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Found 51 results
  1. News Article
    A private hospital facing a police investigation following a patient’s death has been given an urgent warning by the care regulator due to concerns over patient safety. The Huntercombe Hospital in Maidenhead, which treats children with mental health needs, was told it must urgently address safety issues found by the Care Quality Commission (CQC) following an inspection in March. The CQC handed the hospital a formal warning due to concerns over failures in the way staff were carrying out observations of vulnerable patients. The move comes as The Independent revealed police are investigating the hospital in relation to the death of a young girl earlier this year. In a report published last week, the care watchdog said it had received “mainly negative” feedback from young people at the hospital’s Thames ward, a psychiatric intensive care unit which treats acutely unwell children. Commenting on the hospital overall, the report said: “Young people told us that staff did not follow the care plans in relation to their level of observations. They told us that if there was an incident the staff stopped doing intermittent observations. Staff in charge of shifts on wards asked new staff members to do observations before they understood how to do it. Staff had to ask the young person how to carry out their observations as they did not always understand what was expected of them in carrying out different levels of observations.” Read full story Source: The Independent, 19 May 2022
  2. Event
    The Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include National Developments including the recent recommendations on NEWS2 and Covid-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis & Covid-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for the discount code Follow the conference on Twitter @HCUK_Clare #DeterioratingPatient
  3. Content Article
    An investigation started on 9 October 2020 into the death of Matthew Alexander Caseby. Following his admission and subsequent absconsion from the Priory Hospital in Edgbaston, Matthew stepped in front of a train on the 8 September 2020 and was fatally injured. At the time, Matthew was suffering from disorder thinking and did not have the capacity to form any intention to end his life. Matthew absconded from Beech ward over a fence in the courtyard area and at the time of his absconsion Matthew was unattended. It was inappropriate for Matthew to be left unattended in the courtyard. There were concerns regarding Matthew absconding but the recording processes on Beech ward were inadequate which resulted in the communication to staff involved in Matthew's care being lacking. As a result of risks not being fully recorded, Matthew's risk assessment was not adequate as it was not based on all of the available information. Overall, the inadequate risk assessment for Matthew, the inadequate documentation records, the lack of a risk assessment for the courtyard area and the absence of a policy regarding observations levels in the courtyard means that the courtyard was not safe for Matthew to use unattended. His death was contributed to by neglect on the part of the treating hospital.
  4. News Article
    A hospital has admitted clinical negligence over maternity care failings that led to the potentially avoidable death of a 10-day-old baby, The Independent has learned. Kingsley Olasupo and his twin sister Princess were born on 8 April 2019 at Royal Bolton Hospital. Kingsley died 10 days later following a catalogue of mistakes, which included failing to screen him for sepsis. Kingsley and his sister were born premature at 35 weeks. Three days later he was admitted to the special care unit due to a low temperature and “poor” feeding. Despite being reviewed by two doctors he was not screened for an infection and not given antibiotics. His condition deteriorated and on 12 April he was diagnosed with bacterial meningitis and sepsis. Days later scans revealed he had severe brain damage and would not survive. Kingsley’s family said they had been “torn apart” by their son’s death and had pursued the trust to ensure a full independent investigation was carried out and lessons learnt. BFT launched an investigation into Kingsley’s care after Mr Olasupo and Ms Daley raised concerns over their son’s death. According to the trust’s investigation report, seen by The Independent, failings in care included that Kingsley was not screened for sepsis despite several “red flags”. Had this been done he would have been given antibiotics. When midwives first escalated concerns to the neonatal team no physical medical review of Kingsley took place. The investigation also found neonatal staff did not carry out daily reviews, and reviews that were done were incomplete and contained “inaccurate” and “misleading” information. Other failings included: “Ineffective” assessment of Kingsley’s wellbeing on the postnatal ward Poor communication between staff and poor handover processes No consideration was given to the fact Kingsley was not feeding well Inadequate recording of observations. Read full story Source: The Independent, 20 April 2022
  5. News Article
    The chief executive of a mental health trust grappling with care quality failures has described his anger at ‘disrespectful’ staff who have ‘now had to leave the organisation’. In a message to staff, seen by HSJ, Brent Kilmurray, chief executive of Tees Esk and Wear Valleys Foundation Trust, said a number of staff had “stepped away from our values”. HSJ has heard reports of 12 staff members within the trust’s forensic secure inpatient services being suspended in recent weeks, and some dismissed, after being caught sleeping on shifts and using electronic devices while meant to be observing patients. The reports are unconfirmed, but appear to be referenced in a message sent by Brent Kilmurray on 14 March, which said: “I’m sorry to say, there’s been a handful of people who have stepped away from our values and in doing so have now had to leave the organisation." Mr Kilmurray said the staff were in a “minority” and that when the trust investigated these matters “we have found far more excellent caring practice”. He added the trust is working with service leaders “to ensure that they understand their accountabilities for ensuring that services are safe”. Read full story (paywalled) Source: HSJ, 14 April 2022
  6. News Article
    A young woman died following “gross failings” and “neglect” by a mental health hospital in Essex which is also facing a major independent inquiry into patient deaths. Bethany Lilley, 28, died on 16 January whilst she was an inpatient at Basildon Mental Health unit, run by Essex Partnership University Hospitals. The inquest examined the circumstances of her death this week and concluded that her death was contributed by neglect due to a “plethora of failings by Essex University Partnership Trust”. Following the three week inquest, heard before coroner Sean Horstead, a jury found “neglect” contributed to Ms Lilley’s death and identified “gross failures” on behalf of the trust. The jury identified a number of failings in her care including evidence that cocaine had made its way onto a ward where she was an inpatient. There was evidence of “very considerable problems in the record-keeping at EPUT psychiatric units.” It was also concluded staff failed to carry out a risk assessment of Ms Lilley in the days leading up to her death, and failed to carry out observations. Ms Lilley’s death is one of a series of patients who have died under the care of mental health services in Essex, which have been brought into the light following the campaigning of bereaved families. Read full story Source: The Independent, 19 March 2022
  7. Content Article
    Eurocontrol’s HindSight magazine is a magazine on human and organisational factors in operations, in air traffic management and beyond. This issue has articles from front-line staff and specialists in safety, human factors, and human and organisational performance, in aviation and elsewhere. The articles cover all aspects of everyday work, including routine work, unwanted events, and excellence. The authors discuss a variety of ways to learn from everyday work, including observation, discussion, surveys, reflection, and data analysis. There are articles on specific topics to help learn from others’ experience, including from other sectors in ‘views from elsewhere’
  8. Content Article
    A strong focus on systems thinking and an encouragement to apply insights and expertise from human factors and ergonomics is paramount in how we plan, design and deliver healthcare safely. It’s central to the WHO Global Patient Safety Action Plan, the NHS Patient Safety Strategy, new Patient Safety Incident Response Framework (PSIRF) guidance on how to investigate incidents of unsafe care and the National Patient Safety Syllabus.[1-3] It’s something Patient Safety Learning emphasise in our report A Blueprint for Action and is central to the organisational standards for patient safety that we’ve developed.[4] But how should we ‘do’ human factors? How do we apply the concepts, methodologies, tools and techniques in healthcare? What training do we need? How can patient safety managers embed human factors in all of their work, not just a reactive response to incidents of harm? These are some of the questions that patient safety managers have been asking and discussing in the recent Patient Safety Manager Network (PSMN) meetings. The PSMN is an informal voluntary network for patient safety managers in England. Created by and for patient safety managers it provides a weekly drop-in session with guests to talk through issues of importance, providing information, peer support and safe space for discussion. You can find out more about the network here.
  9. News Article
    Serious failings by healthcare staff at Broadmoor Hospital were likely to have contributed to the death of a patient from self-asphyxiation, a jury has found. Following a two-week inquest at Reading Coroner’s Court, a jury found staff failed to recognise and reduce the risks that acutely unwell patient Aaron Clamp presented to himself in the minutes leading to his death. Mr Clamp died on 4 January 2021 after choking in his room at the NHS-run high secure mental health hospital Broadmoor. In the weeks prior to his death, Mr Clamp’s mental health had deteriorated. He was transferred into a “psychiatric intensive care” ward at Broadmoor Hospital and placed in long-term segregation. A summary of the jury’s findings shared with The Independent has found there was “a serious failure in the timely manner to recognise and reduce the level of risk, and a serious failure to recognise and execute the steps to remove the item of fabric” that Mr Clamp choked on. “This omission probably contributed to the death,” the jury said. It was also found there was “insufficient” recording by the trust of previous incidents of self-asphyxiation by Mr Clamp when he died. Jurors said the plan for staff to carry out constant eyesight observations was appropriate, but not all aspects of the plan were adequately followed by staff members. Read full story Source: The Independent, 7 March 2022
  10. Event
    The Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include National Developments including the recent recommendations from the Royal College of Physicians on NEWS2 and Covid-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis & covid-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 not only in an acute setting but also in the community and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit or email kate@hc-uk.org.uk Follow on Twitter @HCUK_Clare #deterioratingpatient hub members can receive a 20% discount. Email info@pslhub.org discount code.
  11. Event
    This Hospital at Night Summit focuses on out of hours care in hospitals delivering high quality safe care at night. Through national updates, networking opportunities and case studies this conference provides a practical guide to delivering a high quality hospital at night, and moving forward during and beyond the Covid-19 pandemic. The conference will also focus on improving staff well-being at night and reducing fatigue. Attending this conference will enable you to: Network with colleagues who are working to improve Hospital at Night Practice Learn from developments as a results of Covid-19 Improve your skills in the recognition management and escalation of deteriorating patients at night Understand and evaluate different models for Hospital at Night Examine the role of task management solutions for Hospital at Night, including handover and eObservations Ensuring effective and safe staffing at night, including adequate breaks Examine Hospital at Night team roles, competence and improve team working Improving safety through the reduction of falls at night Supporting staff and reducing fatigue at night Develop the role of Clinical Practitioner and Advanced Nursing Practice at night Identify key strategies to change practice and ways of working in Hospital at Night Understand how hospitals can improve conditions for night workers and support Junior Doctors Improve the management of pain at night Work across whole systems to improve support for patients out of hours Self assess and reflect on your own practice Gain CPD accreditation points contributing to professional development and revalidation Evidence Register There are a limited number of free places for hub members. Email: info@pslhuborg if interested. Follow on Twitter @HCUK_Clare #hospitalatnight
  12. Content Article
    This blog calls for action on the careful review of established pain medication when a patient is admitted to hospital. Richard describes the experience of two elderly patients who suffered pain due to their long term medication being stopped when they were admitted to hospital. Pain control needs must not be ignored or undermined, there needs to be carer and patient involvement and their consent, and alternative pain control must be considered.
  13. Content Article
    On 11 June 2019 an investigation into the death of Brooke Martin aged 19 started. Brooke was a patient at Isla House, Chadwick Lodge, Milton Keynes and was detained under the Mental Health Act. She had been diagnosed with Emotionally Unstable Personality Disorder and Autism Spectrum Disorder. Brooke was found hanging in her room and was taken to Milton Keynes University Hospital where she died on 11 June 2019.
  14. Content Article
    This article, published in Simulation and Gaming proposes a strategy for ensuing simulation training following the implementation of a thorough Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) training initiative. The strategies include observing Teams in the workplace to facilitate the construction of organisation-wide, follow-on simulation training.
  15. Content Article
    This case story about placental abruption, published by NHS Resolution, highlights the importance of regular risk assessments throughout labour to help prevent harm to mother and baby. It provides learning points and considerations that can be applied across all maternity units.
  16. Content Article
    Responding to abnormalities in patients’ vital signs is a fundamental aspect of nursing. However, failure to respond to patient deterioration is common and often leads to adverse patient outcomes. This study from Smith et al., in the journal Resuscitation, aimed to determine the association between registered nurse (RN) and nursing assistant (NA) staffing levels and the failure to respond promptly to patients’ abnormal physiology. The authors found that RN, but not NA, staffing levels influence the rates of failure to respond for patients with the most abnormal vital signs (NEWS values ≥ 7). These findings offer a possible explanation for the increasingly reported association between low RN staffing and an increased risk of patient death during a hospital admission.
  17. Content Article
    This article from Delaveris et al. outlines one health system's experience implementing a bundle to reduce sepsis-related mortality and the observed connection between adherence to the bundle and improved sepsis care.
  18. Content Article
    A Pareto chart is a type of bar chart in which the factors that contribute to an overall effect are arranged in order from most frequent to least. This ordering helps identify the "vital few" — the factors that warrant the most attention. It also includes a line showing the cumulative % (so you can see easily for example that the top three causes account for 80% of incidents). According to the "Pareto Principle," in any group of things that contribute to a common effect, relatively few account for the majority of the effect.
  19. News Article
    Brain complications, including stroke and psychosis, have been linked to COVID-19 in a study that raises concerns about the potentially extensive impact of the disease in some patients. The study, published in Lancet Psychiatry, is small and based on doctors’ observations, so cannot provide a clear overall picture about the rate of such complications. However, medical experts say the findings highlight the need to investigate the possible effects of COVID-19 in the brain and studies to explore potential treatments. “There have been growing reports of an association between COVID-19 infection and possible neurological or psychiatric complications, but until now these have typically been limited to studies of 10 patients or fewer,” said Benedict Michael, the lead author of the study, from the University of Liverpool. “Ours is the first nationwide study of neurological complications associated with Covid-19, but it is important to note that it is focused on cases that are severe enough to require hospitalisation.” Scientists said the findings were an important snapshot of potential complications, but should be treated with caution as it is not possible to draw any conclusions from the data about the prevalence of such complications. Read full story Source: The Guardian, 26 June 2020
  20. Content Article
    Implementation of high reliability principles in healthcare delivery is recognized as an effective strategy for reducing harm to patients and healthcare workers. With the coronavirus disease 2019 (COVID-19) pandemic upon us, our emergency departments (EDs) are facing an unprecedented safety threat. How does a high reliability ED function during a pandemic, and what are the most important strategies for keeping ourselves and our patients safe? Thull-Freedman et al. discuss this in a commentary in the Canadian Journal of Emergency Medicine.
  21. Content Article
    Investigation of a complaint against the Belfast Health and Social Care Trust A Trust’s failure to perform an examination of a patient on admission to hospital meant he was not assessed by medical staff against this baseline during his time on the ward.
  22. Content Article
    In this blog, Claire discusses the use of NEWS2 in coronavirus patients and the importance of recognising, tracking and alerting the appropriate team that your patient has an increasing oxygen demand to ensure that the risk of more people being exposed to the virus is minimal.
  23. Content Article
    The reference event in this HSIB investigation is the case of a 58-year-old woman who deteriorated and died within 24-hours of presenting at hospital, two weeks after having surgery. The national investigation reviewed relevant research and safety literature relating to recognition and response to deteriorating patients, engaged with national subject matter advisors and consulted with professional bodies.
  24. Content Article
    An honest account from a junior doctor on moving from paper to electronic observation charts and why user testing should be done before rolling it out in hospitals.
  25. Community Post
    I would be interested to know, if overnight, patients who score 0-2 on NEWS which has not changed with no concerns since the last set of observations, what your trust policy is on observation frequency? Does your trust require observations to be carried out 4 hourly minimum regardless of patients NEWS score and stability? Or if there are no concerns and the patient is clinically stable with consecutive NEWS 0-2 that they do not have observations taken overnight? Looking forward to hearing what other trust practices are.
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