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Found 54 results
  1. Content Article
    Hannah Royle was a sixteen-year-old girl on the autism spectrum. Her parents had contacted the NHS 111 service on 20 June 2020 after she became unwell with vomiting and diarrhoea, but they were not advised to go to hospital. Three hours later as her conditioned worsened they phoned again, and the call handler, who took advice from a clinical adviser, opted not to call an ambulance and instead told her parents to make their own way to hospital. She died following a cardiac arrest as she was driven to hospital by her parents. In her findings the Coroner states that the NHS 111 service failed to provide the appropriate triage for Hannah on the information provided to them by her parents. This resulted in a cardio-respiratory arrest arising from an avoidable delay in being adequately resuscitated either by prompt attendance of the emergency services or through earlier admission into hospital.
  2. News Article
    Failings by NHS 111 contributed to the death of an autistic teenager, a coroner has ruled. Hannah Royle, 16, suffered a cardiac arrest as she was driven to hospital by her parents after a 111 algorithm failed to notice she was seriously ill. A coroner said her death had exposed a risk people were being misled about the capability of the system and its staff. An NHS spokesperson said it would act on the findings and learnings "where necessary". Hannah's father Jeff Royle said he regretted dialling 111 and wished he had taken his daughter straight to hospital. "I feel so dreadful, that I have let her down and she has been let down by the NHS," he said. Read full story Source: BBC News, 20 October 2021
  3. Content Article
    Myla Deviren had congenital intestinal malrotation and developed a volvulus on 26 August 2015. Her mother checked the NHS Symptom finder on line and the advice was to take her to A&E but she called 111 for advice. The Health Assistant who took the call did not appreciate the significance of key symptoms due to multiplicity of symptoms described at the outset. He passed the caller on a “ warm” transfer to the Clinical Adviser whose initial reaction on hearing that the symptoms included blue lips and breathlessness was to call an ambulance, ignored her instincts and took mum through a series of digital pathways re lesser symptoms. When directly asking about the breathlessness Myla's mum put the phone close to her daughter enabling the Clinical Adviser to hear the rapid breathing herself however they did not appreciate the significance of it and did not call an ambulance. She did however pass the call to the Out Of Hours Nurse who decided that this was a case of gastroenteritis early in the call and did not appreciate the description of a child with worsening signs. Whilst the precise point at which Myla stopped breathing is not known it was sometime between when she was last seen alive approximately 06.00 and then found unresponsive at 08.00 on the 27 August 2015. She was then taken by ambulance to Peterborough City Hospital where, despite attempts at resuscitation, she did not recover a heartbeat and she died. Post mortem revealed small bowel infarction from untreated small intestinal volvulus. It is probable that with earlier transfer to hospital by ambulance and with appropriate treatment Myla would have survived. 
  4. Content Article
    Last November’s HSJ Patient Safety Virtual Congress focused on the COVID-19 virtual ward model, which enables the early identification and timely management of deteriorating patients in the community - a critical step in reducing avoidable deaths from all conditions. If you missed the vital discussion, you can check it out below.
  5. Event
    The Professional Records Standard Body (PRSB) are holding a workshop on 4 March to help us develop a shared decision-making standard, so that individuals can be more involved in the decisions that affect their health, care and wellbeing. The online workshop will bring together health and care professionals, patients and system vendors to focus on different topics including diabetes and other long-term conditions, mental health, child health, gynaecology, colorectal cancer, genetic conditions, multi-medications and orthopaedics. We will be asking questions about the way information about treatment and care options are discussed and decisions recorded. This would include consent for treatment, when it is agreed, and any pre-operative assessments and requirements. By standardising the process, it will ensure that information can be shared consistently using any digital systems. If you’re interested in getting involved in the project, please contact info@theprsb.org
  6. News Article
    Guidance from NHS England that doctors may lawfully use video assessments during the pandemic to decide whether patients should be detained in hospital under the Mental Health Act was wrong, two High Court judges have ruled. The act makes it a legal requirement that doctors must “personally examine” a patient before recommending detention. A code of practice requires “direct personal examination of the patient and their mental state.” But guidance from NHS England just after the start of the first lockdown last March said that “temporary departures from the code of practice may be justified in the interests of minimising risk to patients, staff, and the public.” Revised guidance in May 2020 included a section drafted jointly by NHS England and the Department of Health and Social Care for England (DHSC) “for use in the pandemic only.” This stated, “It is the opinion of NHS England and NHS Improvement and the DHSC that developments in digital technology are now such that staff may be satisfied, on the basis of video assessments, that they have personally seen or examined a person ‘in a suitable manner.’ ” The guidance added, “While NHS England and NHS Improvement and the DHSC are satisfied that the provisions of the Mental Health Act do allow for video assessments to occur, providers should be aware that only courts can provide a definitive interpretation of the law.” It went on, “Even during the COVID-19 pandemic it is always preferable to carry out a Mental Health Act assessment in person. Decisions should be made on a case-by-case basis and processes must ensure that a high quality assessment occurs.” Read full story Source: BMJ, 25 January 2021
  7. News Article
    Emergency care leaders are warning it will take up to six more months to determine whether pilots of a radical change to accident and emergency are working, even though it is due to go live nationally next week, HSJ has learned. HSJ understands the new “111 First” system — where walk-in patients not in medical emergencies call 111 to “book” urgent care — is set to “go live” across England from next week following pilots in acute trusts which have been run since the summer. From 1 December, people will be able to call NHS 111 from anywhere in the country and have urgent care “booked” for them if needed, it is understood. NHS England has been pursuing the 111 First model to help reduce overcrowding and the risk of nosocomial infections in A&Es. The service is also intended to be able to book them into GP practice appointments. Well-placed sources confirmed most acute trusts have now implemented some form of 111 First and the model is set to be part of their standard operations when the national system “goes live” next week. A national advertising campaign is expected to promote the approach. But the Royal College of Emergency Care Medicine said there was a “vocal minority” of clinicians who are “vehemently against” 111 First as they believe it will increase demand in emergency departments. Read full story (paywalled) Source: HSJ, 25 November 2020
  8. News Article
    An NHS hospital which has faced repeated criticism by regulators for poor standards of care has been fined £4,000 for failing to assess A&E patients quickly enough. The Shrewsbury and Telford Hospitals Trust has been fined by the Care Quality Commission (CQC) after patients were not triaged within 15 mimutes of arrival in A&E – in breach of conditions set by the regulator last year and a national target. The care of emergency patients at the hospital trust, which is also facing an inquiry into poor maternity care, has been a long running concern for the watchdog which has rated the trust inadequate and put it in special measures in 2018. Earlier this year the CQC’s chief inspector of hospitals, Professor Ted Baker, wrote to NHS England warning of a “worsening picture" at the Midlands hospital and demanding action be taken. The CQC said it had issued the fixed penalty notice to the trust because it failed to comply with national clinical guidance that all children and adults must be assessed within 15 minutes of arrival. It also failed to implement a system that ensured all children who left the emergency department without being seen were followed up. After inspections in April 2019 and November 29 the CQC imposed seven conditions on the hospital over emergency care. The regulator said it was now clear the trust had not stuck to the conditions and had breached them both at Royal Shrewsbury Hospital and Princess Royal Hospital. Professor Baker said: "The trust has not responded satisfactorily to previous enforcement action regarding how quickly patients are assessed upon entering the urgent and emergency department." “We have issued a penalty notice due to the severity of the situation and to ensure the necessary, urgent improvements are made. It is essential that patients are seen in a timely way when they arrive at an emergency department; failure to do so could result in deteriorating health, harm, or even death, which is why national guidelines exist and must be followed." Read full story Source: The Independent, 12 October 2020
  9. News Article
    Delays at the Great Ormond Street Hospital led to a boy dying an agonising death, a health watchdog has found. Arvind Jain, 13, who had Duchenne Muscular Dystrophy, died in August 2009 after waiting months for an operation. The ombudsman's report found he had "suffered considerable distress" and criticised referral procedures as "chaotic and substandard". The Great Ormond Street Hospital said there were "failings in clinical care". Arvind's sister Shushma said: "To read that he was suffering all the time, that was disgusting. He had been asking us repeatedly if he would get the operation and we would be constantly reassuring him that he would not die." The degenerative disease Arvind, who lived in Cricklewood, north London, suffered from was not immediately life threatening but in January 2009 his condition had become acute enough for him to struggle with swallowing and feeding. He had a temporary medical solution where a tube was inserted through his nose to help him get the required nutrition. He also experienced a number of other medical complications although none of these was considered life-threatening. The permanent solution recommended by his consultant paediatric neurologist was a gastrostomy insertion which would allow Arvind to feed through his stomach. The Great Ormond Street Hospital Trust (GOSH) excels in such procedures, however, a series of communication errors meant despite repeated and urgent requests from his neurological consultant, proper investigations were not carried out into Arvind's suitability for the operation. After five months of delays he and his family were reassured that as soon as he got the operation he would be much more comfortable. Another hospital also offered to carry out the operation in the event that the delays continued. But the surgical team that was due to carry out the operation never managed to assess Arvind. His condition deteriorated to the point where he was not well enough to be operated on and Arvind died on 9 August 2009. The Parliamentary and Health Service Ombudsman's report said he "suffered considerable distress and discomfort". It also describes a series of basic shortcomings in Arvind's care. The report said: "The standard of care provided for Arvind fell so far below the applicable standards as to amount to service failure." Read full story Source: BBC News, 23 September 2020
  10. News Article
    Nurses and non-medical staff have been stopped from taking patient calls to the NHS coronavirus helpline amid concerns over the safety of their advice. An audit of calls to the telephone assessment service found more than half were potentially unsafe for patients, according to a leaked email shared with The Independent. At least one patient may have come to harm as a result of the way their assessment was handled. The COVID-19 Clinical Assessment Service (CCAS) is a branch of the NHS 111 phone line and is designed to assess patients showing signs of coronavirus to determine whether they need to be taken to hospital or seen by a GP. The helpline was set up at the start of the pandemic to divert patients with symptoms to a phone-based triage to relieve pressure on GPs and prevent them from turning up at surgeries and spreading the virus. GPs, nurses and allied health professionals (AHPs) such as paramedics and physiotherapists were recruited to speak to patients after they were flagged by NHS 111 call handlers. The use of non-medical staff was first paused in July amid concerns about the quality of call handling. Now it has emerged much wider safety issues have surfaced. Read full story Source: The Independent, 18 August 2020
  11. Content Article
    Good foot health and care play an important role in improving overall health and wellbeing of the general population. However, the observations of nurses and podiatrists suggest that people experiencing homelessness, particularly rough sleepers, experience worse foot health than the wider population.  This guidance, from the Queens Nursing Institute, was developed in partnership with podiatrists with experience of working with people who are homeless, and is intended as a resource for community nurses and allied health professionals. It can be used as a reference by others with an interest in the health of people who are homeless, such as hostel staff, day-centre staff and support workers. 
  12. Content Article
    Alexander James Davidson was aged 17 years and 6 months when he died at the Queens Medical Centre on 26 February 2018. Alex was previously fit and well before suddenly taking ill with abdominal pain on 17 January 2018. Between that date and his admission to the Queens Medical Centre on 8 February 2018, Alex made contact with his GP on three occasions, had four telephone triage assessments undertaken by the NHS 111 service and two admissions to his local Accident & Emergency Department at the Kingsmill Hospital. Alex’s symptoms of sudden onset acute abdominal pain, tachycardia, and vomiting and diarrhoea were attributed either to stress or to a bout of gastroenteritis. At no stage prior to 8 February 2018 was gallstones or pancreatitis considered as a differential diagnosis. When Alex was eventually admitted to the Queens Medical Centre Emergency Department on 8 February 2018, he was found to be septic as a result of an infected and necrotic pancreatic pseudocyst, which had evolved as a complication of gallstone pancreatitis, a rare condition in someone of Alex’s age. Despite medical intervention, Alex did not survive. The inquest explored the medical treatment and intervention that Alex received in the six weeks prior to his death. The medical evidence concluded that the pancreatic pseudocyst had likely formed by the time Alex began vomiting on 18 January 2018, and from that point onwards, it was unlikely he would survive even with treatment on account of the high mortality rate associated with this condition
  13. Content Article
    Sebastian Hibberd, 6 years old, became ill on Saturday 10 October having developed intussusception of the bowel. He deteriorated over the weekend. His father sought medical advice on the Monday from NHS 111 and from his GP's surgery. Sebastian's condition went unrecognised as being life threatening. There were several missed opportunities for him to receive life saving treatment. Sebastian suffered a cardiac arrest and transferred to Derriford Hospital where he sadly died in the Emergency Department shortly after his arrival on the 12 October.
  14. Content Article
    Early warning scores are widely used prediction models that are often mandated in daily clinical practice to identify early clinical deterioration in hospital patients. In this paper published in the BMJ, Gerry et al. carried out a systematic review and critical appraisal of early warning scores for adult hospital patients. The results found that many early warning scores in clinical use had methodological weaknesses.The study's authors concluded that the early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care.  “Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice.”
  15. News Article
    Early warning scores are used in the NHS to identify patients in acute care whose health is deteriorating, but medics say it could actually be putting people in danger. The rollout of an early warning system used in hospitals to identify patients at the greatest risk of dying is based on flawed evidence, according to a study published in the BMJ which suggests that much of the research supporting the rollout of NEWS was biased and overly reliant on scores that could put patients at greater risk.. Medical researchers said problems with NHS England's National Early Warning Scores (NEWS) system had emerged "frequently" in reports on avoidable deaths. The system sees each patient given an overall score based on a number of vital signs such as heart rate, oxygen levels, blood pressure and level of consciousness. Doctors and nurses can then prioritise patients with the most urgent NEWS scores. But some professionals have argued that the system has reduced nursing duties to a checklist of tasks rather than a process of providing overall clinical assessment. Professor Alison Leary, a fellow of the Royal College of Nursing and chair of healthcare and workforce modelling at London South Bank University, told The Independent: “In our analysis of prevention of future death reports from coroners, early warning scores and misunderstanding around their use feature frequently". “It's clear that some organisations use scoring systems and a more tick box approach to care as they lack the right amount of appropriately skilled staff, mostly registered nurses.” “Early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care,” the authors of the research conclude. “Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice.” Read full story Source: The Independent, 21 May 2020
  16. News Article
    Doctors who look after patients in a vegetative or minimally conscious state must ensure they initiate regular conversations with relatives about what is in the best interests of the person so that they do not get “lost in the system,” says new guidance. The Royal College of Physicians has published new and revised guidelines on prolonged disorders of consciousness (PDOC) to take into account changes in the law and developments in assessment and management. Read full story (paywalled) Source: BMJ, 6 March 2020
  17. Content Article
    The Prolonged disorders of consciousness national clinical guidelines are a major contribution to clinical and ethical standards of care for people with prolonged disorders of consciousness (PDOC) – including vegetative (VS) and minimally conscious states (MCS) – following sudden onset brain injury, not only in the UK but internationally. For England and Wales, they provide much-needed clarity on legal decision-making. The guidelines were developed by the PDOC Guideline Development Group, which included representation of patients/users and a wide range of stakeholders and professionals involved in the management of patients with PDOC. People in a vegetative or minimally conscious state present a complex array of medical, ethical and legal challenges.
  18. News Article
    Up to half of all patients who suffer an acute aortic dissection may die before reaching crucial specialist care, according to a new Healthcare Safety Investigation Branch (HSIB) report. The report highlights the difficulty which can face hospital staff in recognising acute aortic dissection. The investigation was triggered by the case of Richard, a fit and healthy 54-year old man, who arrived at his local emergency department by ambulance after experiencing chest pain and nausea during exercise. It took four hours before the diagnosis of an acute aortic dissection was made, and he spent a further hour waiting for the results of a CT scan. Although Richard was then transferred urgently by ambulance to the nearest specialist care centre, he sadly died during the journey. The report has identified a number of risks in the diagnostic process which might result in the condition being missed. These include aortic dissection not being suspected because patients can initially appear quite well or because symptoms might be attributed to a heart or lung condition. It also highlighted that, once the diagnosis is suspected, an urgent CT scan is required to confirm that an acute aortic dissection is present. Gareth Owens, Chair of the national patient association Aortic Dissection Awareness UK & Ireland, welcomed the publication of HSIB’s report, saying: “HSIB’s investigation and report have highlighted that timely, accurate recognition of acute Aortic Dissection is a national patient safety issue. This is exactly what patients and bereaved relatives having been telling the NHS, Government and the Royal College of Emergency Medicine for several years." Read full story Source: HSIB, 23 January 2020
  19. News Article
    Mother Natalie Deviren was concerned when her two-year-old daughter Myla awoke in the night crying with a restlessness and sickness familiar to all parents. Natalie was slightly alarmed, however, because at times her child seemed breathless. She consulted an online NHS symptom checker. Myla had been vomiting. Her lips were not their normal colour. And her breathing was rapid. The symptom checker recommended a hospital visit, but suggested she check first with NHS 111, the helpline for urgent medical help. To her bitter regret, Natalie followed the advice. She spoke for 40 minutes to two advisers, but they and their software failed to recognise a life-threatening situation with “red flag” symptoms, including rapid breathing and possible bile in the vomit. Myla died from an intestinal blockage the next day and could have survived with treatment. The two calls to NHS 111 before the referral to the out-of-hours service were audited. Both failed the required standards, but Natalie was told that the first adviser and the out-of-hours nurse had since been promoted. She discovered at Myla’s inquest that “action plans” to prevent future deaths had not been fully implemented. The coroner recommended that NHS 111 have a paediatric clinician available at all times. In her witness statement at her daughter’s inquest in July, Natalie said: “You’re just left with soul-destroying sadness. It is existing with a never-ending ache in your heart. The pure joy she brought to our family is indescribable.” Read full story Source: The Times, 5 January 2020
  20. Content Article
    Our experience of attending the Patient Safety Learning Annual Conference and entering our patient safety initiative into the awards.
  21. Content Article
    Dorit describes the assessment and subsequent death of her much loved daughter-in-law who died during a psychotic episode having been discharged the previous evening. Her story raises a number of questions: How should families be included in making judgements and assessments about the patient and their well-being? What support do they need to care for a very distressed loved one? Why aren't written care and contingency plans provided to the patient and their family? What more needs to be done to ensure standard practices are in place to protect patients with psychosis?
  22. Content Article
    Following the inquest into the death of former patient Amy Allan and the subsequent Preventing Future Deaths report given to Great Ormond Street Hospital for Children, Chief Executive Matthew Shaw would like to outline how the hospital is learning from this and what action has been taken to address the concerns that have been raised.
  23. Content Article
    This blog has been written by a healthcare worker and demonstrates the reality of what it is like caring for patients and families while being chronically low on staff. They describe the impact this has on staff morale and the impact it has on patients, patients family members and the relationship between staff and patients.
  24. Content Article
    The 4AT, developed in the UK, is now widely used internationally as a clinical tool for delirium detection in routine, non-specialist care, with increasing adoption for this specific use as well as in research studies. It has been validated in several published studies.
  25. Content Article
    The Care Quality Commission (CGC) is the independent regulator of health and adult social care in England. They make sure that health and social care services provide people with safe, effective, compassionate, high-quality care and encourage care services to improve.  Independent acute hospitals play an important role in delivering healthcare services in England, providing a range of services, including surgery, diagnostics and medical care. As the independent regulator, the CQC, hold all providers of healthcare to the same standards, regardless of how they are funded. 
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