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Found 1,565 results
  1. News Article
    The Health and Social Care Select Committee have commissioned an Expert Panel to consider the Government’s progress against accepted recommendations from public inquiries and reviews on patient safety. The Panel will consider a range of recommendations made by public inquiries and reviews on both patient safety and whistleblowing and subsequently select a number of these for evaluation. The Panel will in its final report provide a rating of the Government’s progress against each of these recommendations. Panel members are: Professor Dame Jane Dacre (Chair). Sir Robert Francis KC Anita Charlesworth Professor Stephen Peckham Sir David Pearson Professor Emma Cave Read full story Source: House of Commons Health and Social Care Select Committee, 24 October 2023
  2. Content Article
    This is the first report of a national confidential enquiry specifically focussed on child deaths. Confidential enquiries have already contributed to major improvements in obstetrics, neonatal, and perioperative care in the UK. However they are time consuming and require extensive collaboration between various professional groups as well as the attention of a dedicated full-time research team. Hence, when planning a confidential enquiry in a new patient group, it is pertinent to investigate both feasibility and utility at its outset. The aim of this enquiry was to evaluate the feasibility of using this methodology to reduce the number of child deaths and make a significant contribution to child health in the UK. The basic functions of a confidential enquiry are: To develop and maintain a register of the cases under scrutiny. To subject cases in the register (or a specific sample of them) to review by a panel of experts with a focus on identifying avoidable factors where there have been adverse outcomes. Subsequent recommendations are then derived from both the analysis of the register and the conclusions of the expert review panels. This report presents the findings of a feasibility study “The Child Death Review” in which confidential enquiry methodology was applied to child deaths (28 days to 17 years 364 days) occurring in three regions of England, all of Wales and Northern Ireland in the calendar year 2006. A surveillance programme was mounted in order to determine where and when deaths occurred. A comprehensive core dataset was developed and then collected on all deaths. A sample, designed to have an even spread across age groups and the geographical areas involved, was then subjected to more detailed enquiry. This involved scrutiny of the available records by a multidisciplinary panel in each case.
  3. Content Article
    Carl Heneghan discusses the role of modelling in the Covid-19 pandemic.
  4. News Article
    Lessons still have not been learned at a Kent hospital trust which was criticised in a damning report, a mother has said. Dr Bill Kirkup's review found at least 45 babies might have survived with better care at East Kent NHS hospitals. Victoria, whose six-year-old daughter needs 24-hour support, said: "I've had no contact from anyone from the trust." Her case was one of 202 that were examined by Dr Kirkup in his report, which was published exactly a year ago. Victoria, whose daughter is living with the consequences of failings in her care during her birth, said: "Our children have become unwell because of what has happened to them. "I don't feel lessons have been learned whatsoever. "Treatment hadn't been made available as easily as it should have done for children that are still living this experience every day." Read full story Source: BBC News, 19 October 2023
  5. Content Article
    The Thirlwall Inquiry has been set up to examine events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital. This document sets out the terms of reference for this inquiry, following an engagement process led by the inquiry’s independent chair, Lady Justice Thirlwall, with the affected families and other stakeholders.
  6. News Article
    The boss of Britain’s biggest medicines courier has been told to urgently improve its complaints system by the NHS ombudsman amid concerns patients let down by missing deliveries are repeatedly ignored. In a highly unusual development, Darryn Gibson, the chief executive of Sciensus, has received a written warning from Rob Behrens, the parliamentary and health service ombudsman (PHSO). It says patients “should not be ignored” and must be “listened to and taken seriously” or he will consider taking further action. The PHSO investigates complaints that have not been resolved by the NHS or by private providers of NHS care. Sciensus is the single largest provider of homecare medicines services to the NHS and has contracts worth millions of pounds. In an email seen by the Guardian, Behrens told Gibson he had been unable to investigate most reports received about Sciensus because patients had not been able to complete the company’s complaints process. “That is not acceptable or fair to complainants,” Behrens wrote. In a statement, Sciensus said it worked “very hard” to ensure NHS patients received their medicines on time. Its services had “a 95% satisfaction rating”, it added. The move follows a Guardian investigation that exposed how Sciensus put NHS patients at risk of harm with delayed, missed or botched deliveries of medicines for conditions including cancer, heart disease, diabetes, dementia and HIV. It also uncovered how patients’ alarm at vital drugs and medical devices not arriving at their home was often compounded by a struggle to reach Sciensus to complain and fix the problems. Read full story Source: The Guardian, 19 October 2023
  7. News Article
    Financial directors need to take responsibility for safety, which should be at the core of how the NHS runs services, the leadership of the Health Services Safety Investigations Body (HSSIB) said at its launch Wednesday. The Healthcare Safety Investigation Branch is now an independent body – and has been renamed HSSIB – although maternity investigations are hosted by the Care Quality Commission. Questioning how many finance directors across the NHS take responsibility for safety, HSSIB’s interim chief investigator Rosie Benneyworth said: “We need a position where finance directors in every organisation are as responsible for safety as the person leading the safety agenda and vice versa, the safety person works with the finance agenda to support them. “Often you see the finance director and safety lead don’t work effectively together and we need to change that.” Dr Benneyworth said progress will not be made unless operational delivery, financial delivery and safety are tackled “in the same breath”. HSSIB’s new chair Ted Baker also called for safety to become a core part of running services “in the way running the accounts is”, as it is currently still seen “as an add-on”. He stressed that safety “drives efficiencies, enables innovation and saves costs”. Read full story (paywalled) Source: HSJ, 19 October 2023
  8. Content Article
    Healthcare is starting to embrace a shift towards Just Culture. In England, the new Patient Safety Incident Response Framework (PSIRF) prioritises respect, compassion, and systemic improvements. The potential benefits of this, and other initiatives, are significant, as Suzette Woodward reports
  9. Content Article
    Safety Management Systems (SMSs) are an organised approach to managing safety which are widely used in different industries. In this report, the Health Services Safety Investigations Body (HSSIB) identifies the requirements for effective SMSs, how these are used in other safety-critical industries and considers the potential of application of this approach in healthcare. It makes safety recommendations for NHS England and the Care Quality Commission in relation to this. See also HSSIB's video Introduction to safety management systems.
  10. News Article
    High use of agency staff contributed to the care failings exposed at a mental health trust by undercover reporters, an internal inquiry has found. Essex Partnership University Trust was at the centre of a Channel 4 documentary last year which raised concerns over care, including the use of restraints and patient observations. The trust initially refused to release the final report after a freedom of information request by HSJ, but has now released a redacted version on appeal. The report identified a number of concerns in relation to patient and staff safety, saying factors that contributed to these concerns included high usage of temporary staff and high patient acuity on the two acute mental health wards recorded. The internal inquiry looked into allegations of the inappropriate use of restraints raised in the documentary. This section, which contained redactions, found restraint was taught to be used as a last resort, but suggested high temporary staffing levels and a “lack of confident and adequately skilled staff” contributed to guidance not being followed. Another concern was around staff sleeping on duty and the use of mobile phones during patient observations. The internal inquiry found there was an “absence of visible leadership and role modelling” to ensure this did not happen during clinical practice. Read full story (paywalled) Source: HSJ, 17 October 2023
  11. News Article
    An ambulance trust has apologised after a patient who was declared "dead" later woke up in hospital. As first reported by The Northern Echo, the individual was taken by paramedics to Darlington Memorial Hospital on Friday. The newspaper reported they had been declared dead following an incident earlier that day. The North East Ambulance Service (NEAS) apologised to the patient's family and said an inquiry had begun. The patient has not been identified or their current condition revealed. NEAS director of paramedicine Andrew Hodge said: "As soon as we were made aware of this incident, we opened an investigation and contacted the patient's family. "We are deeply sorry for the distress that this has caused them. "A full review of this incident is being undertaken and we are unable to comment any further at this stage. "The colleagues involved are being supported appropriately and we will not be commenting further about any individuals at this point." Read full story Source: BBC News, 17 October 2023
  12. News Article
    The mother of a patient at Muckamore Abbey Hospital has described how her son contracted tuberculosis (TB) while at the hospital. She said he had been left severely disabled after a series of associated strokes. Patient P116 is now 40 years old and has suffered from severe epilepsy since he was a baby. His mother told the inquiry into abuse at the hospital that her concerns over her son's health were ignored. She said that even after he began developing symptoms - including losing six stone (38kg) of weight - staff seemed "not to care". In the end, he was only diagnosed with TB after his mother took him to hospital herself. Due to the delay in the diagnosis and the way the family's complaint was handled, a serious adverse incident review was carried out and P116's mother received a letter of apology from the then permanent secretary at the Department of Health, Richard Pengelly, and Theresa Villiers, who was Northern Ireland secretary at the time. His mother told the inquiry her son's time in Muckamore remained a "major trauma" for the family and she still found it very difficult to talk about. She told the inquiry she felt strongly that "independent expert support" should be given to patients abused or neglected in Muckamore, including specialist counselling for the patients and their families. Read full story Source: BBC News, 12 October 2023
  13. News Article
    Three patients have died after being given a bowel test by a doctor who failed to ensure treatment needed was carried out, a health board has said. NHS Greater Glasgow and Clyde (NHSGGC) said three more patients suffered harm. The six patients were identified in a clinical review the health board carried out of 2,700 people the consultant carried out a colonoscopy on between 2020 and 2022. The consultant, who has not been named, was suspended in November 2022 and has since left the health board. NHSGGC deputy medical director Professor Colin McKay said: “We would like to offer our sincere apologies to patients who were not followed up appropriately and our condolences to the families of those patients who have died." “Our investigations found that the doctor did not consistently follow up the results of investigations that had been completed or requested and therefore missed the opportunity for patients to be treated, including a number of patients who went on to develop malignancy." Read full story Source: The Independent, 11 October 2023
  14. Content Article
    Richard von Abendorff, an outgoing member of the Advisory Panel of the Healthcare Safety Investigation Branch (HSIB), has written an open letter to incoming Directors on what the new Health Services Safety Investigations Body (HSSIB) needs to address urgently and openly to become an exemplary investigatory safety learning service and, more vitally, how it must not contribute to compounded harm to patients and families. The full letter is attached at the end of this page.
  15. Content Article
    In this article for the Journal of Patient Safety, Alan Card from the Department of Pediatrics at the University of California, argues that the purpose of patient safety work is to reduce avoidable patient harm, and this requires us to slay dragons—to eliminate or at least mitigate risks to patients. He expresses the view that current practice focuses almost exclusively on investigating dragons—tracking reports on the number and type of dragons that appear, how many villagers they eat and where, whether they live in caves or forests and so on. He argues that while information about risks is useful to the extent that it informs effective action, it does nothing to make patients safer by itself: "We cannot investigate a dragon to death. No more can we risk assess our way to safer care."
  16. Content Article
    Lewis Chilcott was 23 years old when he died at Royal Sussex County Hospital in Brighton. In this blog, his father Simon describes what happened to Lewis and how his family was treated by the hospital following Lewis’s death. Simon continues to call for greater transparency in the investigation process and improvements to the way hospitals engage with bereaved families.
  17. News Article
    The UK’s largest mental health charity, Mind, has published previously unseen data laying bare the full scale of the emergency in mental healthcare, with staff reporting 17,340 serious incidents in 12 months. The Care Quality Commission (CQC) figures shows mental healthcare staff across England reported an incident two times every hour in the last year, where people are treated for issues including self-harm, eating disorders and psychosis. Incidents included: injuries to patients that caused likely long term sensory, movement or brain damage, or physically damaged their body prolonged physical pain or psychological harm, or shortened life expectancy cases of abuse, including those involving the police injuries for which the patient needed treatment to prevent them dying. All of these incidents involved care providers raising concerns with the CQC under their statutory duty under Regulation 18. Dr Sarah Hughes, Chief Executive of Mind, says: “It is deeply worrying that healthcare staff across the country are so concerned about the situation in mental health settings that they are reporting a serious incident once every half an hour. We knew this was a crisis – now we know the scale of this crisis. People seek mental healthcare to get well, not to endure harm. Families are being let down by a system that’s supposed to protect their loved ones when they are most sick. The consequences can be and have been fatal". Read full story Source: Mind, 10 October 2023
  18. News Article
    An NHS hospital has been accused of posing a continuing risk to patients by “covering up” leadership failures, including not properly investigating the deaths of two babies. Dr Max Mclean, chairman of Bradford Teaching Hospitals trust, has quit in protest at the conduct of the trust’s chief executive, Professor Mel Pickup, after no action was taken over serious concerns about her performance. In a blistering resignation letter, Mclean said he “cannot, in good conscience, work with a CEO who has fallen so short of the standards expected of her role that there is a genuine safety risk to patients and colleagues”. He is calling for senior national NHS figures to establish new leadership at the trust, and has written to the head of NHS England to share his concerns about Pickup, who has been in post since 2019. Mclean told The Times there were parallels with the Lucy Letby scandal, when management ignored the concerns of whistleblowers. “Patients are at risk, babies are at risk, and there could be avoidable deaths unless there is a change of leadership,” he said. The former detective chief superintendent who has chaired the trust since 2019, raised nine serious issues about Pickup’s performance, which he said were confirmed by an independent investigation that concluded last month. However, the trust’s board met on October 2 and decided there would be no further action against Pickup, leaving Mclean with “no option” but to resign and speak publicly. Read full story (paywalled) Source: The Times, 10 October 2023
  19. Content Article
    Full opening statement of the Long Covid groups (Long Covid Support, Long Covid SOS and Long Covid Kids) to Module 2 of the Covid-19 Inquiry as representative organisations for nearly 2 million adults and children who have suffered from Long Covid.
  20. News Article
    Two healthcare workers who exchanged vile texts while needless drugging sick people to ‘keep them quiet’ have been found guilty of ill-treating patients. Senior nurse Catherine Hudson, 54, was found to have regularly tranquillised patients unnecessarily for her own amusement and to have an ‘easy’ shift. While Charlotte Wilmot, 48, an assistant practitioner, wrote vile texts encouraging her to carry out the dangerous acts, with complete disregard for the consequences. Preston Crown Court heard the pair worked on the stroke unit at Blackpool Victoria Hospital and had carried out needless sedations between 2017 and 2018. Restrictions on prescription drugs were so lax in the stroke unit that staff would help themselves and self-medicate or steal drugs to supply to others, the court heard. Drugs such as Zopiclone, a powerful medicine used to treat insomnia, were often stolen and used to drug multiple patients. Police launched an investigation in November 2018 after a student nurse raised concerns about the treatment of patients in the stroke unit. A number of staff members were arrested during the course of the investigation and their mobile devices were seized. Read full story Source: The Independent, 6 October 2023
  21. News Article
    The NHS ombudsman has told a health trust chief to withdraw “not accurate” remarks about him amid an alleged attempt to play down up to 1,000 avoidable patient deaths. Rob Behrens wrote to Stuart Richardson, the head of the Norfolk and Suffolk mental health NHS trust, over remarks he made about him to Norfolk county council’s health scrutiny committee. The councillors on the committee were questioning Richardson over claims reported by the BBC’s Newsnight programme that his trust had “watered down” a report into what are thought to be the avoidable deaths of up to 1,000 patients. The changes between different versions of the document toned down criticism of the trust’s leadership, a move that drew criticism from Behrens and bereaved relatives. For example, the auditors, Grant Thornton, removed references included in the first version to the trust’s governance being “poor, … weak [and] inadequate”, after discussions with trust bosses. The trust and Grant Thornton said the changes were part of a normal factchecking process. Referring to the changes, Behrens had told Newsnight that “the differences in the texts at key points are so huge that this is not just a bureaucratic drafting issue”. Read full story Source: The Guardian, 5 October 2023
  22. Content Article
    Walkthrough analysis is a structured approach to collecting and analysing information about a task or process or a future development (for example, designing a new protocol). It is used to help understand how work is performed and aims to close the gap between work as imagined and work as done to better support human performance. Walkthrough analysis is one of the tools included in the Patient Safety Incident Response Framework (PSIRF). This guide by NHS England provides information on how to carry out walkthrough analysis. It covers: Getting started System considerations Task and tool matrix View further PSIRF content and resources on the hub.
  23. Event
    The Patient Safety Incident Response Framework (PSIRF) arguably represents the most significant change to investigating and managing patient safety incidents in the history of the NHS. To embed PSIRF effectively within organisations, healthcare teams need to understand and utilise a range of new techniques and disciplines. Clinical audit is an established quality improvement methodology that is often overlooked by patient safety teams, but will play an increasingly important role in ensuring that PSIRF fully delivers its stated objectives. CQC reports often highlight the importance of clinical audit as a measurement and assurance tool that can raise red flags if used appropriately. Indeed, both the Ockenden and Kirkup reports highlighted the importance of clinical audit in identifying and quantifying substandard care. While SEIPS, After Action Reviews, more in-depth interviewing techniques, etc. are all receiving much fanfare in relation to PSIRF, the importance of clinical audit needs to be better understood. This short course will explain how organisations who use clinical audit effectively will increase patient safety and better understand why incidents take place. We will look at the key role of audit in understanding work as imagined and works as done and show why national audits can assist with creating patient safety plans. Change analysis and the effective implementation of safety actions are keys to PSIRF delivery and clinical audit will assist in the delivery of both. We will also demonstrate the important, but often under-appreciated role, clinical audit staff will have in the successful delivery of PSIRF. Key learning outcomes: Why clinical audit is an integral element of PSIRF. Why clinical audit staff have a vital role to play in PSIRF. How clinical audit data can help raise red flags and spot risks. Using clinical audit to better understand your incidents. Ensuring your safety actions are working. Using audit to assess your patient safety incident investigations. Register hub members will receive 20% discount. Email info@pslhub.org for a discount code.
  24. Event
    The Patient Safety Incident Response Framework (PSIRF) was published on 16th August 2022 and replaces the Serious incident Framework. This national conference looks at the practicalities of Serious Incident Investigation and how this has changed with the publication of PSIRF. The conference will also update delegates on best practice in serious incident investigation under PSIRF and ensuring the focus is on safety actions for improvement. There will also be an extended focus on learning, including mortality governance and learning from deaths ensuring insight and investigation findings lead to improvement. The conference will include updates from PSIRF early adopter sites. The conference update delegates on the new Patient Safety Incident Response Standards and how to review your current practice against these standards. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/serious-incident-investigation-patient-safety or email kerry@hc-uk.org.uk Follow this conference on Twitter @HCUK_Clare #NHSSeriousIncidents hub members receive a 20% discount. Email info@pslhub.org for a discount code.
  25. Event
    This practical course offers an overview of the principles that underpin a professional safety investigation interview with either a member of staff, a patient or a family. The course aligns to the PSIRF guidance on a systems approach to interviews. The course includes: Planning and preparing for an interview Using a structured hierarchy of questions to facilitate comprehensive, accurate information Asking system-focused questions Closing an interview Register
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