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Content Article
Patient Safety Commissioner: 100 Days Report (2 February 2023)
Patient Safety Learning posted an article in England
In this report, Dr Henrietta Hughes, Patient Safety Commissioner for England, reflects on her first 100 days in this new role. She sets out what she has heard, what she has done and her priorities for the year ahead. -
Content ArticleDr Henrietta Hughes, England's Patient Safety Commissioner, discusses how the experiences of people from Black and minority ethnic groups has worsened since the pandemic and how this has impacted on patient safety, in a blog for the NHS Race & Health Observatory.
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News Article
Contacting the Patient Safety Commissioner for England
Patient Safety Learning posted a news article in News
Dr Henrietta Hughes was appointed as the first ever Patient Safety Commissioner for England in July. She began her role on 12 September. Dr Hughes is an independent point of contact for patients so that patients’ voices are heard and acted upon. She will use patients’ insight to help the government and the healthcare system in England listen and respond to patients’ views and promote patient safety, specifically with regard to medicines and medical devices. For more information on the role of the Patient Safety Commissioner see the fact sheet and the government’s response to a consultation regarding the post. The privacy notice sets out how the Patient Safety Commissioner collects and uses personal data to fulfil the role. Please contact the Patient Safety Commissioner at commissioner@patientsafetycommissioner.org.uk. Source: Department of Health and Social Care, 28 September 2022- Posted
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Content Article
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. -
Content ArticleDr Henrietta Hughes, Patient Safety Commissioner for England, sheds light on the disconnect between the executive corridor and what patients experience.
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Content ArticleMore and more people are dying at home, rather than in a hospital or hospice. With this trend set to continue, how can commissioners ensure that end-of-life care reflects this and meets the needs of people approaching the end of their lives and their loved ones? This new report from the King's Fund explores what we know about commissioning end-of-life care, the inequalities experienced by particular groups, and how NHS and social care commissioners in England are measuring and assuring the quality of care people receive. Drawing on interviews with commissioners, stakeholders and experts in end-of-life care, as well as recently bereaved carers and family members, this report offers reflections and recommendations for those wanting to improve end-of-life care for those dying at home.
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News Article
Trusts should seek extra funding to be ready for major incidents, says inquiry
Patient Safety Learning posted a news article in News
Ambulance trusts should review their ability to respond to mass casualty incidents and press commissioners for any additional resources they need, the report into the Manchester Arena bombing has said. Only 7 of the 319 North West Ambulance Service Trust vehicles available on the night of the attack, in 2017, were able to deploy immediately, the report said. It said experts believed that “such a situation would almost inevitably be replicated if a similar incident were to occur again anywhere in the country”, given current resources and demand. Ambulance trusts are now hugely more stretched than in 2017, with response times having significantly lengthened due to lack of resources. The second volume of the report from the inquiry, chaired by Sir John Saunders, published today, is critical of the emergency services’ response to the bombing which killed 22 people. NWAS “failed to send sufficient paramedics into the City Room [an area adjoining the Arena]” and did not use available stretchers to remove casualties in a safe way, it says. A key role for managing the incident – that of ambulance intervention team commander – was not allocated for half an hour. But it also raised issues of ambulance capacity and availability for major incidents involving mass casualties. “Around the UK, ambulance services are always ’playing catch up,’” it said, with no spare frontline capacity. With demand doubling over the last 10 years, the inability to respond to such incidents is only going to get worse – and lives will be lost if they do not attend the scene quickly and in sufficient numbers, the report said. Read full story (paywalled) Source: HSJ, 3 November 2022 -
News Article
CQC chief sceptical about need for ‘patient safety commissioner’
Patient Safety Learning posted a news article in News
The Care Quality Commission's chief executive Ian Trenholm has said he is sceptical about the need to appoint an NHS patient safety commissioner, one of the key recommendations of the recently published Cumberlege review. In a wide-ranging interview with HSJ, Mr Trenholm also revealed that he wants the Care Quality Commission to review the collaboration of every health system in England. Mr Trenholm told HSJ he is “not sure” a patient safety commissioner was needed and that it would need to perform a “role that was different from what’s already in place” for it to add value. He said: “If you look at the work we’re doing on patient safety, the work that HSIB are doing on patient safety, and then we’ve got people within the NHS itself doing work on patient safety, I think there are enough people playing. The question is, are we all working together as effectively as we possibly could be. “If another player helps that work [then] great, but I’m not sure that’s something that is necessary.” Read full story (paywalled) Source: HSJ, 24 August 2020 -
News Article
Up to 100,000 on antipsychotics with no review
Patient Safety Learning posted a news article in News
A national strategy is needed to tackle health risks linked to antipsychotic drugs because current policy is letting tens of thousands of people fall through the gaps, commissioners in London are warning. Commissioners and clinicians in City and Hackney found more than 1,000 patients in their area who were on these drugs without having regular medication reviews or health checks. They warned that, if their findings applied across England, 100,000 patients could be in the same position. Although NHS England funds GP practices to carry out regular health checks on patients who are on the serious mental illness register, this excludes patients who are prescribed antipsychotics without having an SMI diagnosis — which typically covers psychoses, schizophrenia or bipolar active disorder. An audit by City and Hackney Clinical Commissioning Group, carried out in July 2019 and shared with HSJ, found 1,200 patients in the area were taking antipsychotics but did not have a formal SMI diagnosis. The audit found most of these patients were not receiving regular health checks and a significant number may have benefited from having their medication reduced. Read full story (paywalled) Source: HSJ, 27 January 2020 -
Content ArticleAs part of the Medicines and Medical Devices Act 2021, the UK Government formally committed to establishing the new role of a Patient Safety Commissioner for England. In this blog Dr Victoria Moore explores the role of the proposed Patient Safety Commissioner, arguing that this may not be sufficient to ensure patient safety.
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Content ArticleThe UK Government committed to establishing a Patient Safety Commissioner for England in the Medicines and Medical Devices Act 2021. The decision to create this role came about as a result of a specific recommendation in First Do No Harm: The Report of the Independent Medicines and Medical Devices Safety Review (also known as the Cumberlege Review), published in July 2020. The Department of Health and Social Care held a consultation asking for comments on the proposed arrangements for the appointment and operation of the new Patient Safety Commissioner between 10 June and 5 August 2021. This report analyses responses from the public and other interested parties.
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Content Article
This is the fourth of a short series of blogs in which we take a look back at our work in five areas of patient safety during 2021. In this blog we consider the need for greater patient engagement to support improvements to patient safety. Throughout our work, Patient Safety Learning seeks to harness the knowledge, insights, enthusiasm and commitment of health and social care organisations, professionals and patients for system-wide change and the reduction of avoidable harm. We believe patient safety is not just another priority; it is a core purpose of health and social care. Patient safety should not be negotiable. -
Content Article
House of Lords debate – Patient Safety Commissioner (2 December 2021)
Mark Hughes posted an article in England
This is a debate from the House of Lords on 2 December 2021 about when the process to appoint a Patient Safety Commissioner for England will commence and when the Commissioner is expected to be in post. -
Content ArticleIn the Scottish Government’s Programme for Government 2020-21 it committed to establishing a Patient Safety Commissioner for Scotland. The decision to create this role came about as a result of a specific recommendation in the First Do No Harm: The Report of the Independent Medicines and Medical Devices Safety Review (also known as the Cumberlege Review), published in July 2020. The Scottish Government held a consultation process seeking views on a range of issues relating to the creation of a new Patient Safety Commissioner role between 5 March 2021 and 28 May 2021. This report analyses responses from the public and other interested parties.
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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 -
Community Post
Coexistence of Accreditation and Regulation in Healthcare
Dr Akhil Sangal posted a topic in Innovation programmes in health and care
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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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Content Article
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This 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. -
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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Content Article
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. -
News ArticleAn Independent Patients' Commissioner is set to be appointed to act as champion for people who have been harmed by medicines or medical devices. Baroness Cumberlege, who recommended the new role in a landmark report earlier this year, announced that the government had budged on the issue after initial resistance. She welcomed the move saying: "Had there been a patient safety commissioner before now, much of the suffering we have witnessed could have been avoided." But she added "the risk still remains" and further urgent action is needed to protect patients from potentially harmful drugs." At an online meeting of parliamentarians, the baroness described the testimony of a victim of the medical device vaginal mesh, which has left some patients in chronic pain. The woman had told her review team: "This device took everything from me. My health, my life, my job, my dignity, my marriage, my freedom." Reflecting on this the baroness added: "The scale of suffering we witnessed means nothing short of profound change is necessary. Not necessary in a couple or three years, but necessary now." Read full story Source: Sky News, 16 December 2020
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EventuntilWith general practice in crisis due to workforce shortages, an increasingly complex workload, rising public expectations, and further pressures caused by the Covid-19 pandemic, The King's Fund are providing the time and space for you to reflect, think differently, share and learn. Join peers and experts from The King’s Fund to explore: what the future of general practice looks like how the experience for patients and staff can be improved how to ensure those actions are building blocks towards the future. This event is for GPs, commissioners, nurses, practice managers, allied health professionals, Additional Roles Reimbursement Scheme (ARRS)-funded roles, and other professionals working in multidisciplinary general practice teams and those responsible for general practice at place or neighbourhood level. Register
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Content ArticleInvestigation of a complaint against the Belfast Health and Social Care Trust A Trust’s failure to perform an examination of a patient on admission to hospital meant he was not assessed by medical staff against this baseline during his time on the ward.
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Content Article
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Last week the Professional Standards Authority for Health and Social Care (PSA) published a new report, Safer care for all – solutions from professional regulation and beyond, which examines the current state of professional health and care regulation in the UK. In this blog, Patient Safety Learning considers this report from a patient safety perspective. PSA's chief executive, Alan Clamp, has also written a blog for the hub on the report, which can be read here. -
Content ArticleIn this report the Professional Standards Authority for Health and Social Care sets out its view on the biggest challenges affecting the quality and safety of health and social care. It puts forward a number of recommendations to ensure safer care for all, with its main recommendation being that an independent Health and Social Care Safety Commissioner should be appointed for each UK country to identify current, emerging and potential risks across the whole health and social care system, and bring about the necessary action across organisations.
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