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Found 1,561 results
  1. News Article
    The Campaign to Save Mental Health Services in Norfolk and Suffolk is calling for a criminal investigation into an apparent scandal that decisively surfaced over the summer, centred on the Norfolk and Suffolk NHS foundation trust (or NSFT), which sees to mental health provision across those two very large English counties. It is centred on the “unexpected” deaths of 8,440 people between April 2019 and October 2022, all of whom were either under the care of the trust, or had been up to six months before they died. The story of the failures that led to that statistic date back at least a decade; the campaign says it amounts to nothing less than “the largest deaths crisis in the history of the NHS”. The figure of 8,440 was the key finding of a report by the accounting and consultancy firm Grant Thornton – commissioned by the trust, ironically enough, to respond to anxious claims by campaigners, disputed by the trust, that there had been 1,000 unexpected deaths over nine years. There are no consistent national statistics for such deaths, and no universal definition of “unexpected”: in Norfolk and Suffolk, a death will be recorded as such if the person concerned was not identified by NHS staff as critically or terminally ill; the term includes deaths from natural causes as well as suicide, homicide, abuse and neglect. The period in question includes the worst of the pandemic, although the trust’s own annual deaths figures did not reach a peak until 2022-23. But the numbers still seem jaw-dropping: they represent an average of about 45 deaths a week. To put that in some kind of perspective, earlier reports about the trust’s deaths record had raised the alarm about a similar number of people dying every month. And the Grant Thornton report included another key revelation: the fact that the trust’s record-keeping was so chaotic that in about three-quarters of cases, it did not know the specifics of how or why the people concerned had died. After its publication, moreover, there were more revelations about the trust, and its culture and practices. Read full story Source: The Guardian, 21 January 2024
  2. Content Article
    On the 24 October 2023 the Health and Social Care Select Committee announced that its independent Expert Panel would be undertaking an evaluation of government progress on implementing accepted recommendations to improve patient safety. As part of this review, the Committee wrote to the Secretary of State for Health and Social Care requesting a list of key independent public inquiry and review recommendations pertaining to patient safety and whistleblowing in the NHS that that the Government has accepted since 2010. This letter sets out the response to this request from Maria Caulfield MP, Parliamentary Under Secretary of State.
  3. Content Article
    The systems engineering initiative for patient safety (SEIPS) is a framework to help us understand outcomes within complex socio-technical systems, like healthcare. SEIPS has developed over a number of academic papers and offers a range of tools that can help an investigator to understand why things happen. Deinniol Owens and Dr Helen Vosper highlight how SEIPS can be the investigator’s ‘swiss army knife’ when planning and undertaking patient safety investigations.
  4. News Article
    The publication of a final report into the infected blood scandal has been delayed until May. The chairman of the public inquiry, Sir Brian Langstaff, said more time was needed to prepare "a report of this gravity". Victims and their families were initially told they would learn the findings in autumn last year. That date was pushed back until March, and the inquiry has now confirmed the further delay to 20 May 2024. "I am sorry to tell you that the report will be published later than March. That is not what I had intended," added Sir Brian. "When I reviewed the plans for publication, I nonetheless had to accept that a limited amount of further time is needed to publish a report of this gravity and do justice to what has happened." It is thought about 30,000 people were infected with HIV and hepatitis C through contaminated blood products in the 1970s and 1980s. More than 3,000 have died in what has been described by MPs as the worst treatment disaster in NHS history. Read full story Source: BBC News, 17 January 2024 Further reading on the hub: UK Infected Blood Inquiry
  5. Content Article
    These draft regulations from the Department of Health and Social Care set out how the statutory medical examiner system will operate in the NHS in England from April 2024. Medical examiners will be appointed by NHS bodies to provide independent scrutiny of causes of death and will be a contact for bereaved people who want to ask questions or raise concerns. The draft regulations set out: medical examiners’ terms of appointment, training and payment the procedure for independence additional functions
  6. Content Article
    When a family loses a loved one in unclear or unexplained circumstances, there is one thing that family members need above all else: answers. How did their loved one die, and could their death have been prevented? The Coroner Service is there to answer these questions. But in his annual report published in December, the chief coroner Judge Thomas Teague revealed the extensive delays now occurring in the coroners’ courts. In April 2021 more than 5,000 families waited over a year for the coroner to complete their investigations. This was a staggering increase on pre-pandemic figures, with 2,278 cases having lasted more than 12 months in 2019. And while figures from April 2022 suggest the backlog is gradually reducing (with 4,568 cases taking more than 12 months), it is clear that far too many families are still facing agonising delays, sometimes lasting several years.
  7. 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 receive a 20% discount. Email info@pslhub.org for discount code.
  8. News Article
    The family of an autistic teenager who died from an accidental overdose say they had to investigate the death themselves to find the truth of how he died. Will Melbourne, 19, was found dead at his Cheshire home on December 18, 2020 after he mistakenly had taken a strong synthetic opioid 100 times stronger than morphine he bought on the dark web. The inquest into Will's death took three years to come back and his family say had to investigate the matter themselves to find out what happened. Sally and John Melbourne said their lives were put on hold during the long wait for the inquest to be completed and the family were told at the pre-inquest hearing that the court were short-staff and had a backlog of 500 cases. Parents and friends of the teenager used a trail of digital "breadcrumbs" to uncover that Will had tried to buy oxycodone, a highly addictive opioid that helps with pain relief and anxiety, which turned out to be a synthetic opioid. The blue pills Will had bought on the darknet were found beside his body. The family say the drugs were not tested until they raised it with the coroner's court a year after his death. Will's blood sample had also been destroyed after the company storing it went into administration. The family said they were left traumatised by the time the inquest was concluded. Mrs Melbourne said: "We thought the inquest system was there to give us answers. Instead, we felt blocked at every turn. "It was outrageous that we had to take the investigation on ourselves." Read full story Source: Mail Online, 4 January 2023
  9. Content Article
    Derek Richford’s grandson Harry died in November 2017 at just a week old. Since Harry’s death, Derek has worked tirelessly to uncover the truth about what happened at East Kent Hospitals University Foundation Trust (EKHUFT) to cause Harry’s death.  In a blog published on the Making Families Count website, Derek explores some aspects of how the family's complaints were handled. Further reading on the hub: “Getting the hospital to be honest with us felt like a battle from day one.” An interview with Derek Richford
  10. News Article
    In 2016, Kettering General Hospital (KGH) became the focus of a major criminal inquiry. Documents seen by the BBC reveal detectives looked for evidence of gross negligence manslaughter over the treatment of Jorgie Stanton-Watts, a vulnerable toddler. Seven years of investigations followed, by the hospital, regulators and a coroner. The family has struggled to hold people to account. Since Jorgie's death, a BBC investigation has heard from more than 50 parents with serious concerns about the treatment of their children, many of whom died or suffered injury. The Northamptonshire hospital has also been inspected regularly. In April the Care Quality Commission (CQC) downgraded the hospital's children's services to inadequate, the lowest possible rating. Read full story Source: BBC News, 10 January 2024
  11. News Article
    The former nursing director at the hospital where Lucy Letby murdered seven babies will be among the 'core participants' of the Thirlwall Inquiry. The inquiry, chaired by Lady Justice Thirlwall, will investigate how Letby was able to commit the murders and attempt six others while she worked as a neonatal nurse at Countess of Chester Hospital NHS Foundation Trust in 2015 and 2016. This week, Alison Kelly, who was director of nursing and quality at the trust during the time of Letby's crimes, was announced as 1 of 10 core participants in the inquiry. Also named were former Countess of Chester chief executive Tony Chambers, former medical director Ian Harvey and former human resources director Sue Hodkinson. Ms Kelly and Mr Harvey were among the senior staff at the trust who were accused of failing to act when clinicians first raised concerns about Letby. How managers responded to such concerns is one of the areas due to be investigated by the Thirlwall Inquiry. A number of organisations are also on the list as core participants, including the Nursing and Midwifery Council (NMC), NHS England, the Royal College of Paediatrics and Child Health, the Department of Health and Social Care and Countess of Chester itself. Read full story Source: Nursing Times, 3 January 2024
  12. News Article
    At least 38 babies died in the space of nine years after serious incidents in the country’s maternity units, it has emerged. The total is based on research of both media reports of inquests and settled claims. Before Christmas, a review by the Irish Examiner revealed 21 hospital baby deaths followed one or more serious incidents, between 2013 and 2021. However, further study in the same nine-year period shows the toll to be higher. The worst year was 2018, when not only did at least 10 babies die, but three of them died at the same Dublin hospital over a five-month period. In at least 18 of the 38 deaths, issues around foetal heartbeat monitoring (CTG) were raised either at inquest or in the High Court. At least 18 of the inquests resulted in a verdict of medical misadventure. As well as issues around heart monitoring, the Irish Examiner review shows that in at least seven of the 38 cases, maternity staff missed signs that a woman was in labour, leading to repeated recommendations around training. In at least seven cases, mothers’ concerns were ignored. Read full story Source: Irish Examiner, 29 December 2023
  13. Content Article
    Rob Behrens reflects on the work the Parliamentary and Health Service Ombudsman (PHSO) has done over the last year to drive improvements in patient safety.
  14. Content Article
    Professor Joe McDonald, Principal Associate for health system collaboration for Ethical Healthcare Consulting, explains how the recent trial of Lucy Letby triggered both personal and professional rage – and the desire to do more to keep patients safe across the NHS.
  15. Content Article
    In this article for the Byline Times, Saba Salman highlights the results of the latest NHS-funded annual review of deaths among people with learning disabilities. The report lays bare how people with learning disabilities are less likely to survive health problems that are preventable and treatable than those without learning disabilities. Researchers at King’s College London, the University of Central Lancashire and Kingston University London reviewed the deaths of 3,648 people with a learning disability. Overall, almost half died an avoidable death, compared to two in 10 in the general population. The median age of death in was 63 years, which is around 20 years less than for people without learning disabilities.
  16. Content Article
    The Health Services Safety Investigations Body (HSSIB) Senior Safety Investigator, Helen Jones, blogs about some of the key benefits and risks of electronic patient record (EPR) systems used in healthcare, sharing what we are learning from our safety investigations.
  17. Content Article
    In this blog by Sling The Mesh, the author reflects on the recent case of a mother left in debilitating pain and faecally incontinent from vaginal mesh being awarded a record settlement of at least £1 million. She highlights that in reality many cases are thrown out before they get to court, some never get off the ground owing to being out of the legal time frame and many more women don’t even attempt a medical negligence claim as the process feels too stressful, triggering PTSD and anxiety.
  18. Content Article
    In this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on the charity’s work and some of the key patient safety developments in the past 12 months and looks ahead to 2024.
  19. News Article
    An "evil" nurse who drugged patients on a stroke unit for an "easy shift" and a healthcare worker who conspired with her have been jailed. Catherine Hudson, 54, was found guilty of giving unprescribed sedatives to two patients at Blackpool Victoria Hospital in 2017 and 2018. She was also convicted of conspiring with Charlotte Wilmot, 48, to give a sedative to a third patient. Hudson was jailed for seven years and two months. Wilmot was sentenced to three years. Evidence during the trial highlighted the "dysfunctional" drugs regime on the stroke ward with free and easy access to controlled drugs and medication which led to "wholesale theft" by staff. Prosecutors described it as a "culture of abuse" after police examined WhatsApp phone messages between the co-defendants and other members of staff. The pair were investigated after a student nurse witnessed events while on a work placement on the stroke unit and told senior managers in November 2018, who called in police. The whistleblowing nurse, who the prosecution had asked not to be named, told officers she had concerns over the use of insomnia medication Zopiclone, which can be life-threatening if given inappropriately. She said Hudson had told her the patient had a Do Not Resuscitate Order in place "so she wouldn't be opened up if she died or... came to any harm". Read full story Source: BBC News, 14 December 2023
  20. News Article
    A fresh inquest into the death of Raychel Ferguson has found she died of a cerebral oedema, or swelling in the brain, due to hyponatraemia. He said the "inappropriate infusion of hypertonic saline fluid" was the most significant factor. The nine-year-old died at the Royal Victoria Hospital for Sick Children in June 2001. Coroner Joe McCrisken said her death was due to a series of human errors and not systemic failure. He outlined three causes of the hyponatraemia but said he was satisfied the "inappropriate infusion of hypertonic saline fluid... played the most significant part". The new inquest into Raychel's death was first opened in January 2022 after being ordered by the attorney general but was postponed in October when new evidence came to light. Raychel was one of five children whose deaths over the course of eight years at the same hospital prompted a public inquiry. In 2018 the Hyponatraemia Inquiry - which examined the deaths of five children in Northern Ireland hospitals, including Raychel - found her death was avoidable. The 14-year-long inquiry was heavily critical of the "self-regulating and unmonitored" health service. In his report in 2018, Mr Justice O'Hara found there was a "reluctance among clinicians to openly acknowledge failings" in Raychel's death. Read full story Source: BBC News, 11 December 2023
  21. News Article
    The NHS and a local council have been told to urgently find a home for a 28-year-old autistic man who is facing psychological and physical abuse within a mental health hospital, after an independent review of his care. Nicholas Thornton has autism and learning disabilities and is currently being held in the Rochford mental health unit, in Essex, after a decade of being locked away in places not able to care for him adequately. Now an independent safeguarding review into his care provided at the Essex hospital has ordered the local authority and NHS to find him a home in the community because his relationship with hospital staff has become so bad he is facing psychological and physical harm. He is one of the 2,045 people with learning disabilities and autism trapped within inpatient units across England. Mr Thornton has been in the unit, run by the Essex Partnership University NHS Foundation Trust (EPUT), since May this year. He is not under a mental health section, nor does he need mental health treatment, but he is unable to leave because the local authority has not agreed on a place into which he can be discharged. EPUT is currently facing a public inquiry probing the deaths of 2,000 patients following multiple reviews since 2016 from coroners, the police and health ombudsman criticising the care within the hospital. A safeguarding report into Mr Thornton’s situation, seen by The Independent and Channel Four News, revealed staff working in the Rochford hospital told investigators they cannot adequately care for Mr Thornton themselves as they are not trained in supporting patients with autism. Read full story Source: The Independent, 13 December 2023
  22. Content Article
    A patient safety incident investigation (PSII) is undertaken when an incident or near-miss indicates significant patient safety risks and potential for new learning. Investigations explore decisions or actions as they relate to the situation. The method is based on the premise that actions or decisions are consequences, not causes, and is guided by the principle that people are well intentioned and strive to do the best they can. The goal is to understand why an action and/or decision was deemed appropriate by those involved at the time.  This NHS England document provides an overview of patient safety incident investigation stages, tips and suggested structure for analysis.
  23. News Article
    NHS Highland will no longer receive extra government support in leadership, governance or culture, following improvements after the Sturrock review. The board was initially escalated to Stage 3 of NHS performance escalation framework in 2018 following concerns of a culture of workforce bullying and harassment. An independent report by John Sturrock QC, commissioned by the Scottish government, confirmed “fear, intimidation and inappropriate behaviour” and called for wide-ranging changes. The Healing Process was created in response, with an independent review panel established to speak to victims of bullying and come up with recommendations for the health board to make improvements. A total of 272 current and former NHS Highland and local health and social care partnership staff provided testimony between 2019 and March this year, with more than £2.8m paid out to those affected by bullying. Concerns were raised by some of the first people to go through the healing process that the system was “broken” and many victims could end up “bitterly disappointed”. The board has also established systems and processes to allow colleagues to speak up in the wake of the Sturrock Review, including an independent Guardian Service and staff training in Courageous Conversations. NHS Highland was handed oversight of its own escalation and de-escalation, rather than a Scottish government-led oversight group, in November 2021. Following a letter of assurance from the board chair earlier this year, the Chief Executive of NHS Scotland, Caroline Lamb, agreed to the de-escalation in September. Independent progress tracking shows the board has delivered significantly against many actions laid out by the review but the board concluded in its final June update that ‘culture change is not yet embedded at all levels of our organisation’. Read full story Source: Health and Care Scotland, 2023
  24. News Article
    The expert tasked by government and NHS England to investigate maternity scandals has criticised ministers for failing to provide the funding necessary to address the problems. Donna Ockenden said the funding provided so far was “nowhere near good enough” and progress made to improve services had been “extremely disappointing”. After her investigation into the deaths and harm of 295 babies and nine mothers at Shrewsbury and Telford Hospitals Trust, the Department of Health and Social Care endorsed recommendations to invest an additional £200m to £350m per year into maternity services. IMs Ockenden suggests the recent impact of inflation, pay awards, and other rising costs means the full £350m is required. According to NHSE an additional £165m per year has been invested since 2021, and the DHSC said this would rise to £187m from April. Ms Ockenden, a senior midwife, told HSJ: “What I would like to say loud and clear to the government is that we are broadly 50 per cent of the way there in receiving the money we know is needed for maternity services. That is nowhere near good enough. “There are workforce issues across [the whole team], whether that’s midwives, obstetricians or neonatologists, and it’s hardly surprising. “The government must now do more – whilst we were grateful for the endorsement [of her report], the lack of progress in providing what is known to be the required funding is extremely disappointing.” Read more (paywalled) Source: HSJ, 11 December 2023
  25. News Article
    Campaigners have written to the chief constables of Norfolk and Suffolk to request an investigation into thousands of mental health deaths in those areas. They say coroners are raising safety issues but no improvements are being made. A report by independent auditors found as many as 8,440 patients had died unexpectedly over three years. Norfolk and Suffolk NHS Foundation Trust said it had started a review of patient deaths. Coroners worried about the risk of future deaths highlight unsafe practices in prevention of future deaths reports (PFDs). And authorities are required by law to respond with an action plan within 56 days. The Norfolk and Suffolk trust said it had responded to all PFDs and was working to ensure recommendations and actions were implemented. But Mark Harrison, from the Campaign to Save Mental Health Services in Norfolk and Suffolk, said: "There's a criminal case to answer. And we want the police to investigate, where the same mistakes have been repeated time and time again." He said coroners were repeatedly warning of risks such as delays to treatment, lack of patient follow-ups, chaotic record keeping and disorganised communication between teams. Mr Harrison said: "The mental health trust always responds saying they've learned lessons, they are changing policy and practices. "But then what we're seeing in analysing the orders from the coroner are repeat circumstances where other people have died in similar circumstances to a previous prevention-of-future-deaths notice." Read full story Source: BBC News, 12 December 2023
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