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Showing results for tags 'Duty of Candour'.
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Content ArticleThis report by the charity INQUEST, which provides expertise on state related deaths and their investigation to bereaved people, highlights that families are facing persistent challenges following the death of a loved one in mental health services. Based on conversations at one of INQUEST’s Family Consultation Days, the report shows that families face numerous hurdles during investigations and inquests into their loved ones’ deaths, and that processes are not delivering the change required. The Family Consultation Day heard from 14 family members who were bereaved by deaths in the care of mental health services or settings for people with learning disabilities and/or autism, and had faced or were going through inquests and investigations.
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News Article
Covid inquiry: Families unhappy with Welsh government
Patient Safety Learning posted a news article in News
Bereaved families of coronavirus victims feel the Welsh government has not adequately taken part in the Covid public inquiry, their solicitor says. Craig Court, who represents bereaved families, said the Welsh government had not participated "as well as they should have". He claimed the Welsh government failed to deliver crucial paperwork with just days to go before Tuesday's inquiry. The UK-wide inquiry could go on as long as three years, and will predominantly look at the UK government's approach to the pandemic. A Wales-specific inquiry was blocked by Labour members of the Senedd, with First Minster Mark Drakeford saying it should wait until after the UK-wide investigation had been completed. Mr Court told BBC Wales "there is a great concern over the duty of candour" displayed by the Welsh government. Read full story Source: BBC News, 9 June 2023 -
Content ArticleGood patient communication strategies are an essential prerequisite for developing an effective NHS patient safety culture and the NHS needs to improve on its efforts, writes John Tingle in an article for the British Journal of Nursing.
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Content ArticlePublished in BMC Health Services Research, this is the first review to theorise how open disclosure (OD) works, for whom, in what circumstances, and why. Authors identify and examine from the secondary data the five key mechanisms for successful OD and the three contextual factors that influence this. The next study stage will use interview and ethnographic data to test, deepen, or overturn their five hypothesised programme theories to explain what is required to strengthen OD in maternity services.
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Content ArticleIn this blog, Steve Turner reflects on why genuine patient safety whistleblowers are so frequently ignored, side-lined or victimised. Why staff don't speak out, why measures to change this have not worked and, in some cases, have exacerbated the problems. Steve concludes with optimism that new legislation going through Parliament offers a way forward from which everyone will benefit.
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News Article
Medical records changed as hospitals cover up mistakes, watchdog warns
Patient Safety Learning posted a news article in News
Hospitals are still covering up serious mistakes in patient care and fobbing off families that raise concerns, the head of the watchdog that investigates complaints against the NHS has warned. Rob Behrens told The Times he had seen cases of medical records being changed after a death and spoken to doctors who were too scared to speak out about failings in their hospitals. He called on ministers to change the law to introduce a “duty of candour” on health and other public service staff to “transform” the system and make it more accountable to patients. He warned: “There is a deep reluctance to explain and give an account of what you do in the health service or the public service for fear of retribution. The things that really get to me are the avoidable deaths of babies in the health service — dying because there’s been poor coordination or they’d been wrongly diagnosed or the parents hadn’t been listened to. That is shocking.” Read full story (paywalled) Source: The Times. 6 March 2023- Posted
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Content ArticleIn December 2022, the All Party Parliamentary (APPG) for Whistleblowing heard evidence on the state of the NHS following the recent report on the avoidable deaths and life changing injuries caused to mothers and babies at the East Kent Trust. The culture at this hospital was described as one where “everyone knew the problems” and where whistleblowers were “thrown to the lions”. A culture attributed to 45 of the 65 baby deaths reviewed. This blog first appeared on the Whistleblowers UK website in December 2022.
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Content ArticleIn this blog for Medpage Today, US doctor Diane Solomon talks about the power of apologising to patients. Outlining the tendency of healthcare professionals to defend their practice, she describes how being honest and open with patients about errors demonstrates humanity and compassion. She talks about the importance of being sincere when apologising and outlines how taking responsibility builds trust and can positively change future outcomes.
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Content ArticleIn this editorial. Peter Walsh reflects on 20 years as Chief Executive of Action against Medical Accidents (AVMA) as he retires from the role. AvMA also marks its 40th anniversary this year, and Peter examines the organisation's unique role in focusing on patient safety and justice for patients. He highlights that healthcare systems and patient safety practice still have a long way to go in offering fairness and support to families affected by avoidable harm in healthcare, and argues that focusing on patients and their families must be a top priority when looking at system safety. He highlights the vital role that AvMA has played in bringing Duty of Candour into law in the countries of the UK, and argues that legal action is an important right that must be retained for patients and families who have come to harm as a result of medical error. He also talks about AvMA's recent development of a Harmed Care Pathway in collaboration with the Harmed Patients Alliance, which outlines the specific set of needs that should form part of a package of care for harmed patients and families.
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- Patient engagement
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Content ArticleThis editorial in the Journal of Patient Safety and Risk Management reflects on the achievements of the organisation Action Against Medical Accidents (AvMA) over the past 40 years and looks at the emerging role of Patient Safety Learning amongst organisations working for patient safety. Helen Hughes, Chief Executive of Patient Safety Learning, and Albert Wu, Editor-in-chief of the journal, reflect on the purpose and value of patient safety charities and not-for-profit organisations, highlighting the ways in which they channel and champion the patient voice and campaign to address specific areas of recurrent harm. They discuss the vital nature of the patient perspective in driving safety improvements in healthcare, and look at how these organisations amplify this. They also talk about the role of Patient Safety Learning and what it is doing to both drive system change at policy level, and share widely the knowledge of risk and good practice for safer care. They discuss the ways in which Patient Safety Learning delivers its aim to "listen to and promote the voice of the patient safety front line - patients, families and staff.”
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Content Article
How can Parliament make health and care safer for all? (4 November 2022)
Mark Hughes posted an article in Others
In this blog for the cross-party think tank Policy Connect, 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 outlined in its report Safer care for all - solutions from professional regulation and beyond. It describes gaps in the wider framework to protect the public highlighted in this report and considers where Parliament and the Government have an opportunity to act to support safer care for all. Related reading Patient Safety Learning: Joining up a fragmented landscape: Reflections on the PSA report ‘Safer care for all’ (12 September 2022) Working together to achieve safer care for all: a blog by Alan Clamp (12 September 2022)- Posted
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Content Article
How to complain to the NHS
Patient Safety Learning posted an article in Complaints
You have the right to make a complaint about any aspect of NHS care, treatment or service The information on this NHS page will guide you through the NHS complaints process, as well as the core requirements for NHS complaints handling.- Posted
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Content ArticleA toxic organisational culture has been shown to contribute more to staff leaving and reporting ill health, than pay and other factors. In this blog, Brandi Neal, Director of Content Creation & Marketing at the consultancy Radical Candor, looks at three traits of a toxic company culture: obnoxious aggression, ruinous empathy and manipulative insincerity. She highlights the value of the radical candor approach, which involves caring personally for staff while challenging them directly, and building genuine relationships with your team,
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Content ArticleThe Resilient Surgeon is a podcast by The Society of Thoracic Surgeons in the US. In this episode, Dr Michael Maddaus interviews Dr Amy Edmondson, a scholar of leadership, teamwork and organisational learning. Dr Edmondson defines psychological safety as a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns or mistakes. It makes a team a safe place for interpersonal risk-taking. In this podcast, she explains how psychological safety is the key to unlocking high quality conversations that result in improved team outcomes.
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Community Post
Can the NHS learn from healthcare systems overseas?
Steve Turner posted a topic in Organisational
- Behaviour
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- Duty of Candour
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- Organisational development
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- Safety culture
- Transformation
- Speaking up
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- Benchmarking
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Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS an attractive place to work again, providing the NHS Constitution for England is at the heart of changes and is kept up to date. In my experience, having worked in healthcare for the private sector and the NHS, and lived and worked in other countries, we need to open our eyes. At present it could be argued that we have the worst of both worlds in England. A partially privatised health system and a fully privatised social care system. All strung together by poor commissioning and artificial and toxic barriers, such as the need for continuing care assessments. In my view a change, for example to a German-style system, could improve patient safety through empowering the great managers and leaders we have in the NHS. These key people are held back by the current hierarchical crony-ridden system, and we are at risk of losing them. In England we have a system which all too often punishes those who speak out for patients and hides failings behind a web of denial, obfuscation and secrecy, and in doing this fails to learn. Vast swathes of unnecessary bureaucracy and duplication could be eliminated, gaps more easily identified, and greater focus given to deeply involving patients in the delivery of their own care. This is a contentious subject as people have such reverence for the NHS. I respect the values of the NHS and want to keep them; to do this effectively we need much more open discussion on how it is organised and funded. What are people's views?- Posted
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- Behaviour
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(and 24 more)
Tagged with:
- Behaviour
- Resources / Organisational management
- Communication problems
- Decision making
- Organisation / service factors
- System safety
- User centred design
- Culture of fear
- Duty of Candour
- Just Culture
- Leadership
- Organisational culture
- Organisational development
- Organisational learning
- Safety culture
- Transformation
- Speaking up
- Transparency
- Whistleblowing
- Change management
- Collaboration
- Hierarchy
- Staff support
- Benchmarking
- Clinical governance
- Accountability
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Content ArticleLast 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.
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Content ArticleIn a recent report, the Professional Standards Authority (PSA) for Health and Social Care sets out its view on the biggest challenges affecting the quality and safety of health and social care. In this blog, Alan Clamp, PSA's chief executive, summarises these challenges and the possible solutions. You can also read Patient Safety Learning's reflections on the PSA report here.
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Content ArticleIn this British Journal of Nursing article, John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses some recent reports on the duty of candour and shared decision-making.
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Content ArticleThis guidance was updated on the 30 June 2022 to clarify how healthcare professionals should apply the term “unexpected or unintended” to decide if something qualifies as a notifiable safety event or not. Further detail is included below and you can find the full update here.
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Content ArticlePharmacists and pharmacy technicians across different settings work hard to provide person-centred, safe and effective care to patients. But, in reality sometimes things go wrong. The way that professionals respond to these situations is key to supporting the people affected and improving patient safety for the future. This guidance from the General Pharmaceutical Council aims to provide you with guidance on how to implement the Duty of Candour.
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EventThis one day masterclass will focus on a toolkit to allow organisations to use patient experience and incident to improve patient safety. The Toolkit uses 3 phases: planning, implementation and review. The Francis Report showed that the NHS had stopped listening to the needs of its users. Patient experience is still an underutilised tool in the armoury of a healthcare organisation and commissioners. The toolkit uses the priorities of the Francis Report to improve patient experience and patient safety. These include putting patients first, openness, candour, accountability, complaints handling, culture of caring and compassionate leadership. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/patient-experience-and-learning-from-incidents-to-improve-safety or email aman@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code.
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EventuntilThe Faculty of Clinical Radiology has developed guidance on the duty of candour with the aim of providing radiologists with guidance and real-world examples on the implementation of the duty of candour. The document recognises the unique circumstances faced by radiologists and all who work in imaging. It is not possible to provide guidance for every situation, but the aim is to provide an approach which will help colleagues navigate an unfamiliar process in the best possible way for our patients and the professionals who care for them. The Royal College of Radiologists is hosting a webinar to discuss this new guidance and answer any queries. Please submit any questions in advance to guidance@rcr.ac.uk by Friday 24th June to ensure we are able to answer as many as possible. Register for the webinar
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