gynaecology procedures. If patient-reported outcome measures were routinely collected, this data could be used by healthcare organisations to help identify the scale of harm and amplify the voices of the women affected so that pain is better managed and no one is at risk of trauma. These feedback mechanisms need to be co-designed with those who have lived experience to ensure the data being captured is meaningful, is designed to identify inequalities and used to improve care for all women. Most importantly, whatever the setting, it is critical that women’s experiences of pain whether chronic or acute, are listened to, believed and appropriately responded to. Patients should be empowered with the information, compassion and respect needed to place them at the heart of the decision making around their pain management. Waiting times for elective gynaecology care A 2022 report from the Royal College of Obstetricians and Gynaecologists showed the number of women waiting over a year for elective gynaecology care in England had increased from 66 before the pandemic to nearly 25,000.[11] Their follow up report in 2024 showed that waiting lists had worsened in all parts of the UK, with those living in areas of deprivation most likely to wait longest.[12] With debilitating conditions like endometriosis, already notorious for taking many years to diagnose,[13,14] evidence of continued setbacks in this area, rather than progress, is devastating. Women seeking help and treatment for life-limiting symptoms are being left without the support they need and fearful that their health will worsen. This often has a negative repercussion on other areas of life, including relationships, work and mental health.[15] The Women’s Health Strategy published in 2022 sets out plans for the roll-out of women’s health hubs to provide a ‘one-stop shop’, where services are centred on women’s needs, better coordination of care and reducing the elective backlog.[16] The Strategy notes the wide and varied range of stakeholders that will need to be involved in this effort and states that the Government” will develop a delivery plan for the commitments set out in this strategy”. However, there is currently no timetable for this, or indication of what resources may be allocated to support this work. Despite some early evidence of their success in reducing waiting times,[17] there are concerns that central support for the women’s health hubs has recently been removed,[18,19] and that women’s health has been deprioritised in the NHS health plans.[20] Women’s health needs to urgently be prioritised and invested in to address the worsening wait times for gynaecological care. Healthcare professionals must be given access to the resources needed to be able to provide high quality, safe care to all women so that inequalities do not continue to widen. Without this, patients will continue to suffer avoidable pain and are at risk of further harm relating to their physical and mental health outcomes. Redress for harmed patients Last year the Patient Safety Commissioner for England published The Hughes Report, which sets out options for redress for those who have been harmed by valproate and pelvic mesh.[21] Patient Safety Learning believes, like many individual patients and patient groups, that there must be redress options for patients harmed by the interventions covered by The Independent Medicines and Medical Devices Safety (IMMDS) Review.[22] There is considerable evidence that for many patients the clinical negligence route is simply not viable. In the absence of any system of redress, this leaves them with no assistance to help meet the cost of any additional care and support they may need. We also believe that redress should extend to those affected by hormone pregnancy tests, who fell outside of the scope of The Hughes Report’s recommendations. Excluding patients and family members affected by hormone pregnancy tests from redress is not acceptable or in keeping with the spirit of the IMMDS Review’s recommendations. We believe the Government must respond to this report promptly and take steps to deliver redress for all those affected by pelvic mesh, sodium valproate and hormone pregnancy tests as a matter of urgency. Disparities in maternal outcomes The ‘Saving Lives, Improving Mothers' Care annual reports include: data on women who died during or up to one year after pregnancy in the UK lessons learned from the UK and Ireland confidential enquiries into maternal deaths and morbidity.[23] The most recent report[24] highlights a continuation of inequalities with maternal mortality rates three times as high for women from Black ethnic backgrounds and twice as high for women from Asian ethnic backgrounds when compared to White women. The data also showed that women living in the most deprived areas of the UK and Ireland were twice as likely to die compared to those living in the least deprived areas. The report also highlighted barriers to accessing maternity care for women who had recently arrived in the UK. Many didn’t get the support they needed to understand how to register with a GP to start receiving maternity care and would present for the first time in an emergency setting. Language and literacy barriers were also evident, with patient needs being poorly assessed, recorded and met. The availability of interpreters and accessible written information was inconsistent. It is clear that a continued focus is needed to ensure disparities in maternity are better understood and addressed. All women have the right to access safe maternity care, free from racism, bias and a postcode lottery. Access to information in an accessible format that enables women to give consent to interventions and make decisions about their health and the health of their babies is also vital.[25] Translation capabilities within the health service must be prioritised and properly resourced across the board for these inequalities to be addressed. Summary There are many barriers to women receiving safe and equitable care. This blog has touched on just a few of the areas where action needs to be accelerated. We must recognise there are complex inter-relationships that compound these issues – intersectionality is an essential consideration. It is important to look at all variables in order to effectively identify the barriers and solutions to safer and more equitable care. In the coming months, we hope to see the importance of patient safety in women’s health emphasised and supported through the development of the NHS 10 Year Health Plan. The Royal College of Obstetricians and Gynaecologists has also recently launched a project to identify the most pressing unanswered questions in the health of women and people from the perspective of members of the public themselves.[26] We look forward to hearing more about their findings. We continue to await the Government’s response to the Hughes Report and to support the IMMDS Review’s recommendations for redress for those who have been harmed by valproate, pelvic mesh and hormone pregnancy tests. Helen Hughes, Chief Executive Officer of Patient Safety Learning says: “All patients have the right to access safe care, free from avoidable pain and harm. Women’s health has for centuries been side-lined and action must be accelerated now to address the inequities and barriers that continue to exist. This has to start with a focus on listening to and believing women when they share their experiences. Where harm has occurred, it is vital that we learn from the mistakes made and that this harm is appropriately responded to”. References Nurofen. Gender Pain Gap Index Report Year 3. Oct 2024. Editorial. Gendered pain: a call for recognition and health equity. eClinicalMedicine Mar 2024 Vol 69. C de C Williams, A. Analysis: Women’s pain is routinely underestimated, and gender stereotypes are to blame. The Conversation. Apr 2021. Hoffman KM, Trawalter S, Axt JR et al. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016 Apr 19;113. Nabel EG. Coronary heart disease in women--an ounce of prevention. N Engl J Med. 2000 Aug 24;343. J. H. Bamber, R. Goldacre, D. N. Lucas et al. A national cohort study to investigate the association between ethnicity and the provision of care in obstetric anaesthesia in England between 2011 and 2021. Anaesthesia, 78(7), 820-829. Patient Safety Learning - the hub. Painful hysteroscopy. Community forum - accessed 03/03/25. Patient Safety Learning - the hub. Pain during IUD fitting. Community forum- accessed 03/03/25. Cohen, L. The pain of my IUD fitting was horrific…and I’m not alone. Patient Safety Learning - the hub. Jun 2021. Anonymous. My experience of an IUD insertion: frozen with shock - no one was asking if I was OK. Patient Safety Learning - the hub. Jan 2025. Royal College of Obstetricians and Gynaecologists. Left for too long. 2022. Royal College of Obstetricians and Gynaecologists. Waiting for a way forward. 2024. Endometriosis UK. “Dismissed, ignored and belittled”. The long road to endometriosis diagnosis in the UK. Mar 2024. All Party Parliamentary Group (APPG) on Endometriosis. APPG on Endometriosis Inquiry Report 2020. Endometriosis in the UK: time for change. 2020. Royal College of Obstetricians and Gynaecologists. New RCOG report reveals devastating impact of UK gynaecology care crisis on women and NHS staff. Nov 2024. NHS England. Women's Health Strategy for England. Aug 2022. Crouch, H. Women's Health Hub aims to reduce wait lists for gynaecology. Barts Health NHS Trust. Nov 2024. Royal College of Obstetricians and Gynaecologists. RCOG responds to reports that central support for women’s health hubs will end. Jan 2025. Donnelly, L. Wes Streeting dumps women's health target from NHS plan. The Telegraph online. Jan 2025. NHS England. NHS England 2025/26 priorities and operational planning guidance. Jan 2025. Patient Safety Commissioner. The Hughes Report: Options for redress for those harmed by valproate and pelvic mesh. Feb 2024. Cumberlege, J. First Do No Harm. The report of the Independent Medicines and Medical Devices Safety Review. July 2020. The National Perinatal Epidemiology Unit, MBRRACE-UK. Saving Lives, Improving Mothers' Care annual reports. The National Perinatal Epidemiology Unit, MBRRACE-UK. Saving Lives, Improving Mothers' Care 2024 - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2020-22. Oct 2024. NHS England. Accessible Information Standard (updated Aug 2017). Royal College of Obstetricians and Gynaecologists. Women's Health Research Priorities (WHRP). Jan 2025. Related hub reading Top picks: Women's health inequity Dangerous exclusions: The risk to patient safety of sex and gender bias Failures of informed consent and the impact on women’s health: a Patient Safety Learning blog Gender bias: A threat to women’s health Top picks: Six resources about improving access to cervical screening The normalisation of women’s pain Top Picks: Women campaigning for patient safety TIGER UK: A new network for people passionate about improving gynaecology experiences First Do No Harm APPG public meeting on redress: Speech from Kath Sansom Fitting coils: developing a safe and supportive service

Navigating the healthcare system in the UK can be complex and frustrating for patients, families and carers. We hear time and time again on the hub about the lack of joined up care and communication within and across organisations.  Failing to share the right information at the right time can create significant patient safety risks. Poor communications, both with patients and between healthcare professionals, can result in misunderstandings and mistakes resulting in poor outcomes and potentially patient harm. In a series of blogs on the hub, patients and their relatives describe the challenges and barriers they have faced when trying to navigate the healthcare system.  Although every experience of navigating the healthcare system is different, the blogs in this series highlight some clear themes: Confusing communications and correspondence. Information not accessible across departments. Disjointed electronic systems, often not talking to each other. Concerns around the impact of delays to treatment and diagnostic tests. Near misses managed by patients and family members. Concerns for more vulnerable patients and those without advocates. The negative impact on mental health and stress levels. Not knowing who to contact to chase referrals, appointments or results. Read Sue’s story Sue’s husband Neil has a very rare chronic condition and is under the care of many different specialties. In this blog, Sue shares her and Neil’s experiences of trying to coordinate the healthcare system and highlights the challenges and frustrations they continuously face. Read David’s story In this blog, David shares his story about his elderly sister who has dementia, and a mix up with an urgent referral which led to a near miss. Read Margaret’s story Margaret’s father has dementia and a complex set of health issues. In this blog, Margaret shares her experience of trying to coordinate their elderly father's upcoming surgery. Read a university student’s story Moving to university is a big transition for many. In this anonymous blog, a student describes how persistent health issues led to a frustrating journey through the healthcare system. These stories illustrate how disjointed systems can affect patient and carer experiences and have a negative impact on health outcomes. Commenting on the issues highlighted in the series, Chief Executive of Patient Safety Learning, Helen Hughes says: “Poorly coordinated care is not only confusing and frustrating for patients but also creates safety risks that can result in serious avoidable harm. We hear many examples, such those covered in this blog series, of patients and their families facing a complex and fragmented healthcare environment. When they raise concerns about care and treatment, in too many cases they encounter an unresponsive system where they are left to ‘join the dots for patient safety’. The needs of patients should be central to improving health and care services, actively listening and acting on their experiences and insights when things go wrong for safety improvement.” Share your story What has been your experience of navigating the healthcare system? What is and isn’t working? How does it feel as a patient or carer when you hit barriers? Has your health been affected? Share your story in our community forum or contact our editorial team at [email protected]. Related reading Lost in the system? NHS referrals "I love the NHS, BUT..." Preventing needless harms caused by poor communication in the NHS (DEMOS, November 2023) Robust collaborative practice must become the bedrock of modern healthcare Robbie: A homeless patient’s struggles with the system Digital-only prescription requests: An elderly woman sent round the houses Lost in the system: the need for better admin Digital-only prescription requests: An elderly woman sent round the houses

Frontline19 was established at the start of the Covid pandemic as an urgent response to support frontline workers who were under extreme pressure and experiencing significant mental health challenges. Psychotherapist Claire Goodwin-Fee is the founder and CEO of Frontline19. In this blog, Claire explains how systemic pressures and stigma around mental health are continuing to leave healthcare staff extremely vulnerable. Frontline workers, particularly in healthcare, are often overlooked when it comes to mental health support. These individuals are regularly exposed to traumatic incidents and are frequently required to function under highly stressful conditions. Despite this, there has historically been little provision for their mental health. Frontline19 is working to address this gap, both by providing direct support and by tackling the stigma that prevents many healthcare workers from seeking help. When I set up Frontline 19, I initially thought I’d be able to help around 50 people, but on the first day, 750 people came forward and we had to adapt - fast. Now in 2025, we have supported over a million individuals through one-to-one counselling, psychological support, and group interventions. A broad spectrum of challenges We receive requests for support from individuals facing a broad spectrum of challenges. These include post-traumatic stress disorder (PTSD) - often triggered or exacerbated by their work during the pandemic - as well as suicidal ideation, which remains alarmingly prevalent among healthcare workers. Other common issues include anxiety, stress, and depression. Recently, there’s been a noticeable shift in the nature of calls. While the acute trauma of the pandemic has subsided, the ongoing effects of working during this time as well as the current pressures of working within a severely depleted healthcare system with over 100,000 vacancies are taking their toll. Staff frequently report feeling demoralised, burnt out, and physically and emotionally exhausted. The unrelenting demands of their roles have led to a chronic state of distress for many, highlighting the need for sustained support even beyond crisis periods. 1 in 4 have suicidal thoughts One of my primary concerns is the alarming rate of suicide among healthcare workers; we know that 1 in 4 have experienced these thoughts. The combination of unmanageable workloads, exposure to trauma, and inadequate support creates a perfect storm for acute mental ill health. Additionally, the year-round pressures - such as seasonal surges in patient numbers and the cumulative effects of staff shortages - are creating long-term damage to individuals and the wider system. Systemic pressures and the normalisation of burnout The mental health challenges staff face are deeply intertwined with systemic issues. These include chronic understaffing, lack of resources, and the erosion of social care services, which leave healthcare workers trying to fill impossible gaps. Many also face moral injury - the psychological distress that occurs when they are unable to provide the level of care they know their patients need. The constant exposure to such situations takes a significant toll, leading to feelings of guilt, shame, and helplessness. I’m deeply concerned about the normalisation of burnout. Many staff no longer see chronic stress as an anomaly but rather as an inescapable reality of their jobs. This level of despair and resignation is worrying, as it suggests systemic failures that need urgent attention. Unsafe conditions for staff and patients Many healthcare workers face unsafe conditions daily, where systemic resource shortages create high-risk environments for both patients and staff. When adverse outcomes occur, the consequences can be devastating for patients and deeply distressing for the staff involved. In these situations, professionals often find themselves under intense scrutiny, facing potential repercussions despite having done everything possible within the constraints they are working under. These circumstances place their professional safety in jeopardy, and the level of support they receive afterward varies greatly, leaving many to navigate the aftermath alone. Addressing the root causes We believe in addressing the root causes, not just the symptoms. This means embedding meaningful, mandatory, and regular mental health training for all healthcare staff, from students to senior professionals. Although staff frequently face very difficult situations, the additional pressures of working in a system on its knees means that sadly mental ill health has almost become an occupational hazard - and one that requires the proper understanding and support to address it. The current reliance on “resilience training” is counterproductive. It places the burden on individuals to adapt to broken systems rather than the NHS addressing the systemic issues itself. Instead, we need structural changes, such as improved working conditions, better staffing levels, and access to basic amenities like free parking, 24/7 meal options, rest areas, and designated on-call rooms. Supporting staff wellbeing would have a direct positive impact on patients. When healthcare workers feel valued, supported, and equipped to do their jobs, they are better able to provide high-quality care. This, in turn, enhances patient safety and outcomes. The alarming rate of suicide among healthcare workers should be a wake-up call in the urgent need to support them. Contact Frontline 19 Individuals can visit our website frontline19.com to complete a secure form or email us at [email protected]. From there, they will be triaged and connected with appropriate support. Our services are entirely free for individuals and completely confidential. We are not an immediate crisis response service. If you are experiencing a mental health crisis and you feel at immediate risk of harm, please call 999. Samaritans can be contacted on 116 123 or email [email protected] Share your experience Do you work in healthcare? What did you think about the issues raised in Claire's blog? How could staff wellbeing being better supported? What impact would improvements have on patient safety? Please comment below (sign up first for free) or contact us at [email protected]. Related reading Balancing care: The psychological impact of ensuring patient safety Top picks for staff psychological safety Understanding moral injury: a short film (HEE and NHSE&I) Hidden wounds Why I ‘walk on by’

Ron Daniels is a Consultant in Critical Care, Vice President of the Global Sepsis Alliance, Chief Medical Officer of the United Kingdom Sepsis Trust, and a Topic leader for Patient Safety Learning’s hub.  In this interview, Ron explains why doctors have to carefully manage the use of antibiotics in order to protect patients, now and in the future.  What’s the issue with prescribing antibiotics? For decades we have been using antibiotics to treat and reduce infection, and to stop people dying from infection. Unfortunately, some of the bacteria (and related organisms) we’ve been fighting have become resistant to certain types of antibiotics (or antimicrobials, in the case of other germs such as viruses, parasites and fungi). This is also known as antimicrobial resistance (AMR). Lots of people wrongly think that a patient can become resistant to antibiotics. It’s the bug, not the person. Prescribing antibiotics unnecessarily leads to more and more bugs becoming resistant, leaving patients with fewer treatment options. This is already having a huge impact on healthcare as we know it, with thousands of people affected. We need to manage the risks now, and as we move forward into the future. What does this mean for patients? If you become poorly with a bug that is resistant to a type of antibiotic, prescribing that antibiotic to you will not make you better. Your symptoms will remain or get worse. As you can imagine, this makes those particular bugs very difficult to treat, and serious life-threatening infections like sepsis more likely to occur. Worryingly, statistics indicate that patients in more deprived areas are more likely to be affected. If a doctor is concerned that you are unwell with a bug that cannot be treated with the usual ‘first choice’ course of antibiotics, they may change it or prescribe something called a ‘broad spectrum antibiotic’ to help you feel better. In some circumstances, this is lifesaving. Unfortunately using these ‘broad spectrum antibiotics’ can lead to even more bugs becoming resistant to even more types of antibiotics. There also tends to be more side effects for the patient. What are the big risks? There are a number of risks and challenges that have to be really carefully managed around the use of antibiotics. Essentially, we want to make sure: Standard and broad-spectrum antibiotics are not being prescribed unnecessarily and contributing to the issue of an increasing number of bugs being resistant to our treatments. Patients get the antibiotics they need and do not become seriously unwell or at risk of sepsis. Health inequalities do not widen. How do doctors know what to do for the best? Deciding whether or not to give antibiotics to a patient, and which type is best if you do, can be very difficult. There are tests that can identify what type of bug a patient has and what it is resistant to. There are other tests – called biomarkers – which can help with the decision as to whether or not antibiotics are needed at all. These tests can really help healthcare professionals make decisions around antibiotics, but these services are not yet widely available. What do you hope to see in future? We need to help the public understand these issues and how they are affecting healthcare and decision-making. Many people visiting their doctor will strongly believe that antibiotics are the solution to their problem. There can be a lot of pressure to prescribe them, and it can be hard to explain why that’s not always the best approach. If someone looks very sick, their GP will be sending them straight to hospital. But if not, having access to a biomarker test in the community would help people feel reassured and support that important doctor-patient relationship, especially when antibiotics are not being prescribed. Doctors need to be empowered to make the best and safest decisions for their patients. I believe we should be piloting having biomarker testing within close access to GP surgeries. For those patients deemed in need of antibiotics, further tests should guide the choice of medicine. That way, patients could quickly and easily be offered testing, and the rapid results would help their doctor decide whether to prescribe antibiotics and if so, which type would be most effective. Focusing the pilots in urban areas where there is significant variation in wealth would also help us understand and manage the risk of widening health inequalities. These actions could help reduce unnecessary antibiotic use and protect patients from serious infection. Ultimately, helping to limit the threat to human life both now and in the future. Related content Top picks: 14 key resources on antimicrobial resistance Tackling antibiotic underdosing: Interview with Ruth Dando, Head of Nursing for Theatres, Critical Care and Anaesthetics at BHRUHT What factors in the workplace enable success in antimicrobial stewardship in paediatric intensive care? Tackling antimicrobial resistance: How to keep antibiotics working for the next century Antimicrobial resistance survivors: calling the world to action Patient capacity building for advocacy and research: The case of the European Patient Group on Antimicrobial Resistance Department of Health and Social Care: Confronting antimicrobial resistance 2024 to 2029

In December 2022, Harry Vass died after experiencing Acute Behavioural Disturbance (ABD) and a complex disturbance in normal physiology.     In her first blog, Harry’s mother Julie told us about Harry and the events that preceded his death, during which he suffered with anxiety, addiction and psychosis. She talked about the inquest and how they learned of gaps in Harry’s care, that led the coroner to deem it an avoidable death.  In this second blog, Julie explains more about Acute Behavioural Disturbance and the changes she believes are needed to make sure patients like Harry are cared for appropriately.  Right after Harry was pronounced dead, a paramedic presented us with his belongings in a plastic hospital bag and we were sent home. We were told to ring the hospital bereavement office the following morning. We did so to be told that they didn’t have anything to do with coroner cases, so we knew then that Harry had been referred to the coroner. Our inquest was an article 2 inquest as Harry had died whilst detained under section 136 of the Mental Health Act and his liberty had been taken away for his own, and others, safety. This allows for the scope of the inquest to be slightly wider in exploring the issues prior to, and the cause, of death. The jury concluded that Harry had died of: “…sudden death, most likely as a result of terminal cardiac arrhythmia on a background of psychosis and recent cocaine use leading to an acute disturbance in behaviour and complex disturbance in normal physiology.” Acute Behavioural Disturbance is not a condition in its own right, so the term cannot be used on the death certificate as a standalone cause of death. As the coroner felt that this death was avoidable, a Prevention of Future Deaths Report was written and later a response was received from the Royal College of Nursing. What is Acute Behavioural Disturbance? Acute behavioural disturbance is an umbrella term used to describe a presentation which can include abnormal physiology and/or behaviour. Acute Behavioural Disturbance has previously been called excited delirium, acute behavioural disorder, or agitated delirium. The below represent signs which may be present in Acute Behavioural Disturbance - one or more may be present. Agitation Constant physical activity Bizarre behaviour (incl. paranoia, hypervigilance) Fear, panic Unusual or unexpected strength Sustained non-compliance with police or ambulance staff Pain tolerance, impervious to pain Hot to touch, sweating Rapid breathing Tachycardia.[1] Although the term Acute Behavioural Disturbance has been used over a long period, it is still not consistently known, used or understood across different professional groups. Seven key areas for change Throughout the last two years we have become more aware of the gaps in Harry’s care and support in the lead up to his death. I believe focusing on the seven areas below would help to prevent future deaths. 1. Raising awareness and understanding Making sure that healthcare professionals working in emergency departments and mental health units (especially those caring for acutely ill patients) receive training and education in Acute Behavioural Disturbance. This must include nurses who are the professionals most likely to detect physical changes in a patient’s condition. 2. Consistent terminology Although much has been published since Harry’s death, there is procrastination over terminology used to describe this presentation. There should be collaboration on immediate actions needed, using agreed reference terms, for example; “physiological disarray with psychosis, particularly following the use of illicit drugs”. The simple addition of a few words to training policies and packages could be very powerful in saving lives. 3. Collaborative guidance The National Institute for Health and Care Excellence, the Royal College of Nursing, Royal college of Psychiatrists and Royal College of Emergency Medicine need to agree on the wording of appropriate policies to guide and educate professionals facing this presentation. It is essential to bring nurses to this forum as they have previously been excluded. 4. Post-mortem training The Royal College of Pathologists/ Forensic Pathologists could think about training and education for those undertaking post-mortems for these patients. Knowing what to look for and finding evidence is extremely difficult. In our case, we were told that Harry had previously damaged heart muscle caused by illicit drugs which was not the opinion of the expert witness. 5. Data collection and coding NHS England should have the coding reviewed/ adjusted. “Psychosis with physiological disarray with or without illicit drug use“ (or similar wording) should be available as a coding choice for clinicians and coders. This would allow for proper data capture for these presentations in the NHS. 6. Monitoring of prevention of future deaths reports I believe there should be an overarching body to monitor prevention of future deaths reports, and the responses to these. This body should support any learning and the required remedial actions within appropriate timeframes. It should hold organisations accountable for investment and implementation of remedial plans and ongoing measurement of agreed set outcomes. 7. Research and early intervention We need more research to fully understand those at risk of the presentation of Acute Behavioural Disturbance and why. Early warning signs would then be identified and recommendations made for care pathway interventions for better outcomes. What else can healthcare professionals do? Simply be aware of patients presenting with psychosis, particularly with a history of illicit drug use and previous mental health difficulties. Patients with extreme and prolonged agitation can become physically unwell leading to the medical emergency of cardiac arrhythmia and arrest. Take frequent basic physical observations to be alerted to any changes in physical condition. Healthcare professionals already have training and policies on dealing with a deteriorating patient should a change be detected. What else can Trusts do? Make sure relevant staff receive training, education and support in Acute Behavioural Disturbance. Patients taking illicit drugs who may have mental health issues already should be offered support at the earliest possible opportunity to avoid an escalating situation. Drug and alcohol liaison teams working in emergency departments is good practise and can offer clear pathways to support for these patients. Consider partnership working with wider public services to improve mental health support – Avon and Somerset Constabulary have made changes including working with the ambulance service. Trusts should be proactive in providing an appropriate environment for the care and safety of the patient, staff and other patients. An appropriate environment also avoids the potentially discriminatory actions of removing a patient from a busy emergency department because they are disruptive, without proper examination and care. There is a conflict of interest in offering a family a duty of candour when care doesn’t go to plan, and the need to protect the Trust from potential litigation. We found this so frustrating as it meant that what happened to Harry was not fully shared and understood until the inquest some 18 months after his death. I’m not sure how this could be addressed but it’s a wider issue for Trusts to consider. Our family would have felt far less stressed and emotionally exhausted if we had been told more of the facts and what had not gone to plan at an earlier point. Support and advice for other families Over the weeks and months leading up to the inquest there were periods of so much activity that I found it helpful to write a journal. Journal keeping allowed for thoughts to be put down on paper and “parked” but it has also proved to be good for checking back on dates and events. I would recommend keeping a journal to anyone in a similar position. On the good side, there were people and organisations that we were so grateful for and would highly recommend having their support and input. We would not have made it through this period without them. The Mental Health NHS Trust had a Family Liaison Officer who was able to field our questions, update us on issues such as the serious incident investigation and organise meetings with professionals at which she would support us. I don’t know if this is common practice, but we had clear benefit from this role. We found our way to INQUEST, a charitable organisation which supports families like us through the inquest process. We had our own case worker who was amazing at supporting us in both practical ways as well as giving us valuable information and guidance. We really felt we were not alone as she checked on us regularly. She assisted in the appointment of lawyers and a barrister for the inquest and was able to respond to our questions which were many given we had never been in this situation before. We still have contact now. Final thoughts Since Harry’s death there have been further deaths in hospitals with very similar stories to Harry’s. There is a general feeling that there has been an increase of cases. Use of cocaine and illicit drugs, increase of poor mental health in the population and a developing awareness of this presentation are possible associated factors. We have looked at other recent prevention of future deaths reports to find that Acute Behavioural Disturbance is mentioned fairly consistently. Our concern is that these reports are either not responded to, or are responded to inadequately and no effective action is taken. There is no body responsible for the oversight of these reports and to hold those organisations who can effect change to account. Our lives have changed for ever now. We try not to be angry as we know that no one intended for this to happen. We do want learning to be taken away from this unthinkable event in the hope that something similar will not happen to other families, this is so important to us. [1] Royal College of Emergency Medicine, October 2023. Acute Behavioural Disturbance in Emergency Departments (version 2). Share your insights Do you have insights to share around patient safety? Could your experiences help guide improvements? Or perhaps you're a healthcare professional making changes to reduce risk to patient safety? If you would like to contribute, please comment below (you'll need to sign up here first for free) or contact the editorial team at [email protected]. Related reading Harry’s story: Acute Behavioural Disturbance Prevention of future deaths report: Harry Vass (13 June 2024) Mental Health improvements and initiatives implemented in Avon & Somerset Constabulary Consensus on acute behavioural disturbance in the UK: a multidisciplinary modified Delphi study to determine what it is and how it should be managed (9 May 2023) INQUEST: Skills and support toolkit Acute behavioural disturbance: a physical emergency psychiatrists need to understand (14 October 2020)

In December 2022, Harry Vass died after experiencing Acute Behavioural Disturbance (ABD) and a complex disturbance in normal physiology. Harry’s death was found to be avoidable as carers were not fully aware of this condition associated with acute psychosis. In this blog, Harry’s mother Julie tells us more about Harry and the years that proceeded his death, during which he suffered with anxiety, addiction and psychosis. Julie describes the barriers they faced in getting the right support and care for Harry before he died and highlights the need for healthcare staff to have a greater awareness of ABD and the associated risks of a medical emergency. You can also read a second blog by Julie, where she explains more about Acute Behavioural Disturbance and the changes she believes are needed to make sure patients like Harry are cared for appropriately. Harry Harry was born in Bristol in 1998, a second child with an older sister, to working parents. He had a good childhood attending a local school and did well with good educational achievements. He was a happy boy, had friends and hobbies with football and music being his greatest loves. He had a great sense of humour and when Harry was around, we laughed a lot, often until our sides split! There had been clear symptoms of ADHD earlier in his childhood, but they were manageable. A change of school and friendship groups at 16 years old brought his struggles to a head. Ultimately this led to a formal diagnosis of ADHD and access to supporting medication, both of which helped us all (including Harry) to understand him better and manage his day-to-day anxieties. When addiction entered his life In the sixth form, Harry was introduced to cannabis smoking, and we often reflect that addiction started here for him. He still managed to get good exam results and went on to become a chef. He worked at a local pub, running the kitchen for over 2 years before Covid brought furloughing into play. Harry was at home throughout the Covid period, and it was during this time that cocaine was introduced into his life. We now know that ADHD and cocaine are a “match” and Harry suffered with addiction, which resulted in him leaving his job in December 2021. He became extremely ill for two months, suffering from psychosis. He was prescribed medication, and the mental health crisis team oversaw his treatment at home on a daily basis during that period. As this illness was linked to his addiction, Harry decided to go to rehab, with good results. He had a good period over the spring and summer of 2022 - he went to the gym, played sport, got a job working in the kitchen of a local care home and began to make plans for the future. He wanted to travel America, and he was starting to make career plans. Struggling to access the right support That Autumn, Harry became depressed, he disengaged with the world, took time off sick and occasionally took cocaine and other illicit drugs to self-medicate with the hope of improving his mood. He was given antidepressant medication which had little effect. He engaged with mental health teams but was not able to see a psychiatrist at that time, which he felt was important. He was convinced that his problems were not all about ADHD and anxiety. A psychiatric assessment was scheduled for January 2023, which would end up being the month after Harry died. I remember several frustrations at the time that felt like barriers to Harry getting the care he needed: The ADHD team would not see Harry when he was taking illicit drugs, so he had a long period without their support. The Mental Health Crisis team would not see Harry when he was taking drugs even when feeling suicidal as they felt his symptoms were induced by illicit drugs. We attended the Emergency Department twice in December 2022 with drug related problems, but there was no link to agencies offering help with the reduction of illicit drug taking. Harry was discharged home without support. Access to a clinical psychiatric review seemed very restricted and it was “only to be kind “that Harry did receive an appointment to see a psychiatrist, an appointment that was to be a month after his death. Signs of psychosis Over the Christmas period of 2022, Harry began showing signs of psychosis, he had taken cocaine on Christmas Eve and on Christmas Day. We recognised the same symptoms from the year before. He was hyper anxious and extremely agitated; he believed that people were after him and would kill him. He felt unsafe at home and left the house around 3.40am on 26th December, despite our endeavours to keep him there. We called the Police as we were so concerned for his safety and felt he should be detained. Unfortunately, they returned him home thinking that he might settle and feel safe in his home environment. Once home they lost their powers to detain him. We spent the day trying to get him to sleep as he had not slept for a while, and we had learnt from previous experience how this could resolve the psychosis. This was not possible and by 3pm Harry was deteriorating. The Emergency Department We took him to the Emergency Department at our local Hospital. Harry was seen quickly and triaged as a high-risk mental health patient. In a quiet single room, he had physical observations taken, ECGs and blood taken. He was assessed by two mental health liaison nurses who felt that he had drug induced psychosis. They were very caring in their approach and planned to discharge Harry with medication to induce sleep. The department was very busy at the time. At about 9pm Harry went to the toilet, and on return told us he had taken cocaine. After this, his condition escalated considerably, and he was moved to the main department where he could be better observed. He was given Lorazepam twice. Despite this, he remained extremely agitated, frightened and active, although he had short periods where he was calmer and even appeared lucid. He was sweating profusely and began to look physically unwell. Transferred to a mental health unit Because of the agreed diagnosis of psychosis and the level of agitation, the medical staff felt that Harry was not safe to be cared for in the department and posed a threat to others. The police were called to use the Mental Act section 136 to detain Harry at the secure Mental health unit on the Hospital campus. It was explained to us that Harry would be safe there and fully assessed by a psychiatrist in the morning. The policeman asked the medical team if Harry might have “ABD”. We didn’t know what this was but we heard the discussion, and their response, “no, this is psychosis “. Harry was taken by two policemen to the mental health unit at 10.45pm. We returned home thankful that Harry was safe and would receive proper care and an assessment of his mental health. The day Harry died The telephone woke us at 05.45am the following morning, 27th December. The nurse from the mental health unit informed us that Harry had not settled until about 3am, had then began to vomit and become ill. They had called an ambulance, but Harry continued to deteriorate. Another call for an ambulance was made and before this arrived, Harry’s heart had stopped. They asked us to come as quickly as possible to the Emergency Department as Harry was being transferred back there with an ongoing resuscitation. We arrived there about 06.10am and the Consultant in charge of Harry explained to us that he was very seriously ill and that they were doing everything they could to reverse the drugs he had ‘on board’. We were allowed to be with him whilst the resuscitation was ongoing, but his blood gases were found to be ‘incompatible with life’ and he was pronounced dead at 06.36am. The information we were given at the time about why Harry had died seemed to be around drug overdose. My last words to Harry had been about his choices around drugs, and that we were not angry with him. I now regret this deeply as he didn’t die as a direct result of drugs. Reflecting back on that night, I remember we asked ourselves: Should the Police have taken him to the Emergency Department in the early hourly hours of 26th December instead of bringing him home? Should we have taken him earlier in the day? What was ABD and why was this raised by the policeman? The inquest We waited for 18 months for the Inquest to be held. It was an article 2 Inquest with a full Jury. It was painful to hear the detail leading up to, and at, Harry’s death from the professionals involved and to hear the expert witness opinion. We heard that no physical observations were undertaken in the Emergency Department after the first ones taken on arrival at approximately 5pm, discharge was at 10.45pm when he was taken to the mental health unit. He was restrained in different ways on a few occasions. He did have some short periods of being lucid and was able to apologise to staff for his presentation, they said he appeared kind with a nice sense of humour. At around 3.30am he appeared to settle on a mattress on the floor; they thought he was sleeping. He then began to vomit around 04.10am and at this point his temperature was 39.9c (hyperthermic) pulse in excess of 186 (very rapid) blood pressure unreadable and blood oxygen saturation was 80% (very low). No physical observations were taken on unit until Harry became unwell at around 04.15am. He had escalated in behaviour, was uncontainable in the room, was sweating profusely, hitting walls and himself, scratching at his skin and eyes, responding to unseen stimuli. Aside from not having taken physical observations on the mental health unit, we were disappointed to hear that the duty psychiatrist did not examine Harry other than view him through a glass window. When his heart stopped, this clinician was not skilled enough to insert the tube required to inflate the lungs during the resuscitation. This meant that a nurse had to take this action. Cause of death The expert witness was an experienced pathologist who was clear that Harry had died of ABD (Acute Behavioural Disturbance) - “sudden death, most likely as a result of terminal cardiac arrhythmia on a background of psychosis and recent cocaine use leading to an acute disturbance in behaviour and complex disturbance in normal physiology.” We heard that almost none of the professionals and staff that had cared for Harry in the Emergency Department knew of Acute Behavioural Disturbance. The one that had, thought he had seen it before, but Harry didn’t fit that picture. We also heard that Acute Behavioural Disturbance, and the associated risks of medical emergency, were not known by the mental health staff. Included in the conclusion of the jury: “Given the evidence regarding his treatment in the Mason Unit, it is probable that the failure to perform adequate observations, both physical and non-contact, contributed to Harry’s death as, by failing to prioritise the accurate monitoring of his physical condition and therefore identify it’s deterioration, an opportunity to transfer him promptly back into the Emergency Department was missed.” Included in the ‘Coroner’s Matters of Concern’: “Due to Harry’s level of agitation, he did not undergo the level of observations that would and should have happened either in the emergency department or once on the Mason Unit which may have assisted in assessing his physical health. It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a medical emergency. The decision as to whether a person has ABD is important, Dr Delaney said that” this group are vulnerable to cardiac arrest”, that “deaths are multifactorial”, that “normally in the background a body is maintaining safe limits for e.g. pulse rate, blood pressure, temperature, but with acute disturbance in behaviour the body loses control of these safe parameters.” Life after the unthinkable I was terrified that I would lose the memory of Harry’s face so we gathered together all our photos of him. Silly really as his face, voice, smell and laughter are still with me clearly even now, nearly two years on. You’ll think we’re mad but each of us talk to him as though he is still here. We still lay four places at the table without thinking, we still go to pull over in the car to offer a lift home when we think we see him out. I don’t know how long that takes to go away. Our lives have changed for ever now. We try not to be angry as we know that no one intended for this to happen. We do want learning to be taken away from this unthinkable event in the hope that something similar will not happen to other families. Read Julie ’s second blog, where she explains more about Acute Behavioural Disturbance and the changes she believes are needed to make sure patients like Harry are cared for appropriately. Share your insights Do you have insights to share around patient safety? Could your experiences help guide improvements? Or perhaps you're a healthcare professional making changes to reduce risk to patient safety? If you would like to contribute, please comment below (you'll need to sign up here first for free) or contact the editorial team at [email protected]. Related reading Acute Behavioural Disturbance: preventing future deaths (Julie's second blog) Mental Health improvements and initiatives implemented in Avon & Somerset Constabulary Consensus on acute behavioural disturbance in the UK: a multidisciplinary modified Delphi study to determine what it is and how it should be managed (9 May 2023) INQUEST: Skills and support toolkit Acute behavioural disturbance: a physical emergency psychiatrists need to understand (14 October 2020)