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News Article76 people were unintentionally exposed to ionising radiation in Irish hospitals in 2020, according to the Health and Information Quality Authority (HIQA). This figure represents an 11% increase on the total reported in 2019. HIQA today published an overview report on the 'increase in accidental and unintended exposure to ionising radiation events notified to HIQA in 2020. Under the European Union (Basic Safety Standards for Protection against dangers arising from Medical Exposure to Ionising Radiation) Regulations 2018 and 2019, HIQA is the competent authority for patient protection in relation to medical exposure to ionising radiation in Ireland. In its 2019 report — its first such publication — HIQA expressed hope that the areas of improvement it identified "would help reduce the likelihood of such events and drive quality improvements in safety mechanisms for medical exposures in Ireland." Despite this, eight more accidental exposure incidents were recorded in 2020 than in the previous year. Human error was identified as the main cause of accidental exposure in 58% of the incidents, however, HIQA determined that other factors likely contributed to these. Some 34% of the incidents involved the wrong patient being exposed to ionising radiation. HIQA said these exposures occurred at varying points along the medical exposure pathway. It stressed that the number of unintended exposure to ionising radiation incidents last year was small compared with the total number of procedures carried out, estimated to be in the region of three million. Read full story Source: Irish Examiner, 15 September 2021
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News Article
Pandemic changes affected maternity care for women who had stillbirths
Patient Safety Learning posted a news article in News
Changes to maternity services during the pandemic, including the mandatory redeployment of midwives and doctors to care for infected patients, may have affected the care given to women who had stillborn babies, a Healthcare Safety Investigation Branch (HSIB) investigation has found. The safety watchdog launched an investigation after the number of stillbirths after the onset of labour increased between April and June 2020. During the three months there were 45 stillbirths compared to 24 in the same period in 2019. The HSIB launched a probe examining the care of 37 cases. Among its findings the watchdog said staffing levels were affected because of the NHS response to the pandemic. In its report it said this “influenced normal work patterns and the consistency and availability of clinicians.” As an example, in one maternity unit the staffing numbers were short by three midwives due to sickness and redeployment. In another consultant presence was reduced overnight. During the pandemic both the Royal College of Midwives and the Royal College of Obstetricians criticised NHS trusts for redeploying maternity staff when mothers continued to need services regardless of the pandemic. HSIB said none of the women in its report were recorded as having the virus, but it found the pressures and changes as a result of the pandemic may have affected the care they received. The study stressed that the proportion of consultations undertaken remotely was not known and "the impact of remote consultations is not clear from this review". Read full story Source: The Independent, 16 September 2021 -
News ArticleFailures by a health board led to eight cancer patients not being appropriately monitored or included in treatment targets after being referred to England, the ombudsman has found. Of the 16 patients on Wale's Betsi Cadwaladr health board's prostatectomy waiting list in August 2019, eight were referred to England for treatment. None of those treated in England met the health board's targets. The health board, which covers north Wales, has apologised to the patients. It said it had accepted the findings of the report and agreed to implement its recommendations. The investigation was launched after a report into the case of a prostate cancer patient raised suspicion there were further incidents. Public Services Ombudsman for Wales Nick Bennett said: "Clearly there's consequences for any type of cancer treatment, where people who are treated in England do not receive the same monitoring, do not receive the same harm reviews... "Going forward, this must never happen again." Read full story Source: BBC News, 9 September 2021
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News ArticleThe deaths of three adults with learning disabilities at a failed hospital should prompt a review to prevent further "lethal outcomes" at similar facilities, a report said. The report looked at the deaths of Joanna Bailey, 36, and Nicholas Briant, 33, and Ben King, 32, between April 2018 and July 2020. It found here were significant failures in the care of the patients at Jeesal Cawston Park, Norfolk. Ms Bailey, who had a learning disability, autism, epilepsy and sleep apnoea, was found unresponsive in her bed and staff did not attempt resuscitation, while the mother of Mr King said he was "gasping and couldn't talk" when she last saw him. Mr Briant's inquest heard he died following cardiac arrest and obstruction of his airway after swallowing a piece of plastic cup. The report found: "Excessive" use of restraint and seclusion by unqualified staff. Concerns over "unsafe grouping" of patients. Overmedication of patients. High levels of inactivity and days of "abject boredom". Relatives described "indifferent and harmful hospital practices" and said their questions and "distress" were ignored Joan Maughan, who commissioned the report as chairwoman of the Norfolk Safeguarding Adults Board, said: "This is not the first tragedy of its kind and, unless things change dramatically, it will not be the last." Read full story Source: BBC News, 9 September 2021
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News Article
Healthy baby terminated by hospital in mix-up with sick twin
Patient Safety Learning posted a news article in News
Doctors at a hospital in Birmingham mistakenly terminated a healthy unborn baby in a procedure instead of its sickly twin. The unidentified mother decided to abort one of the fetuses because it was suffering from restrictive growth, which increases the chances of stillbirth and puts the healthy baby at risk. During the procedure at Birmingham Women's and Children's NHS Foundation, surgeons accidentally terminated the wrong twin. The 2019 incident emerged in a Freedom of Information Act survey of hospital blunders. Dr Fiona Reynolds, chief medical officer at Birmingham Women's and Children's NHS Trust, said: "A full and comprehensive investigation was carried out swiftly after this tragic case and the findings were shared with the family, along with our sincere apologies and condolences." "The outcome of that thorough review has led to a new protocol being developed to decrease the likelihood of such an incident happening again." Read full story Source: The Independent, 6 September 2021 -
News ArticleThe family of a senior medic and lifelong NHS campaigner have called for an investigation into his death as it took paramedics more than half an hour to arrive at his home after operators were told he was suffering a cardiac arrest. Professor Kailash Chand, a former British Medical Association deputy chair, had complained of chest pains before one of his neighbours, a consultant anaesthetist at Manchester Royal Infirmary, called 111 for help before telling the call handler within three minutes that he believed his friend was having a cardiac arrest. “I was answering their questions when Kailash’s eyes began rolling and he slipped into unconsciousness. That’s when I said ‘this looks like a cardiac arrest’ and to upgrade the call. They kept asking questions as I started CPR and asked for an urgent ambulance. That was two or two and a half minutes into the call." Evidence seen by i News shows that it took another 30 minutes after the neighbour told the operator about the cardiac arrest for the paramedics to arrive at Professor Chand’s flat in Didsbury, Greater Manchester. National standards for ambulance trusts show that ambulance trusts must respond to category 1 calls – those that are classified as life-threatening and needing immediate intervention and/or resuscitation, such as cardiac or respiratory arrest – in 7 minutes on average, and respond to 90% of Category 1 calls in 15 minutes. Read full story Source: iNews, 3 September 2021
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News ArticleA review into the work of a locum consultant radiologist has so far identified "major discrepancies" affecting 12 cases. A full lookback review of 13,030 radiology images was launched last month. The doctor worked at hospitals run by the Northern Health Trust between July 2019 and February 2020. The review steering group chair said it was "images in levels one and two that we are most concerned about". "To date there are 12 level ones and twos [approximately 0.5% of the total number reviewed]," said Dr Seamus O'Reilly, the Northern Trust medical director. "Most of these concern CT scans where inaccurate initial reading of the scans could, or is likely to, have had an impact on the patient's clinical treatment and outcome." More than 9,000 patients have been contacted as part of the review, which is looking at radiology images taken in Antrim Area, Causeway, Whiteabbey and Mid Ulster Hospitals as well as the Ballymena Health and Care Centre. Read full story Source: BBC News, 28 July 2021
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News ArticleThe boss of a NHS trust that asked hospital staff for fingerprints and handwriting samples as it hunted a whistleblower is stepping down. Dr Stephen Dunn will leave West Suffolk NHS Foundation Trust in the summer after seven years as chief executive. An independent inquiry into the way management handled the affair is expected to report in the autumn. In 2018, Jon Warby received a letter two months after the death of his wife, Susan. It claimed mistakes were made during her bowel surgery. An inquest into her death was subsequently told how she had been given glucose instead of saline fluid via an arterial line. The Doctors' Association described the hospital's attempt to find the author of the letter a "witch-hunt". A subsequent Care Quality Commission (CQC) inspection said the way internal investigations had been conducted by the hospital was "unusual and of concern". Read full story Source: BBC News, 28 July 2021
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News ArticleThe Care Quality Commission may in future be notified when ‘secretive’ external reviews have looked at patient safety issues within trusts. Last summer, HSJ revealed guidance for trusts to publish summaries of royal colleges’ reviews was being widely ignored, with some even failing to inform the CQC. A recent BBC Panorama programme has again raised the issue, with Academy of Medical Royal Colleges chair Helen Stokes-Lampard saying she was “dismayed” the body’s guidance was not being followed. But she has now told HSJ of “advanced discussions” with the CQC about changes which would see the royal colleges routinely inform the regulator when reviews raise patient safety issues. Read full story (paywalled) Source: HSJ, 3 June 2021
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News ArticleA second “mutilated” patient left with life-changing injuries after botched hospital surgery has described how she was left in urine-soaked bed sheets for days by nurses who called her lazy when she was unable to get out of bed. Lucy Wilson told The Independent she believes she would have been better looked after at a veterinary practice compared to the level of care she received from nurses at Norfolk and Norwich Hospital Trust in January last year. She was one of three patients harmed by surgeon Camilo Valero in the same week and almost died after Dr Valero and other staff failed to recognise her life-threatening injuries following the operation to remove her gall bladder. Dr Valero is under investigation by the General Medical Council but is still practising under supervision at the trust, which has refused to say whether the third patient survived their ordeal. After requests by The Independent, bosses at the NHS trust have now committed to publishing details of a secret review carried out by the Royal College of Surgeons into Dr Valero’s work and the wider surgical services at the trust. Read full story Source: The Independent, 31 May 2021
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News Article
Cumberland Infirmary patient 'dropped' from operating table dies within weeks
Patient Safety Learning posted a news article in News
A woman has died after being "dropped" on the floor during surgery on her hip, which she had broken while in hospital. Jeannette Shields, 70, had been receiving treatment for gall stones in Cumberland Infirmary in Carlisle. North Cumbria Integrated Care NHS Trust said an investigation was under way "in relation to an incident involving a patient in one of our theatres". Mrs Shields' husband, John, said he told the hospital he would not be "pushing this thing under the carpet". His wife left her bed to go to the toilet by herself after getting no response to her buzzer, Mr Shields said. She felt dizzy, fell and broke her hip, he told the BBC. Two days later she had surgery to repair it, after which the hospital called Mr Shields to say the operation had been successful but that "unfortunately they dropped her off the operating [table] after the surgery", he said. "Then they had to use the sliding board to pick her up and rush her in and do scans on her," he said. "She had a great big bump on the back of her head and she just deteriorated and then she just passed away, just died. It is not clear what happened or how Mrs Shields ended up falling from the operating table. Read full story Source: BBC News, 28 May 2021 -
News ArticleSerious patient safety concerns have been raised about a third major specialty at a struggling acute trust, with inspectors also flagging wider leadership issues. The Care Quality Commission (CQC) has issued an immediate warning notice in relation to the stroke service at University Hospitals of Morecambe Bay Foundation Trust, following an inspection earlier this month. A full report will be published later this year, but the immediate issues have been outlined within various documents published ahead of the trust’s board meeting on 26 May. According to a summary within the papers, the CQC warning notice has flagged “a range of incidents… identifying poor care that requires investigation”, governance concerns around the grading of incidents, poor levels of training and competencies, and worrying delays around administering thrombolysis. The problems were predominantly found at Royal Lancaster Infirmary. Read full story (paywalled) Source: HSJ, 25 May 2021
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News Article“Human error” resulted in a man having the wrong leg amputated at a major Austrian hospital. The error occurred when a healthcare employee marked the wrong leg for amputation during pre-surgical procedures. The mistake was not noticed anytime during the surgery, or even during the immediate postoperative period. It was recognised during a routine wound dressing change, about 48 hours postoperatively. “A disastrous combination of circumstances led to the patient’s right leg being amputated instead of his left,” the hospital’s statement said. “We would also like to affirm that we will be doing everything to unravel the case, to investigate all internal processes and critically analyze them. Any necessary steps will immediately be taken.” Read full story Source: Lansing Injury Law News, 24 May 2021
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News Article
Contaminated blood inquiry: Matt Hancock to give evidence
Patient Safety Learning posted a news article in News
The health secretary will face questions about compensation for victims of the contaminated blood scandal on Friday afternoon. Matt Hancock will give evidence at a public inquiry into what's been called the worst NHS treatment disaster. Around 3,000 people have died after being given blood containing HIV and hepatitis C in the 1970s and 1980s. Ministers announced a public inquiry into the scandal in 2017 after decades of campaigning by victims and their families. Nearly 5,000 people with the blood disorder haemophilia were infected with potentially fatal viruses after being given a clotting agent called Factor VIII. Much of the drug was imported from the US, where prisoners and other at-risk groups were often paid to donate the plasma used to make it. Victims included dozens of young haemophiliacs at a boarding school in Hampshire who died after contracting HIV as a result. Tens of thousands more victims may have been exposed to viral hepatitis through blood transfusions after an operation or childbirth. Read full story Source: BBC News, 21 May 2021 -
News Article
Baby death raises questions over maternity care
Patient Safety Learning posted a news article in News
Beth and Dan Wankiewicz want answers about why their baby son Clay died last year, shortly after his birth at Doncaster Royal Infirmary. Despite a low-risk pregnancy, the family say Clay died from multiple skull fractures. Doncaster and Bassetlaw NHS Foundation Trust said "the provision and delivery of high-quality" care is a priority. The BBC has found a 2016 review flagging concerns about the hospital's maternity care was never published. The report - one of scores of unpublished reports discovered by a Freedom of Information request by BBC's Panorama programme - highlighted significant patient safety concerns. Beth Wankiewicz was admitted to hospital last July, but after a day of labour her baby had still not been born. With no consultant doctor on site, a junior doctor made two attempts to deliver the baby with forceps, after getting advice on the phone. Father, Dan, remembers the second attempt with forceps being much more vigorous "which was a bit of a shock". The family say there was a further delay before they had a Caesarean section. Their baby had to be pushed back up the birth canal into the womb for the C-section to be performed. "I think after about 10 minutes, we both looked at the clock, and we said it's not looking good," said Dan. Around 20 minutes after their son was born, despite attempts to resuscitate him, they were told he had died. The following day they say a midwife told them she was being pressurised by other staff to say Clay had been stillborn, but she was sure he had been born alive, and she had heard a heartbeat. The family now believe this was to avoid scrutiny and the need for a coroner's inquest, which doesn't happen with still births. Read full story Source: BBC News, 19 May 2021 -
EventNote: this conference has been rescheduled from the 14 September 2022. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts and will reflect on learning from deaths. There will be a focus on mortality review during the Covid pandemic and how mortality investigation should be managed in these cases. The conference will discuss the role of Medical Examiners in learning from deaths which is now being extended to all non-coronial deaths wherever they occur. The conference will also update delegates on the New National Patient Safety Incident Response Framework including sharing experience from an early adopter site. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-and-learning-from-deaths-in-nhs-trusts or email nicki@hc-uk.org.uk hub members can receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #LFDNHS
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Root Cause Analysis: 1 day masterclass
Patient Safety Learning posted an event in Community Calendar
This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. The course pays particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. We advocate Root Cause Analysis as a team-based approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/root-cause-analysis-1-day-masterclass or email kate@hc-uk.org.uk. We are pleased to offer hub members a 20% discount. Please email info@pslhub.org for the code. -
Event
Root Cause Analysis: 1 day masterclass
Patient Safety Learning posted an event in Community Calendar
This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. The course pays particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. We advocate Root Cause Analysis as a team-based approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/root-cause-analysis-1-day-masterclass or email kate@hc-uk.org.uk. We are pleased to offer hub members a 20% discount. Please email info@pslhub.org for the code. -
EventThis national conference looks at the practicalities of Serious Incident Investigation and Learning from Deaths in Mental Health Services. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework). NHS Improvement is working with these early adopters to test implementation, and analysis of this will inform the final version with the revised framework due in Spring 2022. Local systems and organisations outside of the early adopter areas are free to use the already published version of the PSIRF to start to plan and prepare for PSIRF’s full introduction. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement, and updates from PSIRF early adopter sites in mental health. The conference will also examine how the new framework will fit with the Royal College of Psychiatrists Care Review Tool for mortality review. This conference will enable you to: Network with colleagues who are working to improve the investigation of serious incidents and deaths in mental health services. Ensure your approach to Serious Incident Investigation is in line with the Patient Safety Incident Response Framework (PSIRF). Learn from outstanding practice in implementing the Royal College of Psychiatrists Mortality Care Review Tool. Reflect on the lived experience of a bereaved relative. Improve the way you involve and engage families and carers in the investigation process. Develop your skills in incident investigation and mortality review. Understand how you can improve serious incident investigation and learn from Mental Health early adopters of the New Patient Safety Incident Response Framework. Identify key strategies for undertaking a self assessment, and continuous review of deaths and investigation practice in your organisation. Understand how human factors can help improve learning from serious incident investigation. Ensure you are up to date with the role of the coroner. Understand how you can better support staff when a serious incident occurs. Self assess and reflect on your own practice. Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register
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EventThis conference, chaired by Simon Hammond Director of Claims Management NHS Resolution will update clinicians and managers on Clinical Negligence with a particular focus on current issues and the Covid-19 pandemic and the impact on clinical negligence claims. Featuring leading legal experts, and experienced clinicians the event will provide an update on current claims the conference will discuss why patients litigate, and responding to claims including claims regarding Covid-19. There will be an extended masterclass on trends in clinical negligence claims and responding to claims followed by an extended focus on maternity claims, and also claims related to medication error. The conference will close with a case study on the advantages of bringing together complaints, claims and patients safety investigation, and practical experiences of Coronavirus complaints at claims at an NHS Trust – including understanding the standard of care on which services should be judged, and a final session on supporting clinicians when a claim is made against them. For further information and to book your place visit: https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/clinical-negligence or email nicki@hc-uk.org.uk We are delighted to offer 3 free places for hub members. Email info@pslhub.org for the discount code. Follow on Twitter @HCUK_Clare #clinicalnegligence
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EventuntilThis seminar is hosted by the Yorkshire Quality and Safety Research Group and hosted by Professor Jane O'Hara from the University of Leeds. Understanding what happens when things go wrong in healthcare remains the cornerstone of patient safety policy globally. Organisations want, and need, to learn about safety failures in order to try and reduce the likelihood of similar events happening in the future. Patients and families also want to prevent future recurrence of safety failures. On the face of it, engaging with patients and families in serious incident investigations seems like an obviously important aim, and perhaps one that should be relatively straightforward to achieve. However, despite a range of policy directives for involving patients and families in the process of investigating serious safety failures, the practice of involvement remains variable. This webinar will present findings from a programme of work funded by the National Institute for Health Research, which has developed, and is now testing, new guidance for engaging patients and families in serious incident investigations. I will discuss what patients and families want from incident investigations, and how this has shaped our co-design of the new guidance. I will also consider how sometimes, different understandings of what justice might mean for responses to safety failures, can lead to problems for organisations, staff and patients and families. I will propose that involvement of patients and families is a deceptively simple endeavour, and that without careful articulation of what different stakeholders want and need following safety failures, we can compromise organisational learning, and most importantly, risk compounding the harm for those affected. Biography Jane O’Hara is Professor of Healthcare Quality and Safety, based within the School of Healthcare, University of Leeds, UK. She is Deputy Director of the Yorkshire Quality and Safety Research Group, and theme lead for the Patient Involvement in Patient Safety theme within the NIHR Yorkshire & Humber Patient Safety Translational Research Centre. Jane also holds a Visiting Professor position at the SHARE Centre for Resilience in Healthcare at the University of Stavanger, Norway. Register for this event. If you have questions about this event, please contact the seminar organisers Siobhan McHugh or Helen Smith.
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EventThis national conference looks at the practicalities of Serious Incident Investigation and Learning. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) a version of which has now been published and which is being tested in early adopter sites. NHS Improvement is working with these early adopters to test implementation, and analysis of this will inform the final version. Local systems and organisations outside of the early adopter areas are free to use the already published version of the PSIRF to start to plan and prepare for PSIRF’s full introduction from Spring 2022. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/serious-incident-investigation-patient-safety or email kate@hc-uk.org.uk Follow on Twitter @HCUK_Clare #NHSSeriousIncidents hub members can receive a 20% discount. Email info@pslhub.org discount code.
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Investigation and learning from deaths in NHS Trusts
Sam posted an event in Community Calendar
The National Guidance on Learning from Deaths has driven a strengthening of systems of mortality case review with emphasis on learning. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts and will reflect on learning from deaths during the Covid pandemic and how mortality investigation should be managed in these cases. The conference will discuss the role of Medical Examiners in learning from deaths which is now being extended to all non-coronial deaths wherever they occur. This conference will also update delegates on the New National Patient Safety Incident Response Framework including sharing experience from an early adopter site. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-and-learning-from-deaths-in-nhs-trusts or email kate@hc-uk.org.uk Follow the conference on Twitter @HCUK_Clare #CQCDeathsreview hub members receive a 20% discount. Email info@pslhub.org for discount code. -
EventThis Westminster Forum conference will be an important opportunity to examine the next steps for improving patient safety in the NHS in the context of the ongoing pandemic, the updated Patient Safety Strategy, and the MHRA consultation launched to improve patient safety and regulation around medical devices. Delegates will also discuss priorities in the context of the Health and Care Bill, which includes measures aiming to strengthen the role of the Healthcare Safety Investigation Branch (HSIB) in improving patient safety. Key areas for discussion include: system learning - assessing approaches, sharing best practice, supporting the workforce, education and training, and building a learning culture patient involvement - examining priorities for involving patients and the public within patient safety regulation - options for a more flexible and adaptable approach clinical negligence - how best to improve the negligence system the role of the HSIB - including its scope going forward and informing whole system learning COVID-19 - looking at what has been learned for patient safety and how best to drive improvements in recovery from the pandemic and into the future. Register
