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Found 124 results
  1. Community Post
    Stephen Moss, Patient Safety Learning Trustee, suggests four practical tips to help staff keep patients safe: With your colleagues ask a random selection of patients if they have felt unsafe in the last 24 hours (you might want to select a different form of words). If the answer is yes, get under the skin of why they have felt unsafe, pool the knowledge and agree what action you are going to take, or what might need escalating to your line manager. Have a discussion with your colleagues about how you can support each other to uphold your values and professionalism when the going gets tough. Be clear about what help you might need from outside of the team, and follow it up. When looking at your Ward Assurance results, satisfy yourself that where it is possible, they are outcome orientated rather than just focusing on compliance with a process. Look for ways of 'humanising' the data i.e. use a language that identifies the impact on patients and, importantly, use language throughout that will be understood by patients and the public. Too many times I see Ward Assurance results on ward corridors, for the attention of patients and families, written in 'NHS speak' ! When measuring your compliance with the Duty of Candour, don't just look at the numbers! Find a way that also establishes how families feel about the 'quality' of the response, i.e. was it open, honest and transparent and did it give what they needed. How do you think these tips could benefit your patients or service users? Have you tried anything similar that you've found has really helped? Let us know your thoughts and please feedback if you try any of them.
  2. Content Article
    In a new report analysing healthcare complaint investigations, the Parliamentary and Health Service Ombudsman (PHSO) have set out the need for the NHS to do more to accept accountability and learn from mistakes in cases of avoidable harm. This blog sets out Patient Safety Learning’s reflections on this report.
  3. Content Article
    Good 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.
  4. Content Article
    Published 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.
  5. News Article
    Great Ormond Street Hospital may have broken the law by failing to share information with parents that showed its errors had contributed to their son’s death, The Independent understands. The care watchdog is speaking to Great Ormond Street about its handling of an expert report into five-year-old Walif Yafi in 2017. It showed that the hospital’s failure to share results that showed a deadly infection had played a role in Walif’s death. But the boy’s parents were only told about the findings after inquiries by The Independent – months after settling a lawsuit with Great Ormond Street in which the trust denied responsibility. The Care Quality Commission is looking at concerns relating to duty of candour regulations, which require hospitals to be open and honest with families about mistakes made that result in serious harm to patients. Breaching the regulations is a criminal offence and can lead to prosecution. Read full story Source: The Independent, 7 December 2020
  6. News Article
    A major acute trust has confirmed the health service inspectorate has begun a criminal investigation into three incidents at its hospitals. University Hospitals Birmingham FT told HSJ the Care Quality Commission (CQC) has started a criminal investigation into incidents involving potential errors around the provision of anti-coagulant medication. The trust received a letter from the CQC this month informing it that the regulator has begun the investigation under regulation 22 of the Health and Social Care Act 2008 (regulated activities) regulations 2014. The incidents happened at Queen Elizabeth Hospital in Birmingham and Good Hope Hospital — the trust’s two main sites. Regulation 22 says: “In order to safeguard the health, safety and welfare of service users, the registered person must take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced persons employed for the purposes of carrying on the regulated activity.” The CQC launched a prosecution into East Kent Hospitals University FT this month for failing to meet fundamental standards of care. The regulator also successfully prosecuted University Hospitals Plymouth Trust in September after it pleaded guilty to breaching the duty of candour. Read full story (paywalled) Source: HSJ, 23 October 2020
  7. News Article
    A hospital trust has been fined for failing to be open and transparent with the bereaved family of a 91-year-old woman in the first prosecution of its kind. Elsie Woodfield died at Derriford hospital in Plymouth after suffering a perforated oesophagus during an endoscopy. The Care Quality Commission (CQC) took University Hospitals Plymouth NHS trust to court under duty of candour regulations, accusing it of not being open with Woodfield’s family about her death and not apologising in a timely way. Judge Joanna Matson was told Woodfield’s daughter Anna Davidson eventually received a letter apologising over her mother’s death, which happened in December 2017, but she felt it lacked remorse. Davidson said she still had many unanswered questions and found it “impossible to grieve”. The judge said: “This offence is a very good example of why these regulatory offences are very important. Not only have [the family] had to come to terms with their tragic death, but their loss has been compounded by the trust’s lack of candour.” Speaking afterwards, Nigel Acheson, the CQC’s deputy chief inspector of hospitals, said: “All care providers have a duty to be open and transparent with patients and their loved ones, particularly when something goes wrong, and this case sends a clear message that we will not hesitate to take action when that does not happen." Lenny Byrne, the trust’s chief nurse, issued a “wholehearted apology” to Woodfield’s family. “We pleaded guilty to failure to comply with the duty of candour and fully accept the court’s decision. We have made significant changes in our processes.” Read full story Source: The Guardian, 23 September 2020
  8. News Article
    An NHS trust is to appear in court today charged with breaking the law on being open and transparent after a woman’s death in the first ever court case of its kind. The Care Quality Commission (CQC) has brought a criminal prosecution against University Hospitals Plymouth Trust which will appear at Plymouth Magistrates Court tomorrow morning. The trust is charged with breaching the duty of candour regulations under the Health and Social Care Act 2008 which require hospitals to be honest with families and patients after a safety incident or error in their care. Hospitals are legally required to notify patients or families and investigate what has happened and communicate the findings to families and offer an apology. The case relates to how the Plymouth trust communicated with a woman’s family after her death which happened after she underwent an endoscopy procedure at Derriford Hospital in December 2017. The trust was required by law to communicate in an open and transparent way. The CQC has accused the trust of failing to do this. Read full story Source: The Independent, 22 September 2020
  9. News Article
    A private healthcare provider has been ordered to pay £20,000 after failing to disclose errors in the treatment of patients under the care of a surgeon. Spire Healthcare was prosecuted today in what the Care Quality Commission (CQC) said was “the first prosecution of its kind against an independent provider of healthcare”. The CQC said concerns around the treatment of four patients were initially raised by Leeds Clinical Commissioning Group, several physiotherapists at the hospital and another surgeon. The patients had surgical procedures carried out by Michael Walsh, a shoulder surgeon who held practising privileges at Spire Leeds until his suspension in April 2018. The procedures resulted in the patients suffering prolonged pain and requiring further remedial surgery. The CQC said it brought the prosecution after Spire failed to share details of what happened to the patients who were being treated by Mr Walsh, in line with their duty of candour responsibilities to be transparent and provide timely apologies when serious incidents occur. Read full story (paywalled) Source: HSJ, 29 April 2021
  10. News Article
    Bereaved families have been left feeling like their efforts to improve patient safety have been ‘in vain’ as progress of a government programme instigated by Jeremy Hunt appears to have ‘stalled’. The Learning from Deaths programme board, which was set up in 2017 to develop guidance for trusts working with families on investigations of deaths, has not met since June 2019. Josephine Ocloo and David Smith, two bereaved family members who were on the board, have written to HSJ, saying the programme’s progress has “stalled”. They added many of the issues it was set up to consider have not yet been addressed, including the need for a national inquiry into unresolved historical cases, the independence of the NHS’ investigatory systems, lack of effectiveness of the duty of candour, and the disproportionate impact on ethnic minorities and those with mental ill-health or learning disabilities. They said: “We now have serious concerns that what these families went through [in November 2017] in recalling — and effectively reliving — their experiences, in order to ensure the terrible things that happened to them could not happen to others, was in vain… “If [the issues] are not to be addressed by the new board, the families will have every right to feel betrayed and to feel as if they have been used as pawns in a political game. Once again, harmed and let down by a system that has used us and then cast us aside.” Read full story (paywalled) Source: HSJ, 26 February 2021
  11. Event
    This 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.
  12. Event
    until
    The 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
  13. Event
    This masterclass will cover the new guidance and provide participants with an in-depth knowledge of what needs to be done to comply with the duty of candour; clarify ‘grey areas’ and provide advice on dealing with difficult situations which may arise. It will provide participants with an understanding of good practice in implementing the duty and, in particular doing so in a meaningful way with empathy, to not only comply, but to work with patients and loved ones in a way that puts the emotional experience at the heart of communication. Anyone with responsibility for implementing the duty of candour should attend, whether as a health or social care professional or at an organisational level, be it in the NHS, private healthcare or social care. Health and social care professionals; staff with responsibility for quality, safety, clinical governance, safety investigations, complaints or CQC compliance, patient experience and executive teams would benefit from attending. See flyer attached below: Implementing the Duty of Candour with Empathy generic leaflet.pdf For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/duty-of-candour or click on the title above or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for a discount code.
  14. Event
    This masterclass will cover the new guidance and provide participants with an in-depth knowledge of what needs to be done to comply with the duty of candour; clarify ‘grey areas’ and provide advice on dealing with difficult situations which may arise. It will provide participants with an understanding of good practice in implementing the duty and, in particular doing so in a meaningful way with empathy, to not only comply, but to work with patients and loved ones in a way that puts the emotional experience at the heart of communication. Anyone with responsibility for implementing the duty of candour should attend, whether as a health or social care professional or at an organisational level, be it in the NHS, private healthcare or social care. Health and social care professionals; staff with responsibility for quality, safety, clinical governance, safety investigations, complaints or CQC compliance, patient experience and executive teams would benefit from attending. See flyer attached below: Implementing the Duty of Candour with Empathy generic leaflet.pdf For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/duty-of-candour or click on the title above or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for a discount code.
  15. Event
    until
    The duty of candour is a central to patient safety – the idea that, when things go wrong, healthcare professionals should be open and honest about this with patients and colleagues. But while incident reporting is a central plank to patient safety, the evidence still suggests that adverse outcomes and near misses are under-reported. This even before the challenges of the pandemic – which has left staff understandably exhausted, overstretched and under pressure – is taken into account. So how, in an environment as challenging as the service currently finds itself in, can candour in healthcare continue to be supported? How can leaders ensure that their colleagues have the time and space to report issues as they emerge? How can a no-blame culture continue to be fostered, from the boardroom down? What barriers remain to consistent reporting of incidents, how have they changed since the pandemic, and how can they be overcome? How might a culture of openness help combat health inequalities, not least those linked to ethnicity? This HSJ webinar, run in association with RLDatix, will bring together a small panel to discuss these important issues. Register
  16. Event
    This masterclass will cover the new guidance and provide participants with an in-depth knowledge of what needs to be done to comply with the duty of candour; clarify ‘grey areas’ and provide advice on dealing with difficult situations which may arise. It will provide participants with an understanding of good practice in implementing the duty and, in particular doing so in a meaningful way with empathy, to not only comply, but to work with patients and loved ones in a way that puts the emotional experience at the heart of communication. Anyone with responsibility for implementing the duty of candour should attend, whether as a health or social care professional or at an organisational level, be it in the NHS, private healthcare or social care. Health and social care professionals; staff with responsibility for quality, safety, clinical governance, safety investigations, complaints or CQC compliance, patient experience and executive teams would benefit from attending. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/duty-of-candour or email kerry@hc-uk.org.uk hub members receive a 20% discount. Please email info@pslhub.org for discount code
  17. Event
    This masterclass will provide participants with an in-depth knowledge of what needs to be done to comply with the duty of candour; clarify ‘grey areas’ and provide guidance on dealing with difficult situations which may arise. It will provide participants with an understanding of good practice in implementing the duty and, in particular doing so in a meaningful way with empathy, to not only comply, but to work with patients and loved ones in a way that puts the emotional experience at the heart of communication. Anyone with responsibility for implementing the duty of candour should attend, whether as a health or social care professional or at an organisational level, be it in the NHS, private healthcare or social care. Health and social care professionals; staff with responsibility for quality, safety, clinical governance, safety investigations, complaints or CQC compliance, patient experience and executive teams would benefit from attending. Further information and registration or email: nicki@hc-uk.org.uk hub members receive 10% discount. Email: info@pslhub.org
  18. Content Article
    The duty of candour is a general duty to be open and transparent with people receiving care from you. It applies to every health and social care provider that CQC regulates. The duty of candour requires registered providers and registered managers (known as ‘registered persons’) to act in an open and transparent way with people receiving care or treatment from them. The regulation also defines ‘notifiable safety incidents’ and specifies how registered persons must apply the duty of candour if these incidents occur. This document from the Care Quality Commission (CQC) gives the background to the duty of candour and explains the statutory and professional duties of candour.
  19. Content Article
    Pharmacists 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.
  20. Content Article
    This guidance from The Royal College of Radiologists aims to provide radiologists with guidance on how to implement the duty of candour, recognising the unique circumstances they face. It includes real-world examples and provides an approach which will help radiologists navigate an unfamiliar process in the best possible way. The guidance covers: The principles of candour Why this can be difficult in a radiological context Candour in different situations (reactive and proactive candour) and departmental disclosure policies Candour processes in practice The difference between discrepancy assessment and education/Radiology Events and Learning Meetings (REALM) Specific considerations (interventional radiology and remote reporting within an imaging network).
  21. Content Article
    In the aftermath of an adverse event, an apology can bring comfort to the patient, forgiveness to the health practitioner, and help restore trust to their relationship. According to the Health and Disability Commissioner: "The way a practitioner handles the situation at the outset can influence a patient's decision about what further action to take, and an appropriate apology may prevent the problem escalating into a complaint to HDC". Yet, for many health practitioners saying "I'm sorry" remains a difficult and uncomfortable thing to do. We can help to bring down this wall of silence by developing a clear understanding of the importance of apologies to patients and health practitioners; appreciating the difference between expressing empathy and accepting legal responsibility for an adverse outcome; knowing the key elements of a full apology and when they should be used; and supporting those who have the honesty and courage to say "I'm sorry" to patients who have been harmed while receiving healthcare.
  22. Content Article
    Fifteen years after a “moral moment” transformed patient safety here, new systems and a change in culture at John Hopkins Medicine have gone a long way toward eradicating errors.
  23. Content Article
    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.
  24. Content Article
    The Patients Association was formed over fifty years ago. Since then, it has listened to patients concerns and spoken out on their behalf. Not long after the Patients Association took up its role, legislation was enacted by the government to establish the Parliamentary and Health Service Ombudsman (PHSO). Both organisations have similar values and agendas, intended to help and support the public, the difference being, one is an independent charity, the other a government body afforded all the power and legislation to act with credibility. However, sadly the Patients Association has no confidence that the PHSO will carry out an independent, fair, open, honest and robust investigation. The Ombudsman is frequently quoted as saying patients who suffer harm or poor care in hospitals are failed by a “toxic cocktail” within the health service, whereby complaints go unheard and lessons unlearned. The Ombudsman states: ”We are the last resort for complaints about the NHS. We listen to individual complaints and where things have gone wrong, help to get them put right.” The Patients Association, in partnership with the families of those who have contributed to this report, challenge that statement. Nearly 50 years after the PHSO was established, it is time for real and robust change, not just promises and more recommendations. The Patients Association have a clear request to the Government and Public Administration Select Committee-read our patients stories, listen to their concerns, consider our conclusions, recommendations and finally, hold the PHSO to account for its action.
  25. Content Article
    In 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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