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Content ArticleIn this interview for inews, Professor Ted Baker, Chair of the new Health Services Safety Investigations Body (HSSIB), talks about the role of HSSIB in identifying system-wide safety issues in the NHS. He discusses why we need new approaches to tackling patient safety problems and outlines the importance of considering how the wider system leads to human error. He also talks about the impact of bullying on NHS staff, describing his own experiences as a junior doctor, which nearly led him to give up his career. He also describes the vital role of whistleblowers in making changes that genuinely improve patient safety, highlighting the problems currently facing staff who speak up for patient safety.
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News ArticleA hospital trust has admitted that a young autistic boy should still be alive had they delivered the appropriate level of care. In an exclusive interview with ITV News, the day before the inquest into his death, Mattheus Vieira's heartbroken parents described him as "special", adding: "And special in a good way, not just special needs." "People may think because he was autistic he was difficult, but it's not the case, he was very easy. "He was the boss of the house, we just miss his presence." Mattheus, aged 11, was taken to King's Lynn Hospital, in Norfolk, with a kidney infection. He struggled to cope with medical staff taking observations, and his notes recorded him as "uncooperative". His dad, Vitor Vieira, told ITV News: "He doesn't like to be touched, even a plaster he doesn't like. "And they say 'Oh he does not co-operate'. He was an autistic boy, what do you expect? Mr Vieira believes staff did not understand his son's behaviour. Mattheus was non verbal and so unable to articulate his distress. Observations were dismissed as "inaccurate" by some medical staff. In fact, they were accurate and indicated that his kidney infection had developed into septic shock. He suffered a cardiac arrest and died, aged 11. Read full story Source: ITV News, 26 February 2024
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News Article
Concerns raised over former surgeon at children's hospital
Patient Safety Learning posted a news article in News
Great Ormond Street Hospital has written to the families of all children treated by one of its former surgeons after concerns were raised about his practice. Yaser Jabbar, a consultant orthopaedic surgeon, has not had a licence to practise medicine in the UK since 8 January, the medical register shows. Independent experts are now reviewing the concerns raised. The hospital trust said the Royal College of Surgeons (RCS) was asked to review its paediatric orthopaedic service following concerns raised by family members and staff. The RCS then raised concerns about Mr Jabbar, which the trust said were being taken "incredibly seriously" and would be reviewed by independent experts from other paediatric hospitals. A spokesman for the trust said: "We are sorry for the worry and uncertainty this may cause the families who are impacted. "We are committed to learning from every single patient that we treat, and to being open and transparent with our families when care falls below the high standards we strive for." The spokesperson said Mr Jabbar, reported to be an expert in limb reconstruction, no longer worked at the hospital. Read full story Source: BBC News, 28 February 2024 -
News Article
Baby death inquiries are poor and incomplete, experts say
Patient Safety Learning posted a news article in News
Deaths of newborn babies should be more thoroughly investigated by health boards in Scotland, experts have said after reviewing an increase in infant mortality. The team found inquiries into baby deaths conducted by health boards were “poor quality, inconsistent and incomplete”. The experts added that information about staffing levels on maternity wards at the time of the deaths was so poor that they could not draw any conclusions. They were also unable to determine if health boards enlisted independent, external advisers when considering if deaths could have been prevented. Helen Mactier, a retired neonatologist and chairwoman of the Neonatal Mortality Review, said: “This review has helped to get a clearer understanding of the increase in neonatal deaths that occurred in 2021-22. “We understand that there are still unanswered questions, and our recommendations are focused on ensuring that future opportunities to learn are not missed and acted on in a timely and comprehensive manner.” Read full story (paywalled) Source: The Times, 27 February 2024 -
News Article
'Overwhelming' response to birth trauma inquiry
Patient Safety Learning posted a news article in News
An inquiry into birth trauma has received more than 1,300 submissions from families. It is estimated that 30,000 women a year in the UK have suffered negative experiences during the delivery of their babies, while 1 in 20 develop post-traumatic stress disorder. The investigation is a cross-party initiative, led by MPs Theo Clarke and Rosie Duffield, in collaboration with the Birth Trauma Association. Ms Clarke the Conservative MP for Stafford, triggered the first ever parliamentary debate on the issue in October. In an emotional exchange in the House of Commons, she described her own experience following her daughter's birth at the Royal Stoke University Hospital in 2022. She bled heavily after suffering a tear and had to undergo two-hour surgery without general anaesthetic, due to an earlier epidural. The Birth Trauma Association, which is administering the inquiry, invited the public to submit written accounts of their own experiences. Dr Kim Thomas, from the association, said she had received an "overwhelming" number of personal accounts. Some cases date back as far as the 1960s. Read full story Source: BBC News, 25 February 2024 -
News Article
Wales Covid families want answers as inquiry arrives
Patient Safety Learning posted a news article in News
Accountability is top of the wishlist from the Covid inquiry as it comes to Wales, say bereaved families and those charged with protecting vulnerable people. Over the next three weeks the focus will largely be on the decisions made by the Welsh government during the pandemic. From the timings of lockdowns to the rationale of doing things differently to the UK government, the hearings will scrutinise actions taken in Wales. For many, it will be a chance to hear the justifications for policies that they say left them feeling unsupported and alone. Ann Richards did not get to say a final goodbye to her husband Eirwyn before he died from hospital-acquired Covid in January 2021. Ann still wonders if non-urgent healthcare had been fully up and running, could Eirwyn have been discharged sooner, or perhaps even avoided a hospital admission altogether? Additional rules put in place to reduce the spread of the virus meant there were delays in getting a purpose-built wheelchair – delaying his discharge from hospital. "I understand there had to be rules in place," said Ann. "But it's the wellbeing of the patients I think they lost a lot of." Read full story Source: BBC News, 26 February 2024 -
News Article
Over 30 sepsis deaths linked to ‘systemic’ failings, investigation reveals
Patient Safety Learning posted a news article in News
Major progress made in sepsis care during the previous decade has been significantly reversed amid repeated failures in recognising and treating the condition. HSJ has identified 31 deaths in the last five years where coroners have warned of systemic problems with diagnosing and treating sepsis, including nine cases relating to children. Many of the deaths were deemed avoidable. Meanwhile, investigations suggest a majority of acute trusts are failing to record their treatment rates for sepsis, which is deemed a crucial aspect of driving improvements. Repeated shortcomings raised by coroners, including 10 separate cases in 2023, include delays or failures to administer antibiotics, not following protocols for identifying sepsis, and inaccurate, missed or skipped observations. Health ombudsman Rob Behrens, who issued a report on sepsis failures last year, said the same mistakes were “clearly being repeated time and time again”. He added: “What is chilling to me is that these [coroners’ reports] fit in almost exactly with the issues we raised in our sepsis report… and even the 2013 sepsis report issued by my predecessor, including unnecessary delays, wrong diagnosis, and failure to provide adequate plans for sepsis.” Read full story (paywalled) Source: HSJ, 27 February 2024 -
Event
HSSIB: Investigative interviewing
Sam posted an event in Community Calendar
untilThis is for those in NHS Trusts in England only. This practical course offers an overview of the principles that underpin a professional safety investigation interview with either a member of staff, a patient or a family. The course aligns to the PSIRF guidance on a systems approach to interviews. The course includes: Planning and preparing for an interview. Using a structured hierarchy of questions to facilitate comprehensive, accurate information. Asking system-focused questions. Closing an interview. Learning objectives Understand and describe the working elements of a standardised and tested approach to investigative interviewing. Understand how to apply the model to plan, conduct and evaluate your investigative interviews. Conduct more ethical and professional interviews. Reach stronger defensible investigation conclusions. Increase your own and others confidence in your ability to investigate complex matters. Register -
Event
HSSIB: Investigative interviewing
Sam posted an event in Community Calendar
untilThis is for those in NHS Trusts in England only. This practical course offers an overview of the principles that underpin a professional safety investigation interview with either a member of staff, a patient or a family. The course aligns to the PSIRF guidance on a systems approach to interviews. The course includes: Planning and preparing for an interview. Using a structured hierarchy of questions to facilitate comprehensive, accurate information. Asking system-focused questions. Closing an interview. Learning objectives Understand and describe the working elements of a standardised and tested approach to investigative interviewing. Understand how to apply the model to plan, conduct and evaluate your investigative interviews. Conduct more ethical and professional interviews. Reach stronger defensible investigation conclusions. Increase your own and others confidence in your ability to investigate complex matters. Register -
Event
HSSIB: Investigative interviewing
Sam posted an event in Community Calendar
untilThis is for those in NHS Trusts in England only. This practical course offers an overview of the principles that underpin a professional safety investigation interview with either a member of staff, a patient or a family. The course aligns to the PSIRF guidance on a systems approach to interviews. The course includes: Planning and preparing for an interview. Using a structured hierarchy of questions to facilitate comprehensive, accurate information. Asking system-focused questions. Closing an interview. Learning objectives Understand and describe the working elements of a standardised and tested approach to investigative interviewing. Understand how to apply the model to plan, conduct and evaluate your investigative interviews. Conduct more ethical and professional interviews. Reach stronger defensible investigation conclusions. Increase your own and others confidence in your ability to investigate complex matters. Register -
Event
HSSIB: Demystifying thematic analysis
Sam posted an event in Community Calendar
This is for those in NHS Trusts in England only. This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. Learning objectives: Define thematic analysis and its key concepts. Understand the relevance of using thematic analysis in the context of healthcare safety learning responses. Code a sample data set and develop themes. Relate the use of thematic analysis to your own safety learning response practice. Registration -
Event
HSSIB: Demystifying thematic analysis
Sam posted an event in Community Calendar
This is for those in NHS Trusts in England only. This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. Learning objectives: Define thematic analysis and its key concepts. Understand the relevance of using thematic analysis in the context of healthcare safety learning responses. Code a sample data set and develop themes. Relate the use of thematic analysis to your own safety learning response practice. Register -
Event
HSSIB: Demystifying thematic analysis
Sam posted an event in Community Calendar
This is for those in NHS Trusts in England only. This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. Learning objectives: Define thematic analysis and its key concepts. Understand the relevance of using thematic analysis in the context of healthcare safety learning responses. Code a sample data set and develop themes. Relate the use of thematic analysis to your own safety learning response practice. Register -
Event
HSSIB: Demystifying thematic analysis
Sam posted an event in Community Calendar
This is for those in NHS Trusts in England only. This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. Learning objectives: Define thematic analysis and its key concepts. Understand the relevance of using thematic analysis in the context of healthcare safety learning responses. Code a sample data set and develop themes. Relate the use of thematic analysis to your own safety learning response practice. Register -
Event
HSSIB: After Action Review
Sam posted an event in Community Calendar
This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register -
Event
HSSIB: After Action Review
Sam posted an event in Community Calendar
This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register -
Event
HSSIB: After Action Review
Sam posted an event in Community Calendar
This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register -
Event
HSSIB: After Action Review
Sam posted an event in Community Calendar
This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register -
News Article
Health secretary urges patients to report ‘horrific’ sexual abuse allegations
Patient Safety Learning posted a news article in News
Health secretary Victoria Atkins has said mental health patients and staff must report the “horrific” sexual abuse allegations uncovered by The Independent to the police. Ms Atkins said victims would have her full support if they reported their claims to the police. Her intervention comes following a joint investigation by The Independent and Sky News, which revealed almost 20,000 reports of sexual harassment and abuse on NHS mental health wards in England. The allegations uncovered include patients claiming to have been raped by staff and other patients while being treated on mental health wards. In response to the initial investigation, Ms Atkins said a review launched last year into mental health services would now also look into sexual assault within the sector. Speaking on Sky News, she said: “These are horrific allegations that should not and must not happen in our care. Very, very vulnerable people have to stay in mental health inpatient facilities, and they do so because they need care, support, and treatment. “Some of the behaviours that have come to light are criminal offences, and so I would encourage anyone who feels able to – and I appreciate it is a difficult step – to go to the police and please report them, because they are crimes and we must drive them out.” Read full story Source: The Independent, 21 February 2024 -
Content ArticleIn this letter to Health Secretary Steve Brine MP, members of the All Party Parliamentary Group (APPG) on Pandemic Response and Recovery raise serious concerns about the approach of the Medicines and Healthcare Products Regulatory Agency (MHRA) to patient safety. They outline problems within the MHRA that continue to put patients at serious risk of harm. The letter also highlights the role of the Independent Medicines and Medical Devices Safety Review (IMMDS), in its thorough investigation of Primodos, sodium valproate and pelvic mesh in bringing some of these concerns to the fore. It points to recent evidence presented to the APPG that indicates that the MHRA is at the heart of wider endemic failings, with issues uncovered so far being "the tip of a sizeable iceberg of failure." The letter outlines concerns about the following areas: The Yellow Card Scheme Conflicts of interest and transparency History of regulatory failures in the MHRA It calls on the Health and Social Care Select Committee to investigate these issues and make recommendations to the government on: legislative changes as to who is obligated to report adverse drug reactions. funding changes to the MHRA. separation of regulatory approval duties from post marketing pharmacovigilance. more inclusion of patients. greater transparency across the board. proper enforcement of Part 14 of the Human Medicines Regulations 2012.
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News ArticleIn 2009, Emma Murphy took a phone call from her sister that changed her life. “At first, I couldn’t make out what she was saying; she was crying so much,” Murphy says. “All I could hear was ‘Epilim’.” This was a brand name for sodium valproate, the medication Murphy had been taking since she was 12 to manage her epilepsy. Her sister explained that a woman, Janet Williams, on the local news had claimed that taking the drug during her pregnancies had harmed her children. She was appealing for other women who might have experienced this to come forward. Murphy found the news segment that evening and watched it. “I was just stunned,” she says. “Watching that, I knew. I knew there and then that my children had been affected.” At that point, Murphy was a mother to five children, all under six, and married to Joe, a taxi driver in Manchester. “My kids are fabulous, all of them, but I’d known for years that something was wrong,” she says. “They weren’t meeting milestones. There was delayed speech, slowness to crawl, not walking. There was a lot of drooling – that was really apparent. They were poorly, with constant infections. I was always at the doctors with one of them." A call between Murphy and Janet Williams was the start of an incredible partnership. It led to the report published this month by England’s patient safety commissioner, Dr Henrietta Hughes, which recommended a compensation scheme for families of children harmed by valproate taken in pregnancy. Hughes has suggested initial payments of £100,000 and described the damage caused by the drug as “a bigger scandal than thalidomide”. It is estimated that 20,000 British children have been exposed to the drug while in the womb. Williams and Murphy have campaigned relentlessly to reach this point. It is by no means the endpoint – even now, an estimated three babies are born each month having been exposed to the drug. Together, the women formed In-Fact (the Independent Fetal Anti Convulsant Trust) to find and support families like theirs. They were instrumental in the creation of an all-party parliamentary group to raise awareness in government. Read full story Source: The Guardian, 22 February 2024
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News ArticleAn unprecedented number of women are being investigated by police on suspicion of illegally ending a pregnancy, the BBC has been told. Abortion provider MSI says it knows of up to 60 criminal inquiries in England and Wales since 2018, compared with almost zero before. Some investigations followed natural pregnancy loss, File on 4 found. Pregnancy loss is investigated only if credible evidence suggests a crime, the National Police Chiefs' Council says. File on 4 has spoken to women who say that they have been "traumatised" and left feeling "suicidal" following criminal investigations lasting years. Speaking for the first time, one woman described how she had been placed under investigation after giving birth prematurely, despite maintaining that she had never attempted an abortion. Dr Jonathan Lord, medical director at MSI, which is one of the UK's main abortion providers, believes the "unprecedented" number of women now falling under investigation may be linked to the police's increased awareness of the availability of the "pills by post" scheme - introduced in England and Wales during the Covid-19 lockdown. Scotland also introduced a similar programme. These "telemedicine" schemes, which allow pregnancies up to 10 weeks to be terminated at home, remain in effect. Campaigners are concerned that it is possible for women to knowingly or unknowingly use the pills after this point. MSI's Dr Lord says criminal investigations and prosecutions further "traumatise" women after abortions, and that women deserve "compassion" rather than "punishment". "These women are often vulnerable and in desperate situations - they need help, not investigation and punishment," he says. Read full story Source: BBC News, 20 February 2024
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News ArticleAn NHS trust has concluded that its former chief executive is not a “fit and proper person” to be on an NHS board, after investigating allegations of sexual harassment and inappropriate behaviour, HSJ has learned. HSJ understands The Robert Jones and Agnes Hunt (RJAH) Orthopaedic Hospital Foundation Trust commissioned a specialist external workplace investigation into Mark Brandreth, which considered serious allegations made about his behaviour during his time as trust chief executive between April 2016 and August 2021. Mr Brandreth is understood to dispute the allegations as well as the investigation’s findings, and is seeking to challenge RJAH’s handling of the complaints and its process for deciding he did not meet the Fit and Proper Person Test. Sources with knowledge of the situation said almost 30 female RJAH staff members came forward to give information to the investigation, but it focused on 12 employees who were willing to give evidence. HSJ has been told that as a result of the investigation, which concluded at the end of last year, the trust’s chair has informed NHSE in writing that it believes Mr Brandreth does not meet the “Fit and Proper Person Test”, implying he should be ruled out of board roles – or roles with equivalent responsibility – at English NHS organisations and adult social care providers. However, the trust, in Shropshire, is not planning to publish its ruling and – with no professional regulation in place for health and care managers and/or board members – it is unclear how effective the conclusion will be if it is not made public. A female staff member told HSJ of her concerns that “nothing is being done”. Read full story (paywalled) Source: HSJ, 21 February 2024
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News Article
Italy announces inquiry into its handling of Covid-19 pandemic
Patient Safety Learning posted a news article in News
Italy will carry out an inquiry into its handling of the coronavirus pandemic in a move hailed as “a great victory” by the relatives of people killed by the virus but criticised by those who were in power at the time. Italy was the first western country to report an outbreak and has the second highest Covid-related death toll to date in Europe, at more than 196,000. Only the UK’s death toll is higher. The creation of a commission to examine “the government’s actions and the measures adopted by it to prevent and address the Covid-19 epidemiological emergency” was approved by the lower house of parliament after passing in the senate. Consuelo Locati, a lawyer representing hundreds of families who brought legal proceedings against former leaders, said: “The families were the first to ask for a commission and so for us this is a great victory. The commission is important because it has the task, at least on paper, to analyse what went wrong and the errors committed so as not to repeat the massacre we all suffered.” Read full story Source: The Guardian, 15 February 2024 -
Content ArticleA swarm is designed to start as soon as possible after a patient safety incident occurs. Healthcare organisations in the US1 and UK2 have used swarm-based huddles to identify learning from patient safety incidents. Immediately after an incident, staff ‘swarm’ to the site to quickly analyse what happened and how it happened and decide what needs to be done to reduce risk. Swarms enable insights and reflections to be quickly sought and generate prompt learning. They can prevent: those affected forgetting key information because there is a time delay before their perspective on what happened is sought fear, gossip and blame; by providing an opportunity to remind those involved that the aim following an incident is learning and improvement information about what happened and ‘work as done’ being lost because those affected leave the organisation where the incident occurred. This swarm tool provided by NHS England integrates the SEIPS3 framework and swarm approach to explore in a post-incident huddle what happened and how it happened in the context of how care was being delivered in the real world (ie work as done).
