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Found 1,566 results
  1. Content Article
    In this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on some of the key patient safety issues and developments over the past 12 months and looks ahead to 2023.
  2. Content Article
    On the 19 July 2021, an investigation commenced into the death of Quinn Lias Parker, born on the 14 July 2021, who died on 16 July 2021. The investigation continues and the case will come to Inquest in 2022. Quinn was born in a very poor condition, and it was sadly clear within 1- 2 hours of his birth, that he remained extremely unwell, and there was a high probability that he would not survive. There were concerns raised by his parents at this early point, regarding the care provided by The Trust, in relation to the management of Emmie, his mother, in late pregnancy, and regarding the timing of Quinn’s delivery. In the event of Quinn’s death, it would therefore require referral to the coroner, and thought needed to be given to the preservation of the placenta, to ensure that it was available for examination as part of the Paediatric post mortem. In this case, the placenta was cut into/dissected after Quinn’s death without discussion with the Coroner. This has affected the ability of the Paediatric Pathologist instructed by the Coroner, to determine the likely cause of Emmie’s antepartum haemorrhage. Whilst the medical cause of Quinn’s death will be explored in full at the Inquest, it is likely that the antepartum haemorrhage, and the underlying pathology causing it, is directly related to Quinn’s death. It is not clear how the placenta was cut into after Quinn’s death without discussion with the Coroner - this will be fully explored at the Inquest, but what is clear is that the outcome is highly detrimental to the independent investigation by the Coroner and other agencies investigating the circumstances of this case. This death follows a number of similar early neonatal deaths in Nottingham, where the placenta has not been retained, and therefore key information regarding placental pathology has been lost
  3. Content Article
    This 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.”
  4. Content Article
    Jenny Edwards died in February 2022 from pulmonary embolism, following misdiagnosis. In this blog, her son Tim introduces us to Jenny, illustrating the deep loss felt following her premature passing. He talks about the care she received and argues that there were multiple points at which pulmonary embolism should have been suspected. Tim found the investigation that followed Jenny’s death to be lacking in objectivity and assurance that any learning could be taken forward. He has since produced an independent report, drawing on existing data, freedom of information requests and his mother’s case, to highlight broader safety issues.
  5. Content Article
    This cross-sectional study in BMJ Evidence-Based Medicine aimed to understand the relationship between financial conflicts of interest and recommendations for atrial fibrillation (AF) screening in the UK. The authors looked at whether the UK media recommend for or against screening for AF and the financial conflicts of interests of AF screening commentators. The authors found that the vast majority of UK media promotes screening for AF, in contrast to the position of the independent UK National Screening Committee, which recommends against screening. Most commentators, internal NHS organisations and UK charities promoting screening had a direct or indirect financial conflict of interest. Independent information was rare and the reasons for this are unknown. They recommend readers consider the potential impact of financial conflicts on recommendations to screen.
  6. Content Article
    This report from the National Child Mortality Database (NCMD) covers the two-year period from 2019 to 2021, and is unique in two ways. It is the first national report to have investigated all unexpected deaths of infants and children—not just those that remained unexplained. It is also the first national review of the 'multi-agency investigation process' into unexpected deaths. The report found that, of all infant and child deaths occurring between April 2019 and March 2021 in England, 30% occurred suddenly and unexpectedly, and of these 64% had no immediately apparent cause. Other key findings relating to sudden and unexpected infant deaths (under 1 year) include: 70% were aged between 28 and 364 days, and 57% were male Infant death rates were higher in urban areas and the most deprived neighbourhoods For sudden and unexpected infant deaths that occurred during 2020 and had been fully reviewed, 52% were classified as unexplained (Sudden Infant Death Syndrome) and 48% went on to be explained by other causes such as metabolic or cardiac conditions.
  7. Content Article
    This policy paper, published by the Department of Health and Social Care, provides an update on the UK Government’s progress in implementing the recommendations of the Independent Medicines and Medical Devices Safety (IMMDS) Review, sometimes referred to as the Cumberlege Review.
  8. Content Article
    Patient safety incident investigations (PSII) are system-based responses to a patient safety incident for learning and improvement. Typically, a PSII includes four phases: planning, information gathering, synthesis, and interpreting and improving. More meaningful involvement can help reduce the risk of compounded harm for patients, families and staff, and can improve organisational learning, by listening to and valuing different perspectives.
  9. Content Article
    The Invited Reviews service was formed in 1998 and offers consultancy services to healthcare organisations on which they may require independent and external advice. Reviews provide an opportunity to healthcare organisations to deal with issues and concerns at an early stage. Medical directors (MDs) or chief executive officers (CEOs) of healthcare organisations can request an invited review when they feel the practice of clinical medicine is compromised and there are potential concerns over patient safety. The Royal College of Physicians (RCP) Invited Reviews service has gained a wealth of experience dealing with demanding situations involving individuals, teams, departments and services. This is their learning from invited reviews report. It brings together their experiences across multiple specialities, identifying common themes and crystallising some of our generic findings, which will prove useful to all in clinical leadership roles.
  10. Content Article
    In this episode of the What the HealthTech? podcast, Radar Healthcare's Chief Product Officer Mark Fewster speaks to Helen Hughes, Chief Executive of Patient Safety Learning. to get the lowdown on NHS England's new Patient Safety Incident Response Framework (PSIRF). Helen talks about how PSIRF is going to drive an open and just culture, what can be expected after the transition and why the implementation process is key to PSIRF's success. Listen on Spotify Listen on YouTube
  11. Content Article
    Pulmonary embolism is the third most common cause of cardiovascular death worldwide after stroke and heart attack. Although life-threatening, when diagnosed promptly survival rates are good.  This report, authored by risk expert Tim Edwards and published by Patient Safety Learning, highlights serious and widespread patient safety concerns relating to the misdiagnosis of pulmonary embolisms.  Drawing on existing data, freedom of information requests and his mother’s case, he outlines nine calls for action to improve pulmonary embolism care. 
  12. Content Article
    An expert review of the clinical records of 44 deceased patients who had been under the care of neurologist Dr Michael Watt has found there were “significant failures” in their treatment and care. Dr Watt, a former Belfast Health and Social Care Trust consultant neurologist, was at the centre of Northern Ireland’s largest ever recall of patients, which began in 2018, after concerns were raised about his clinical work. More than 4,000 of his former patients attended recall appointments. At the direction of the Department of Health, in August 2021, the Regulation and Quality Improvement Authority (RQIA) commissioned the Royal College of Physicians to undertake an expert review of the clinical records of certain deceased patients who had been under the care of Dr Watt, with the intention to understand his clinical practice, to ensure learning for others and to help make care better and safer in the future.
  13. Content Article
    The Secretary of State for Health and Social Care, Rt Hon Steve Barclay MP has announced that Dr Ted Baker has been formally appointed as the new chair of the Health Services Safety Investigations Body (HSSIB). This blog describes Dr Baker's experience and outlines what his new role will involve, including setting up the new board for HSSIB. He said, “My focus will be to build on the strong legacy of the HSIB and make sure, as the HSSIB, that we take even greater strides along our journey to improving patient safety.”
  14. Content Article
    A recently published report highlights the shortcomings in care provided by the NHS. Peter Walsh, Joanne Hughes and James Titcombe emphasise how millions could be saved if people were empowered early on to have their needs met without the need to turn to litigation
  15. Content Article
    This open letter from patient safety campaigner Richard von Abendorff calls for patients, their families and safety campaigners to help improve patient investigation and patient inclusive systems. Richard highlights a new role coming up at the new Health Services Safety Investigations Body (HSSIB).
  16. Content Article
    A complaint from a patient was made to the Scottish Public Services Ombudsman (SPSO) about the care and treatment provided during the period January 2018 to September 2021. In January 2018 the patient underwent emergency surgery for a perforated sigmoid diverticulum (a complication of diverticulitis, an infection or inflammation of pouches that can form in the intestines). An emergency Hartmann's procedure (a surgical procedure for the removal of a section of the bowel and the formation of a stoma - an opening in the bowel) was performed. In April 2018, the patient was seen in an outpatient clinic and informed it would be possible to have a stoma reversal. The patient complained that the Board had continually delayed the stoma reversal surgery which they required, which as of September 2021 had not taken place. The patient also complained that Covid-19 could not account for the delays between the Board informing patient they were ready for surgery around December 2018 and the start of the pandemic in March 2020. The patient noted that as a consequence they had developed significant complications: a large hernia. The patient added that this had severely impacted their personal life and self-esteem, and left them unable to work and reliant on welfare benefits.
  17. Content Article
    The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. In this video, Megan Pontin, Patient Safety Incident Investigator at West Suffolk NHS Foundation Trust, talks about her experience as an early adopter of PSIRF. She describes the process of engaging staff, patients and families in incident investigations, and how PSIRF enables people to share what happened from their perspective. She talks about the open way in which investigation reports are compiled and reviewed to ensure everyone involved is happy with the way events are presented.
  18. Content Article
    The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. In this video, Lucy Winstanley, Head of Patient Safety and Quality at West Suffolk NHS Foundation Trust, reflects on her trust's experience of being a PSIRF early adopter. Lucy talks about the benefits of PSIRF and how to make it work in practice. She highlights the need for effective collaboration between teams and the importance of engaging with patients, families and staff in new ways.
  19. Content Article
    Radar Healthcare has published its 'Incident Reporting in Secondary Care' whitepaper – an in-depth analysis of reporting within secondary care and its effects on patient safety. It has taken a look into the current state of incident reporting: the good work being done, the concerns across the sector, and how we can all aim to improve the situation. The report was conducted using a panel provided by SERMO from its database of UK Nurses and includes the views from 100 nursing staff members working in hospital wards across the UK. Those surveyed work with hospital in-patients daily and are responsible for reporting safety and regulatory incidents involving patients to senior colleagues.
  20. News Article
    The Care Quality Commission (CQC) has issued two fixed penalty notices to University Hospitals Birmingham NHS Foundation Trust totalling £8,000 for failing to seek consent to care and treatment of someone in their care. A 55-year-old gentleman who had diagnoses of epilepsy and autism was admitted to Good Hope Hospital in Birmingham on six occasions between 12 May 2019 and 6 October 2019. He had also been deaf since birth and communicated via British Sign Language (BSL) and lip reading. These fixed penalty notices relate to the trust’s care and treatment of the patient at Good Hope Hospital in relation to three medical procedures, which occurred in September, October and November 2019. CQC found that on these three occasions, the trust did not comply with Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, requiring registered persons to obtain the consent of the relevant person when providing care and treatment to them. Regulation 11 also states if someone is 16 or over and is unable to give consent because they lack capacity, the registered person must act in accordance with the Mental Capacity Act 2005. The three procedures where CQC found consent failures, were feeding tubes, aimed at providing nutritional support to the patient, who was struggling with food. Read full story Source: CQC, 7 October 2022
  21. News Article
    The Covid public inquiry has asked to see Boris Johnson's WhatsApp messages during his time as prime minister as part of its probe into decision-making. Counsel for the inquiry, Hugo Keith KC, said the messages had been requested alongside thousands of other documents. He said a major focus of this part of the inquiry was understanding how the "momentous" decisions to impose lockdowns and restrictions were taken. The revelations came as he set out the details of how this module will work. The inquiry is being broken down into different sections - or modules as they are being called. The preliminary hearing for module one, looking at how well prepared the UK was, took place last month. Monday marked the start of the preliminary hearing for module two, which is looking at the political decision-making. Mr Keith said this allowed the inquiry to take a "targeted approach". He said it would look at whether lives could have been saved by introducing an earlier lockdown at the start of 2020. Read full story Source: BBC News, 31 October 2022
  22. News Article
    Ministers have been urged to launch a public inquiry into the care of mental health patients after The Independent revealed allegations that patients had suffered “systemic abuse” in inpatient units. A joint investigation with Sky News found that teenagers at facilities run by The Huntercombe Group had been left with post-traumatic stress disorder by their treatment despite hundreds of warnings to regulators and the NHS. Now the government is facing calls to review all mental health care services over fears that these cases are “the tip of the iceberg”. Labour’s shadow mental health minister Dr Rosena Allin-Khan has called for a “rapid review” by the government into inpatient mental health services, while Deborah Coles, the chief executive of charity Inquest, has called on the new health secretary Steve Barclay to launch a statutory public inquiry. Read full story Source: The Independent, 28 October 2022
  23. News Article
    Children say they were "treated like animals" and left traumatised as part of a decade of “systemic abuse” by a group of mental health hospitals, an investigation by The Independent and Sky News has found. The Department of Health and Social Care has now launched a probe into the allegations of 22 young women who were patients in units run by The Huntercombe Group, which has run at least six children’s mental health hospitals, between 2012 and this year. They say they suffered treatment including the use of “painful” restraints and being held down for hours by male nurses, being stopped from going outside for months and living in wards with blood-stained walls. They also allege they were given so much medication they had become “zombies” and were force-fed. But despite reports to police and regulators dating back seven years, and findings by the Care Quality Commission (CQC) that the units were inadequate, the NHS has still handed Huntercombe nearly £190m since 2015-16 to admit children to its mental health beds. Through witness testimony, documents obtained by Freedom of Information request and leaked reports, the investigation has uncovered: The CQC has received more than 700 whistleblowing and safeguarding reports, including “incidents of concern” and several “sexual safety” concerns. NHS England was notified of 195 safeguarding reports between 2020 and 2021. A 2018 internal report at Meadow Lodge hospital in Newton Abbot (now closed) found staff members using sexually inappropriate language in front of patients. 160 reports investigated by Staffordshire police about Huntercombe Staffordshire between 2015 and 2022. Between March 2021 and 2022, the CQC gave permission for 29 patients to be admitted to Maidenhead hospital after it was placed in special measures. Read full story Source: The Independent, 27 October 2022
  24. News Article
    About 4,000 UK victims of the infected blood scandal are to receive interim compensation payments of £100,000 by the end of this month. It is being paid to those whose health is failing after developing blood borne viruses like hepatitis and HIV. It is also being paid to partners of people who have died. Conan McIlwrath, from Larne in County Antrim, who is among the 100 or so victims affected in Northern Ireland said it was "very much welcomed". "This is the first compensation that's ever been paid - anything prior has been support," he told BBC News NI. All victims have campaigned for actual 'compensation' as they have said only this would acknowledge decades of physical and social injury, as well as loss of earnings and the cost of care. Read full story Source: BBC News, 22 October 2022
  25. News Article
    A quarter of services the Care Quality Commission has recently inspected required enforcement action from the regulator, its chief executive has revealed. Speaking at the launch of the regulator’s annual State of Care report, Ian Trenholm called for a “long-term, sustainable funding solution” from the government to aid a service that was ”genuinely struggling to cope”. Mr Trenholm said “about a quarter of the services” the CQC has inspected in 2022 had resulted in it having to take “enforcement action”. Examples of action taken against NHS trusts in the last year included enforcement measures placed on Nottingham University Hospitals, University Hospitals Sussex, and Princess Alexandra Hospital. In response to a question from HSJ about the robustness of the CQC’s inspection regime following further care quality and safety scandals, Mr Trenholm said observers should not focus solely on the ratings given to trusts by the CQC as there was a lot ”work going on in the background, whether that’s enforcement or otherwise”. He added the CQC had significantly increased the amount of information it was gathering in relation to concerns about services. Read full story Source: HSJ, 21 October 2022
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