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Content ArticleWe know from several reports, reviews, and inquiries over recent years that the patient and family voice has not been heard. These voices are essential to learning and improvement because of their unique insight into how care is delivered. To improve safety we must understand its reality as experienced by patients. In a blog for the Patient Safety Commissioner website, Rosie Benneyworth, interim chief executive officer of the Health Services Safety Investigations Body (HSSIB), explains how HSSIB involves families in its investigations.
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Content ArticleLetter Patient Safety Commissioner, Henrietta Hughes, wrote to Amanda Pritchard, NHS England, on the implementation of Martha's Rule.
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Content ArticleOmbudsman, Rob Behrens and Patient Safety Commissioner, Henrietta Hughes, have written a letter to the Government sharing their joint concerns regarding what they see as the confrontational culture created by the complaints process in some areas of the NHS that undermines patient safety.
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Content ArticleAs the Cumberlege Review and Paterson Inquiry made clear, having accurate and timely data on treatments and outcomes is critical to patient safety. NHS England is working to strengthen this data by implementing a central database to collect key details of implantable devices at the time of operation. The new Outcomes and Registry Platform will bring existing registries together for the first time and introduce new registries. In a blog for the Patient Safety Commissioner website, Scott Pryde, Programme Director for NHS England’s Outcomes and Registries Programme, and Katherine Wilson, Clinical Steering Group Chair of the programme, discuss the new National Registry of Hearing Implants, a registry specifically for cochlear implants. They highlight the importance of collaboration between patients, clinicians, regulators and medical device manufacturers.
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Content ArticleIn late 2023, the Minister for Mental Health and Women’s Health Strategy, Maria Caulfield MP, asked the Patient Safety Commissioner for England to explore redress options for those who have been harmed by pelvic mesh and sodium valproate. This report sets out the outcome of this project and is designed to help the government understand the options available for providing redress to those patients harmed by pelvic mesh and valproate.
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News ArticleSenior leaders are resorting to “ticking the duty of candour box” instead of developing a “just and learning” culture in their organisations because their bandwidth is full, the patient safety commissioner has said. Speaking with HSJ as she begins the second year of her first term in the newly-established role, Henrietta Hughes said the bandwidth of senior leaders is “too full for them to make and maintain the necessary culture change”. She warned the duty of candour — giving patients and families the right to receive open and transparent communication when care goes wrong — gets seen as a “bit of a tick box exercise, ‘doc tick’ as it’s described to me, which is a bit depressing really”. A GP herself, she said individual doctors typically respond to concerns or they are handled by someone who knows the patient. Elsewhere, complaints are often addressed through a chief executive’s office, once all staff have provided written statements, she said. She added: “[In general practice] it feels more compassionate and empathetic… I find it’s often quicker to have a conversation with the patient before it turns into a formal complaint and resolves it quickly.” “What needs to change is that [NHS] trusts are currently held accountable to a very narrow set of criteria — financial and operational performance,” she said. “This is how we will improve safety and experience, transparency, a just and learning culture, and improve morale.” Read full story (paywalled) Source: HSJ, 30 January 2024
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Content ArticleIn this infographic, the Patient Safety Commissioner for England, Dr Henrietta Hughes, sets out her strategy for supporting the development of a new culture for the health system centred on listening to patients.
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Content ArticleThe second annual Safety For All conference was held at the Royal College of Physicians in London on Tuesday 5th December 2023. Over 100 members of the healthcare community attended this event, including occupational health professionals, patient safety experts, frontline staff, patients and academics. The conference was hosted by the Safer Healthcare and Biosafety Network and Patient Safety Learning as part of the Safety For All campaign, supported by B. Braun, BD, Boston Scientific and Stryker. Attendees had the opportunity to hear from two keynote speakers: Lynn Woolsey, UK Deputy Chief Nurse at the Royal College of Nursing and Dr Henrietta Hughes, Patient Safety Commissioner for England. The conference was chaired and facilitated by Dr Rob Galloway, A&E Consultant at Brighton and Sussex Hospital NHS Trust, with a welcome introduction from Dr Ian Bullock, CEO of the Royal College of Physicians. There were a number of panel sessions and presentations throughout the day which are summarised in the attachment below, including on sustainability, antimicrobial resistance and antibiotic underdosing, violence at work, clinical communications, human factors, implementing the Patient Safety Incident Response Framework (PSIRF), and women's health and the menopause.
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Content ArticleHospital leaders need to embed a safety culture across their organisations - read the latest guest blog on the Patient Safety Commissioner website from Maria Caulfield, the minister for mental health and women's health strategy. Maria gives three examples of how we are advancing patient safety across our NHS.
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Content ArticleIn her latest blog, Patient Safety Commissioner Henrietta Hughes discusses MHRA's Yellow Card reporting system and why, until we have mandatory reporting, including for devices that are working as designed, we will continue to see avoidable harm occurring to patients. She stresses that it is vital that the voices and views of patients, clinicians, manufacturer, and health providers participate in the design and delivery of devices.
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News Article
Martha’s rule must be available 24/7, England’s patient safety commissioner says
Patient Safety Learning posted a news article in News
Patients and their relatives will be able to request a second opinion from senior medics around the clock when the “Martha’s rule” system starts in hospitals in England. The government’s patient safety commissioner, asked by the health secretary, Steve Barclay, to advise on how to implement the change, has said access to a medic’s opinion must operate 24/7. Dr Henrietta Hughes made clear to Barclay in a letter that inpatients and families worried that their loved one’s health is deteriorating should be able to seek a second opinion at any time of day or night. In her letter, which she published on Wednesday, Hughes also said the availability of that service must be widely advertised in hospitals, so patients know they can use it. She told Barclay that all staff in acute and specialist medical NHS trusts in England “must have 24/7 access to a rapid review from a critical care outreach team who they can contact should they have concerns about a patient”. Hughes added: “All patients, their families, carers and advocates must also have access to the same 24/7 rapid review from a critical care outreach team which they can contact via mechanisms advertised around the hospital and more widely if they are worried about the patient’s condition. This is Martha’s rule.” Read full story Source: The Guardian, 3 November 2023 -
Content ArticleIt is essential that the voices of people from diverse communities are heard and acted upon because we will only be effective in improving patient safety for everyone if we include these groups. This blog from the Patient Safety Commissioner Dr Henrietta Hughes outlines the importance of listening to patients and staff from diverse communities to identify and act on patient safety issues – and how to make this happen.
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Content ArticleThe protests outside the Scottish Parliament took an alarming turn recently with people wearing hospital gowns spattered with blood. The demonstrators were former patients of neurosurgeon Sam Eljamel, many allegedly harmed by him and still suffering and searching for answers years later. A public inquiry has been announced by the First Minister. As the Patient Safety Commissioner for Scotland Bill makes its way into law, Alan Clamp, chief executive officer of the Professional Standards Authority for Health and Social Care, asks what this means for Scotland and the safety of its patients? See also: Working together to achieve safer care for all: a blog by Alan Clamp
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News Article
Scotland: MSPs to vote on patient safety commissioner plan
Patient Safety Learning posted a news article in News
MSPs are set to vote on a new law to establish a patient safety commissioner. The bill to create an "independent public advocate" for patients will go through its final stage on Wednesday. Public Health Minister Jenny Minto has said the commissioner would be able to challenge the healthcare system and ensure patient voices were heard. The Scottish government has been told the new watchdog must have the power to prevent future scandals. In 2020, former UK Health Minister Baroness Julia Cumberlege published a review into the safety of medicines and medical devices like Primodos, transvaginal mesh and the epilepsy drug sodium valproate. She told the House of Lords: "Warnings ignored. Patients' concerns ignored. A system that seemed unwilling or unable to listen let alone respond, unwilling or unable to stop the harm." Her findings led to the recommendation for a patient safety commissioner. Speaking ahead of the vote on the Patient Safety Commissioner for Scotland Bill, Ms Minto said the watchdog would listen to patients' views. "I think it's a really important role for us to have in Scotland," she said. "There's been a number of inquiries or situations where the patient's voice really needs to be listened to and that's what a patient safety commissioner will do." Read full story Source: BBC News, 27 September 2023- Posted
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Content Article
Patient Safety Commissioner initiatives
Patient Safety Learning posted an article in England
Patients need to be involved in all aspects of the design and delivery of healthcare and to make quality improvements that prevent harm. The Patient Safety Commissioner website shows examples of where working in partnership with patients and families, listening to patients’ voice and acting upon their concerns have made positive changes.- Posted
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Content Article
Patient Safety Commissioner Annual Report 2022-23 (July 2023)
Patient Safety Learning posted an article in England
The Independent Medicines and Medical Devices Safety review set out the devastating impact on people’s lives when patients’ voices go unheard. Recommendation 2 from the review was the appointment of an independent Patient Safety Commissioner to promote the safety of medicines and medical devices and to amplify the voices and views of patients and the public so that future harm is avoided. The Patient Safety Commissioner (PSC) was appointed on 13 July 2022 and took up her post officially on 12 September 2022. Here is the first Patient Safety Commissioner's first annual report.- Posted
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News Article
Welsh Government criticised for failing to appoint a Patient Safety Commissioner
Patient Safety Learning posted a news article in News
The Welsh Government is facing criticism after refusing to appoint an independent Patient Safety Commissioner – a role established in England last year and currently being legislated for in Scotland. The moves in England and Scotland follow publication of the Independent Medicines and Medical Devices Safety Review in 2020, which investigated a series of scandals where patients suffered because of negligence and inaction. The review recommended the establishment of a Patient Safety Commissioner in England, and last September Dr Henrietta Hughes became the first such commissioner. The Scottish Parliament is currently legislating to introduce a Patient Safety Commissioner. A Welsh Government spokesman said: “The situation here is different to the other devolved nations. We’ve recently introduced our own legislation and other measures to improve patient safety. “We strengthened the powers of the Public Service Ombudsman for Wales to undertake their own investigations and introduced new duties of quality, including safety, and candour for NHS bodies. We have created [the body] Llais to give a stronger voice to people in all parts of Wales on their health and social care services. It has a specific remit to consider patient safety and has the power to make representations to NHS bodies and local authorities and undertake work on a nationwide basis. “Our view is that introducing a Patient Safety Commissioner in Wales at this time would create considerable complexity and confusion. Also one of the main roles of the proposed commissioner is in relation to medicines and medical devices, which are not devolved to Wales.” Read full story Source: Nation Cymru, 6 July 2023- Posted
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Content ArticleThis blog provides an overview of a Patient Safety Management Network (PSMN) meeting discussion on 9 June 2023. At this meeting, members of the Network were joined by Dr Henrietta Hughes, Patient Safety Commissioner for England. The PSMN is an informal voluntary network for patient safety professionals in England. Created by and for patient safety managers, it provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. Find out about the network.
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Event
Patients and PSRIF: Changing culture
Sam posted an event in Community Calendar
untilSpeakers for this session are Dr Tracey Herlihey, head of patient safety incident response policy at NHS England, and Dr Henrietta Hughes OBE, patient safety commissioner. Dr Herlihey will discuss how the patient safety incident response framework (PSIRF) is changing the culture amongst healthcare workers and what this means for individuals. Dr Hughes will discuss the events leading up to the creation of the patient safety commissioner role, her priorities, the role of leaders and ‘what matters to you.’ That is, why we must listen to patients and what happens if we don’t. Register- Posted
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Content ArticleThis letter is a resource for patients to help GPs identify the complications of pelvic mesh. It explains signs and symptoms of women presenting with pelvic mesh-related conditions and if required, where to signpost them for further help. It has been issued by the Patient Safety Commissioner for England, developed in partnership with the patient campaign groups Sling the Mesh and the Rectopexy mesh victims and support.
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Patient Safety Commissioner for England website
Patient Safety Learning posted an article in England
The role of the Patient Safety Commissioner for England is to promote patient safety in relation to medicines and medical devices and to promote patients’ voices. This site provides information and resources related to this role and is for everyone interested in promoting patient safety and making sure that patients’ voices are heard.- Posted
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News Article
Watchdog hits out at DHSC ‘ambiguity and delay’
Patient Safety Learning posted a news article in News
The national patient safety commissioner has hit out at government for failing to confirm her budget a month into the financial year, warning that she is ‘incredibly limited’ in what she can achieve. In an strongly worded letter released today, Henrietta Hughes states: “Despite it now being the end of April the Department has still not provided me with a budget for this financial year.” She added: “This ambiguity and delay is impacting on my ability to arrange patient engagement events as these require a budget”. It appears to be an almost unprecedented public intervention from an official who is appointed and hosted by the DHSC. In the letter to Commons Health and Social Care Committee chair Steve Brine, she also says she does not have enough resources to fulfil the role, and is only able to employ four members of staff. Read full story (paywalled) Source: HSJ, 3 May 2023- Posted
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Patient Safety Commissioner for England update (22 March 2023)
Patient Safety Learning posted an article in England
This article* is an update from Dr Henrietta Hughes, Patient Safety Commissioner for England.- Posted
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News Article
Watchdog says its lack of funding is compromising safety
Patient Safety Learning posted a news article in News
The patient safety commissioner has complained to MPs that she does not have enough staff to cope with her ‘significant workload’, it has emerged. Henrietta Hughes’ concerns are revealed in a letter from Commons health and social care committee chair Steve Brine to health and social care secretary Steve Barclay. Mr Brine asks for assurances over the commissioner’s resources and says he was “concerned” Dr Hughes had told him her current funding was “too little to make the necessary improvements” to safety oversight. Mr Brine wrote on 6 March: “I am in regular contact with Dr Hughes and the matter of resources for her office is something that she has raised with me. She tells me that her office is under extreme pressure, with a significant workload, including correspondence from patients.” Mr Brine told Mr Barclay he shared Dr Hughes’ concerns that without “sufficient resourcing” there was a risk that the safety commissioner role would – according to Dr Hughes – “let down the hopes of patients that were raised by the publication of Baroness Cumberlege’s report”. Read full story (paywalled) Source: HSJ, 14 March 2023- Posted
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News Article
Infighting delays valproate compensation
Patient Safety Learning posted a news article in News
Source: The Times. 5 March Shared on Twitter @ShaunLintern- Posted
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