PatientSafetyLearning Team

AvMA’s self-help guides have been written by experts to help guide you through the process of taking action following a medical injury. In clear and straightforward language, they set out the procedures you will need to follow, and legal rights and obligations, and contain useful contact details for regulatory bodies, advice services and other organisations that may be of help. AvMA’s services General information Making a complaint about NHS or private healthcare Accessing medical records Serious incident reports Brain injuries at birth Help with an inquest Raising concerns about a healthcare worker Making a legal claim for compensation Understanding legal claims Complaining about your solicitor.

If you are not happy with the treatment that you or a loved one has received from the NHS you are legally entitled to an investigation and full response by the NHS body that provided the treatment. This is known as the NHS complaints procedure. This self-help guide from Action Against Medical Accidents (AvMA) contains all the information you should need to make a complaint. If you have any further questions, please visit AvMA's website where you will find more advice and a range of specialised self-help guides, or call their helpline on 0845 123 2352.

This US-based article, published on Endocrine Web, includes testimonials from people who have experienced prolonged and debilitating symptoms of COVID-19. They are often referred to as people with 'long-COVID' or as 'long-haulers'.

This report summarises how National Voices engaged with people who have ongoing health and care needs during the first phase of the pandemic and how this engagement led to a set of statements that describe what people who use health and care services now expect these services to look and feel like.These statements express people’s reasonable expectations of healthcare. Most would see the demand to be listened to and have one’s decisions respected as basic tenets of normal healthcare. The power of these statements lies in the fact that they are truly reflective of what people with significant health and care needs said they needed and wanted. National Voices believe that their simplicity, their self-evident realism and the pragmatism they therefore inspire demand an equally practical and grounded response from system leaders, and everyone tasked with designing and delivering health and care.

This is a video recording of the All Party Parliamentary Group (APPG) for First Do No Harm meeting with Nadine Dorries MP, the Minister for Patient Safety, Suicide Prevention and Mental Health. The meeting took place on 26 January 2021 and is chaired by Baroness Cumberlege who is the Co-Chair of the APPG. The APPG was set up to raise awareness of and build support for the recommendations in 'First Do No Harm', the report of the Independent Medicines and Medical Devices Safety Review, and to ensure the implementation of the recommendations by the UK government and others.

The Faculty of Occupational Medicine (FOM) has published guidance for healthcare professionals to assist them in facilitating the return to work of people who are unable to work due to Long-COVID. Follow the link below or download the guidance as a pdf.

This BMJ editorial is written by Marian Knight, professor of maternal and child population health and Charlotte Bevan, a bereaved parent. They argue that systems and thinking need to change, and that our healthcare structures are biased against complexity and are not set up to deliver seamless multidisciplinary care. 

The author of this review argues that, while many of us benefit from advances and new technologies used in medical drug development, there is one group that has barely made any gains at all: pregnant women. This review presents an overview of the current situation for this group, the issues and the available evidence; as well as exploring the barriers and options in better addressing pregnancy and maternal health. This document was written on behalf of the Birmingham Health Partners Centre for Regulatory Science and Innovation.

In this short guide, Kent Community Health explain why patient engagement in quality improvement is vital. They provide tips for how to get started and how to involve patients, clients and service users and carers/family members.

UK legislation and government policy favour women’s rights to bodily autonomy and active involvement in childbirth decision-making including the right to decline recommendations of care/treatment. However, evidence suggests that both women and maternity professionals can face challenges enacting decisions outside of sociocultural norms. This study, published in PLOS ONE, explored how NHS midwives facilitated women’s alternative physiological birthing choices, defined in this study as ‘birth choices that go outside of local/national maternity guidelines or when women decline recommended treatment of care, in the pursuit of a physiological birth.' Due to the wide range of women’s choices this study reported, the knowledge generated has applications as heuristic knowledge which can be used by midwives more broadly within their clinical care delivery. The benefits being that the findings can be applied to most ‘out of guidelines’ clinical situations by any maternity professional. Delivering such care can be achieved by meaningful engagement with women’; through mechanisms of trust and information sharing, care plans and safety measures can be implemented to support women’s autonomous decision-making. 

Good patient communication is key, particularly when a patient is waiting for planned care or treatment. From referral by a primary care clinician through to discharge from secondary care – clear, accessible communication is vital throughout. The Elective Recovery Delivery Plan commits to providing better information and support to patients. As we begin to implement new, innovative ways of delivering healthcare, it is more important than ever that patients feel confident they are supported throughout their journey. Prolonged periods of industrial action and continuing pressures have inevitably had an impact on planned care. In this context, it is important that integrated care boards (ICBs) and providers do all they can to offer support to those affected by delays, including with patient communications. This guide sets out key communication principles to help providers deliver personalised, patient-centred communications. It includes considerations for communicating to patients about new models of care as well as helpful information and resources.

‘Never events’ are patient safety incidents that are defined as being wholly preventable. They are considered wholly preventable because guidance or safety recommendations are in place at a national level and should have been implemented by all providers in the healthcare system. This should act as a strong systemic barrier to prevent the serious incident from happening. The latest national report from the Healthcare Safety Investigation Branch (HSIB) says that 'Never Events' should not be defined as such if they don’t have strong enough barriers in place to stop them happening.It recommends that seven Never Events on a list of 15 should be removed until better barriers are in place. They are using the Safety Engineering Initiative for Patient Safety (SEIPS) model to carry out the analysis. SEIPS provides a framework for understanding structures, processes and outcomes in healthcare, and their relationships. HSIB has made three safety recommendations as a result of this report - two to NHS England and NHS Improvement, and one to the Centre for Perioperative Care. NHS England and NHS Improvement It is recommended that NHS England and NHS Improvement revises the Never Events list to remove events, such as those presented in this national learning report, that do not have strong and systemic safety barriers. It is recommended that NHS England and NHS Improvement develops and commissions programmes of work to find strong and systemic safety barriers for specific incidents where barriers are felt to be possible but are not currently available. Centre for Perioperative Care It is recommended that the Centre for Perioperative Care reviews and revises the National Safety Standards for Invasive Procedures (NatSSIPs) policy to increase standardisation of safety critical steps that are common across all procedures.

This letter to the UK Prime Minister and published in the BMJ, was written on behalf of the Long COVID SOS Group. In it, the group call for Boris Johnson to make Long COVID a primary consideration in policy decision making for lifting restrictions. 

In this blog, Patient Safety Learning reflects on a recent response from Nadine Dorries MP, Minister of State for Mental Health, Suicide Prevention and Patient Safety, regarding concerns about painful hysteroscopy procedures in the NHS. Towards the end of last year, Patient Safety Learning published a blog outlining five calls to action that could be taken to improve the safety of hysteroscopy procedures in the NHS.[1] This has been an issue raised by patients, campaign groups and politicians in recent years, highlighting concerns that women having been suffering avoidable harm from hysteroscopies. We wrote to several key stakeholders in healthcare across England, Northern Ireland, Scotland and Wales, to raise awareness of this issue and call for urgent action to prevent future harm. While we welcome the Minister in her response supporting the general principles of informed consent and good practice guidance for hysteroscopy, we know that many women are still not being offered a choice of pain relief or given adequate information before consenting to the procedure. It remains unclear from her response whether the Government will take action to investigate the frequency of these experiences and respond to improve hysteroscopy safety. Concerns about painful hysteroscopy Hysteroscopy is a procedure used as a diagnostic tool to identify the cause of common problems, such as abnormal bleeding, unexplained pain or unusually heavy periods in women. It involves a long, thin tube being passed into the womb, often with little or no anaesthesia. In a blog late last year, we reflected on some key patient safety concerns relating to these procedures in the NHS: Despite a significant number of women who undergo this procedure and experience high levels of pain, in many cases their remains little or no access to pain relief. Recent research, published in the British Journal of Anaesthesia, shows that 17.6% of women rate their pain during hysteroscopy as greater than 7/10, and only 7.8% report no pain at all.[2] A growing number of women do not believe they were given sufficient information about this procedure beforehand and were therefore unable to provide informed consent. Patient experiences and concerns are not being adequately captured, recognised or listened to. Some women have been left traumatised by their experience of hysteroscopy, fearful to access further gynaecological investigations or screenings. There are reports that the good practice guidance available from the Royal College of Obstetricians and Gynaecologists (RCOG) is not being adhered to.[3] We wrote to several key stakeholders in healthcare across England, Northern Ireland, Scotland and Wales highlighting these issues, including Nadine Dorries MP, Minister of State for Mental Health, Suicide Prevention and Patient Safety. Below, we reflect on the response we recently received from her on these issues, in the context of our five calls for action to improve hysteroscopy safety. We have also included our correspondence with her in full at the end of this blog. Nadine Dorries’ response to our five calls to action 1) National guidance for outpatient hysteroscopy to be consistently applied The Minister states her support for the NHS England and NHS Improvement position on this issue, specifically that the information leaflet produced by RCOG and the British Society for Gynaecological Endoscopy should be provided to all patients prior to their hysteroscopy. While her support for the use of this guidance is welcome, she does not address the problem that, in many cases, this guidance is simply not followed. She also advises that RCOG are now in the process of developing a second edition of its patient leaflet. However, while there remains barriers which may prevent clinicians from using this guidance, or where clinicians may be reluctant to follow the guidance, women will continue to be susceptible to varied standards of NHS hysteroscopy care. 2) Women to be provided with information and advice to inform their consent Nadine Dorries indicates her support that patients are provided with all the information they need prior to hysteroscopy procedures to help inform their consent. As with the previous point regarding the consistent application of the guidance, however the issue remains that support for this in principle does not necessarily translate into the experience of patients undergoing this procedure. We are disappointed that the Minister fails to acknowledge that this remains a significant issue and does not provide any assurance that action will be taken to address a failure of informed consent. 3) Women to be offered and provided with pain relief Her response notes support for women having the choice of a general or regional anaesthetic for the procedure. She also outlines forthcoming changes in the NHS that intend to remove the best practice tariff. This is important as this system has provided a financial incentive for hospital trusts to perform procedures, such as hysteroscopy, as outpatient services without a general anaesthetic, creating a perverse incentive against the use of pain relief. 4) Significant pain to be considered an adverse event and recorded and reported as such and 5) Research to assess the scale of unsafe care and pain, the extent to which women are suffering, and to inform the implementation of national guidelines and the appropriateness of financial incentives without proper safeguards Finally, on the issue of the pain experienced by a significant number of women who undergo a hysteroscopy procedure, in her response the Minister acknowledges that, in cases of severe pain, “it has become clear over the last few years that we can do better in terms of the services we provide for women”. However, on both this and the issue of further research, she does not make any specific commitments on hysteroscopy. Patient Safety Learning believes that significant pain resulting from procedures such as hysteroscopy should be considered as an adverse event, being recorded, reported and responded to appropriately. We also believe that there needs to be specific research into the scale of unsafe care and pain of these procedures. We recently shared a blog on the hub by Dr Richard Harrison, a pain researcher at the University of Reading, reflecting on his recent research on this issue.[4] Improved guidance requires practical implementation While the Department of Health and Social Care shows a clear recognition of concerns about hysteroscopy procedures in the NHS, the Minister’s response is focused on overarching principles and guidance, rather than how this is implemented in practice. We know that many women are still not being offered a choice of pain relief or given adequate information before consenting to the procedure. It remains unclear from this response whether any action will be taken to investigate the prevalence of these experiences and respond accordingly. This is an example of the type of patient safety issue that we believe the recently announced Patient Safety Commissioner for England should investigate, and is something we intend to promote with them when this role is introduced.[5] Patient Safety Learning is working collaboratively with patients, researchers and clinicians to understand the barriers to safe hysteroscopy care. We continue to speak to and support patient groups to help raise awareness of safety concerns and amplify their voices. Our aim is that all patients have access to pain relief and the information they need to properly consent to treatments. Read our initial email to Nadine Dorries MP (also attached) Read Nadine Dorries' full response (also attached) References [1] Patient Safety Learning, Improving hysteroscopy safety, Patient Safety Learning's the hub, 6 November 2020. [2] Harrison, Richard., Kuteesa, William., and Kapila, A, Pain-free day surgery? Evaluating pain and pain assessment during hysteroscopy, British Journal of Anaesthesia, 2020. [3] RCOG, Information for you: Outpatient hysteroscopy, December 2019. [4] Harrison, Richard, Pain free hysteroscopy, Dr Richard Harrison’s website, 2020. [5] Hughes, Helen, Early thoughts on a Patient Safety Commissioner for England (a blog by Helen Hughes, Chief Executive of Patient Safety Learning), Patient Safety Learning’s the hub, 23 December 2020.

In this opinion piece for the British Medical Journal, David Oliver, consultant in geriatrics and acute general medicine, highlights the high rates of COVID-19 infection that have been acquired in hospital. David looks at an example in the US where rigid infection control measures have been implemented with success, arguing that more needs to be done to challenge and address these worrying statistics here in the UK.

This report, the seventh MBRRACE-UK annual report of the Confidential Enquiry into Maternal Deaths and Morbidity, includes surveillance data on women who died during or up to one year after pregnancy between 2016 and 2018 in the UK. In addition, it also includes Confidential Enquiries into the care of women who died between 2016 and 2018 in the UK and Ireland from epilepsy and stroke, general medical and surgical disorders, anaesthetic causes, haemorrhage, amniotic fluid embolism and sepsis. The report also includes a Morbidity Confidential Enquiry into the care of women with pulmonary embolism. The majority of recommendations which MBRRACE-UK assessors have identified to improve care are drawn directly from existing guidance or reports and denote areas where implementation of existing guidance needs strengthening. In a small number of instances, actions are needed for which national guidelines are not available. These are included below. To access the report and the full list of recommendations, please click on the link at the bottom of this page. New recommendations to improve care: For professional organisations 1. Develop guidance to ensure SUDEP awareness, risk assessment and risk minimisation is standard care for women with epilepsy before, during and after pregnancy and ensure this is embedded in pathways of care. [ACTION: Royal Colleges of Obstetricians and Gynaecologists, Physicians]. 2. Develop guidance to indicate the need for definitive radiological diagnosis in women who have an inconclusive VQ scan [ACTION: Royal Colleges of Physicians, Radiologists, Obstetricians and Gynaecologists]. 3. Produce guidance on which bedside tests should be used for assessment of coagulation and the required training to perform and interpret those tests [ACTION: Royal Colleges of Anaesthetists, Obstetricians and Gynaecologists, Physicians] 4. Establish a mechanism to disseminate the learning from this report, not only to maternity staff, but more widely to GPs, emergency department practitioners, physicians and surgeons [ACTION: Academy of Medical Royal Colleges]. For policy makers, service planners/commissioners and service managers 5. Develop clear standards of care for joint maternity and neurology services, which allow for: early referral in pregnancy, particularly if pregnancy is unplanned, to optimise anti-epileptic drug regimens; rapid referral for neurology review if women have worsening epilepsy symptoms; pathways for immediate advice for junior staff out of hours; postnatal review to ensure anti-epileptic drug doses are appropriately adjusted [ACTION: NHSE/I and equivalents in the devolved nations and Ireland]. 6. Ensure each regional maternal medicine network has a pathway to enable women to access their designated epilepsy care team within a maximum of two weeks. [ACTION: Maternal Medicine Networks and equivalent structures in Ireland and the devolved nations]. 7. Ensure all maternity units have access to an epilepsy team [ACTION: Service Planners/Commissioners, Hospitals/Trusts/Health Boards]. 8. Establish pathways to facilitate rapid specialist stroke care for women with stroke diagnosed in inpatient maternity settings [ACTION: Service Planners/Commissioners, Hospitals/Trusts/Health Boards]. 9. Provide specialist multidisciplinary care for pregnant women who have had bariatric surgery by a team who have expertise in bariatric disorders [ACTION: Service Planners/Commissioners, Hospitals/Trusts/Health Boards]. 10. Use the scenarios identified from review of the care of women who died for ‘skills and drills’ training [ACTION: Hospitals/Trusts/Health Boards]. 11. Ensure early senior involvement in the care of women with extremely preterm prelabour rupture of membranes and a full explanation of the risks and benefits of continuing the pregnancy. This should include discussion of termination of pregnancy [ACTION: Hospitals/Trusts/Health Boards]. For health professionals 12. Regard nocturnal seizures as a ‘red flag’ indicating women with epilepsy need urgent referral to an epilepsy service or obstetric physician [ACTION: All Health Professionals]. 13. Ensure that women on prophylactic and treatment dose anticoagulation have a structured management plan to guide practitioners during the antenatal, intrapartum and postpartum period [ACTION: All HealthProfessionals]. 14. Ensure at least one senior clinician takes a ‘helicopter view’ of the management of a woman with major obstetric haemorrhage to coordinate all aspects of care [ACTION: All Health Professionals]. iv MBRRACE-UK - Saving Lives, Improving Mothers’ Care 2020 15. Ensure that the response to obstetric haemorrhage is tailored to the proportionate blood loss as a percentage of circulating blood volume based on a woman’s body weight [ACTION: All Health Professionals]. 16. Do not perform controlled cord traction if there are no signs of placental separation (blood loss and lengthening of the cord) and take steps to manage the placenta as retained [ACTION: All Health Professionals]. 17. Be aware that signs of uterine inversion include pain when attempting to deliver the placenta, a rapid deterioration of maternal condition and a loss of fundal height without delivery of the placenta [ACTION: All Health Professionals].

In this written statement to Parliament, the Minister for Patient Safety, Suicide Prevention and Mental Health, Nadine Dorries, gives an update on the government’s response to the recommendations of the Independent Medicines and Medical Devices Safety (IMMDS) Review, sometimes referred to as the Cumberlege Review. Nadine Dorries concludes: "The report of the IMMDS Review powerfully demonstrates the importance of hearing the patient voice in patient safety matters. The actions outlined here demonstrate the government’s commitment to learning from this report, and will support vital work already underway to hear the voice of the patient as part of the NHS Patient Safety Strategy. We currently plan to respond further to the report of the IMMDS Review during 2021."