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Found 1,531 results
  1. 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
  2. News Article
    A coroner has found neglect contributed to a baby's death at the hospital where he was born. Jasper Brooks died at the Darent Valley Hospital in Kent on 15 April 2021. The coroner found gross failures by midwives and consultants at the hospital and says Jasper's death was "wholly avoidable". Jasper was a second child for Jim and Phoebe Brooks. Due to a complication during pregnancy of her first child, Phoebe was booked in to have an elective Caesarean section to deliver Jasper. But in April 2021 those plans changed overnight. A check-up found Phoebe had raised blood pressure. She was told to remain in hospital and that the C-section would happen the following morning - nine days earlier than planned - when there were more staff on duty. Jasper's parents say the midwives caring for Phoebe repeatedly failed to listen to her and Jim's concerns - that she was shaking violently, feeling sick, and thought she was bleeding internally. "We felt like an inconvenience - no-one wanted to deal with me that night," Phoebe says. "The doctor didn't want to do my C-section, the midwife that's meant to be looking after me, she just doesn't really care. "I remember saying clearly to her, 'my whole body is shaking - something's happening, and no-one's taking the time to listen to what I'm saying or listen in on my baby'." At the inquest hearing, midwife Jennifer Davis was accused by the family's barrister, Richard Baker KC, of "failing to act on signs of blood loss, failing to determine if Phoebe was in active labour, and failing to call a senior doctor when necessary". Jasper was born without a heartbeat, so a resuscitation team was called. But during the inquest, the family learned that further errors were made because the correct people failed to attend the resuscitation. There was no consultant neonatologist on site - a doctor with expertise in looking after newborn infants or those born prematurely. Intubation, the process of placing a breathing tube into the windpipe - which should only take a few minutes - did not occur for 18 minutes. There was also a delay in administering adrenaline to try to stimulate Jasper's heart. Read full story Source BBC News, 24 October 2023
  3. 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
  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. News Article
    The BMA’s GP Committee (GPC) has demanded an investigation into the Government and NHS England’s ‘mismanagement’ of this year’s vaccination programmes. A motion was passed at the GPC England meeting today which called for a review of the ‘circumstances which led to muddled and mismanaged communications’ and for reflection on how to ‘prevent a repeat occurrence’. Last month, there was confusion over the start date for the adult flu and Covid vaccination programmes, which usually start in September. NHS England said the programmes would start in October this year – a move which the BMA said would cause ‘serious disruption’. But the Government then announced that vaccination will begin on 11 September, in what the BMA has called a ‘u-turn’, following the identification of a new Covid variant. GPs were asked to vaccinate ‘as many people as possible’ by the end of October. The GPC has said today that these ‘conflicting instructions’ led to confusion among GPs while also impacting on patient safety. Read full story Source: Pulse, 21 September 2023
  6. News Article
    The family of a young trans woman who is believed to have taken her own life have said she was “failed by those tasked with her care”, as the coroner investigating her death described services for transgender people as “underfunded and insufficiently resourced”. Alice Litman had been waiting to receive gender-affirming healthcare for more than three years when she died in Brighton at the age of 20 in May 2022. Ahead of an inquest which began in Hove on Monday, her mother, Dr Caroline Litman, described Alice’s death as “preventable with access to the right support”. Adjourning the inquest on Wednesday to give a narrative conclusion in two weeks’ time, the coroner Sarah Clarke told the court: “It seems to me that all of these services are underfunded and insufficiently resourced for the level of need that the society we live in now presents". Describing the trans healthcare system as “not fit for purpose”, Alice's family, who are being supported by the Good Law Project, added: “We are grateful that the coroner has agreed that the conditions of Alice’s death warrant a report to prevent future deaths.” Read full story Source: The Guardian, 20 September 2023
  7. News Article
    The death of a mentally ill teenager who died after drinking an excessive amount of water was preventable, an investigation has found. The 18-year-old, known at Mr D, was being detained under the Mental Health Act at the time of his death. An inquiry by the Mental Welfare Commission said he had previously been treated for drinking too much water. It found several areas where a different course of action could have prevented his death. The teenager was admitted out-of-hours to an adult mental health service (AMHS) inpatient unit in a health board neighbouring his own on 5 December 2018 as there were no local beds available. This move was described in the report as a "high-risk action". On the evening of 7 December he suffered a seizure after drinking too much water and was transferred to intensive care. He died three days later from the consequences of water intoxication. Suzanne McGuinness, executive director (social work) at the Mental Welfare Commission, said: "This was a tragic death of a young man while he was being cared for in hospital. "We found that a more assertive approach to the treatment of Mr D's psychotic illness in the two years before his death was warranted. The risks associated with psychotic illness were not coherently managed." Read full story Source: BBC News, 21 September 2023
  8. 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.
  9. Content Article
    NHS England published the new Patient Safety Incident Response Framework (PSIRF) in August 2022 outlining how organisations providing NHS-funded care should respond to patient safety incidents to facilitate ongoing learning and improvement.   From Autumn 2023, PSIRF will replace the current Serious Incident Framework. It will change the way all healthcare providers, which deliver NHS funded care, including independent healthcare organisations respond to patient safety incidents. Linda Jones, Head of Patient Safety & Quality Governance at Independent Healthcare Providers Network (IHPN), writes about the significant changes that introducing a new approach to managing risk and patient safety will entail for the independent sector, and how we’re supporting members to be ready.
  10. Content Article
    This blog captures a recent discussion at a Patient Safety Management Network (PSMN) meeting, where members of the network raised a number of important questions and issues relating to the Patient Safety Incident Response Framework (PSIRF). PSIRF is currently being rolled out across all NHS trusts in England and takes a new approach to investigating patient safety incidents.
  11. Content Article
    Carl Heneghan discusses the role of modelling in the Covid-19 pandemic.
  12. 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.
  13. 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
  14. 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.
  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. News Article
    The UK's biggest chain of GP practices lets less qualified staff see patients without adequate supervision, an undercover BBC Panorama investigation has found. Operose Health is putting patients at risk by prioritising profit, says a senior GP. The company, with almost 600,000 NHS patients, is owned by US healthcare giant Centene Corporation. BBC Panorama sent undercover reporter Jacqui Wakefield to work as a receptionist at one of the UK company's 51 London surgeries. A GP working at the practice said they were short of eight doctors. The practice manager said they hired less qualified medical staff called physician associates (PAs), because they were "cheaper" than GPs. Physician associates were first introduced by the NHS in 2003, so that doctors could deal with more complex patient needs. PAs are healthcare professionals who have completed two years of post-graduate studies on top of a science degree, as opposed to 10 years education and training for GPs. They support GPs in the diagnosis and management of patients, but should have oversight from a doctor. Panorama gathered evidence that PAs were not being properly supervised at the Operose practice. The PAs told the undercover reporter they saw all sorts of patients, sometimes without any clinical supervision. They said the practice treated them as equivalent to GPs. Prof Sir Sam Everington, a senior practising GP at an unconnected partner-run practice, reviewed BBC Panorama's undercover footage and said he was concerned for patient safety. During the undercover investigation at the London practice, administrative workers also revealed a backlog of thousands of medical test results and hospital letters on Operose computer systems. One worker said they were tasked with getting through 200 documents a day, deciding which were important enough to be seen by a GP or pharmacist and which would be filed to the patient's records. One member of staff, worried about making mistakes said they sometimes used Google to help them work out what to do with the documents. Read full story Source: BBC News, 11 June 2022
  17. 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.
  18. 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
  19. 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
  20. 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.
  21. 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.
  22. 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.
  23. 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
  24. 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
  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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