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Found 399 results
  1. News Article
    Thousands of women are to be called for smear tests after errors in Scotland's cervical screening programme. In June 2021 it was discovered that several women had died from cervical cancer after being wrongly excluded from NHS Scotland's screening list. Now a further review expects to find 13,000 patients who have had a hysterectomy will need further tests. MSPs were told two years ago that a small number had died from cervical cancer after wrongful exclusion from the programme, and that further incorrect exclusions were possible. The most common reason for exclusion was after a total hysterectomy, where the entire cervix has been removed, meaning there was no need for cervical screening. But some were recorded as having had this procedure where there was only a sub-total or partial hysterectomy, meaning cervical screening was still needed. An urgent audit followed and all affected women were invited for follow-up examination. Now, a wider audit of 150,000 women who have had subtotal hysterectomies has been launched. Read full story Source: BBC News, 17 April 2023
  2. Content Article
    The following account has been shared with Patient Safety Learning anonymously. We’d like to thank the patient for to sharing their experience to help raise awareness of the patient safety issues surrounding outpatient hysteroscopy care.
  3. Content Article
    Footage from the Black Maternal Health Conference UK 2023 is now available for download. Sessions highlight the gaps within the system and disparities - and provide nuance, to further reiterate the importance of Black women receiving health care that is respectful, culturally competent, safe and of the highest quality. Hosted by Sandra Igwe, Chief Executive of The Motherhood Group. You can purchase the full recording, or specific sessions, from the event via the link below.
  4. Content Article
    In this blog, Sonia Barnfield, Clinical Adviser for Maternity Investigations at the Healthcare Safety Investigation Branch (HSIB), looks at risk assessments during the maternity care pathway, following HSIB's recent national learning report on the same subject. Sonia outlines the need for change in the way that risk during pregnancy is assessed and managed, highlighting that there is currently no single national guidance and that HSIB identified repeated examples of insufficiently robust, continuous risk assessment in the maternity pathway. She lays out six key themes highlighted in HSIB's report and looks at how risk assessments should change to improve safety for pregnant women and their babies.
  5. Content Article
    This is Patient Safety Learning’s submission to the consultation by the Royal College of Obstetricians and Gynaecologists seeking views on a draft Green-top Guideline on outpatient hysteroscopy. The aim of this guideline is to provide clinicians with up to date, evidence-based information regarding outpatient hysteroscopy, with particular reference to minimising pain and optimising the patient experience. The consultation is now closed.
  6. Content Article
    Hysteroscopy is a procedure used as a diagnostic tool to identify the cause of common issues such as abnormal bleeding, unexplained pain or unusually heavy periods. It involves a long, thin tube being passed through the vagina and cervix, into the womb, often with little or no anaesthesia.  Studies indicate that some women do not find hysteroscopy procedures painful. However, it is now widely recognised that many women experience severely painful and traumatic hysteroscopies.[1-5]  At Patient Safety Learning, we have worked with patients, campaigners, clinicians and researchers to understand the barriers to safe care and call for improvements.[6] We believe that no woman should have to endure extreme pain or trauma when accessing essential healthcare.  In this blog we will:  outline the key safety concerns around hysteroscopy procedures summarise recent national discussions highlighting these concerns reflect on the new national guidance outline six calls for action. 
  7. Content Article
    In this blog, Dr Ciaran Crowe, an ST6 doctor in obstetrics and gynaecology, talks about bullying in the healthcare system and what we can do to tackle unacceptable behaviour. He highlights the results of the 2014 National Training Survey, in which 8% respondents reported being bullied and 13.8% reported witnessing bullying, and points out that certain specialities have a higher than average number of bullying incidents reported. He also examines the triggers for bullying in healthcare settings and looks at ways to tackle the issue.
  8. News Article
    A third of those with a women’s health condition have been made to wait three years or longer for a diagnosis, damning new research has revealed. The same study found half of those women took a year or more to be given their diagnosis. Srdjan Saso, a consultant gynaecologist and surgeon who works with King Edward VII’s Hospital, told The Independent: “A delayed diagnosis can mean a severe impact on quality of life both professionally and personally. “It can have a significant impact on a woman’s day-to-day life and hence needs to be addressed properly and seriously. From a more sinister perspective, in certain cases, it can be cancer and we are picking it up late.” Source: Independent, 14 February 2023 Read full story
  9. Content Article
    The Royal College of Obstetricians and Gynaecologists (RCOG) has launched a consultation to seek views on the draft Green-top Guideline on Outpatient Hysteroscopy document. This consultation is open to both professionals and patients. You can return your comments using this online form by midnight Monday 13 March 2023. Please also see the guidance for reviewers page on the RCOG website.  
  10. Content Article
    Hysteroscopy is a common and valuable intervention to diagnose and treat gynaecological conditions arising in the uterus. Many women have an acceptable experience of outpatient hysteroscopy, with pain levels tolerable to them and rapid recovery. However, it is important to recognise that hysteroscopy can cause severe pain and be traumatic for women. This is difficult to predict. Therefore, units need to share with women clear, accurate and relevant, written and verbal information. This Good Practice Paper from the Royal College of Obstetricians and Gynaecologists has been written for healthcare professionals who are involved in providing outpatient hysteroscopy with the aim of achieving optimal outcomes for women.
  11. Content Article
    This blog by Carl Heneghan, Professor of Evidence-based Medicine at the University of Oxford and Clinical Epidemiologist Tom Jefferson, looks at safety and regulatory issues associated with Essure, a permanent contraceptive implant. Essure anchors inside the fallopian tubes and reacts with the tissues, causing them to become inflamed and scarred. The resulting scar tissue then blocks the tubes off, intending to prevent fertilisation. The devices are about 4cm long and contain a stainless steel, nickel and titanium inner coil and an expanding outer coil containing iron, chromium and tin. Essure has been shown to cause allergic reactions, lifelong inflammatory reactions and internal injuries. The authors examine how Essure came to be approved for use in the USA, the UK and the rest of Europe, highlighting regulatory failings and conflicts of interest with the medical tech industry. They also highlight how pressure from women harmed by Essure resulted in its use being banned in several countries. The blog then describes ongoing efforts to access UK data on reports of adverse events due to Essure that are held by the Medicines and Healthcare Regulations Agency (MHRA). Freedom of Information requests for this data have been denied.
  12. Content Article
    In this report, Dr Henrietta Hughes, Patient Safety Commissioner for England, reflects on her first 100 days in this new role. She sets out what she has heard, what she has done and her priorities for the year ahead.
  13. Content Article
    In this blog, Patient Safety Learning’s Chief Executive, Helen Hughes, reflects on a recent discussion about hysteroscopy and patient safety at a conference in January 2023, hosted by the Association of Anaesthetists.
  14. Content Article
    This is a brief summary of a Westminster Hall debate in the House of Commons on the 31 January 2023 on NHS hysteroscopy treatment, tabled by Lyn Brown MP.
  15. Content Article
    This blog for Refinery 29 by journalist Sarah Graham examines the gender health gap, a term used to describe the inequalities in treatment and health outcomes that men and women experience. She talks about the stories relating to sexism and institutional bias she has come across during her time as a health journalist, that result in poor care experiences and outcomes for women. While acknowledging that women should not have to make extra effort to be heard by the health system, Sarah offers tips for women to help them voice their concerns and improve their chances of being listened to by medical professionals.
  16. Content Article
    Fatigue and sleep deprivation may affect healthcare professionals' skills and communication style and also may affect clinical outcomes. However, there are no current guidelines limiting the volume of deliveries and procedures performed by a single individual, or on the length of time that they can be on call. This Committee Opinion from the American College of Obstetricians and Gynecologists (ACOG) analyses research relating to fatigue and performance in healthcare professionals in order to make recommendations to doctors and managers to improve staff and patient safety.
  17. News Article
    The Conservatives have been accused of “failing women” as analysis reveals gynaecology waiting times have trebled in the past decade, with more than 540,000 waiting for NHS care. NHS England data shows that in October 2012, the average waiting time to see a gynaecologist was 4.8 weeks. By October 2022, the most recent month for which figures are available, that figure had increased by 225% to 15.6 weeks. Many of the conditions experienced by women waiting to see a gynaecologist are progressive. Left untreated, they can need more complex or invasive surgery. Thousands are living in extreme pain as a result of the long waits, doctors, health experts and charities told the Guardian. The figures reveal that 38,231 women have been waiting more than a year. Ten years ago there were 15 women in England waiting longer than 12 months – and no one waiting two years. Today, 69 women have been waiting more than 24 months. Dr Ranee Thakar, the president of the Royal College of Obstetricians and Gynaecologists, said: “This new analysis adds to our own research that gynaecology waiting lists were outstripping other specialities long before the pandemic, and they continue to grow rapidly. “Shockingly, the fact we can now track this pattern back 10 years, shows how long overdue action is to address the unequal growth in waiting lists.” Thakar added: “Women’s health has been consistently deprioritised. Gynaecology waiting times are currently the longest we’ve seen since waiting list targets were introduced, leaving thousands of women with symptoms including extreme pain, heavy menstrual bleeding and incontinence.” Read full story Source: The Guardian, 19 December 2022
  18. Content Article
    This is an Adjournment Debate from the House of Commons on Wednesday 7 December 2022 on fatalities relating to foetal valproate spectrum disorder.
  19. News Article
    More than 1000 investigations have been launched in Scotland over the past decade into adverse events affecting women and infants' healthcare. Figures obtained by the Herald show that at least 1,032 Significant Adverse Event Reviews (Saers) have been initiated by health boards since 2012 following "near misses" or instances of unexpected harm or death in relation to obstetrics, maternity, gynaecology or neonatal services. The true figure will be higher as two health boards - Grampian and Orkney - have yet to respond to the freedom of information request, and a number of health boards reported the totals per year as "less than five" to protect patient confidentiality. Saers are internal health board investigations which are carried out following events that could have, or did, result in major harm or death for a patient. Major harm is generally classified as long-term disability or where medical intervention was required to save the patient's life. They are intended as learning exercises to establish what went wrong and whether it could have been avoided. Not all Saers find fault with the patient's care, but the objective is to improve safety. NHS Lanarkshire was only able to provide data from April 2015 onwards, but this revealed a total of 194 Saers - of which 102 related to neonatal or maternity services, and 80 for obstetrics. A Fatal Accident Inquiry involving NHS Lanarkshire has already been ordered into the deaths of three infants - Leo Lamont and Ellie McCormick in 2019, and Mirabelle Bosch in 2021 - because they had died in "circumstances giving rise to serious public concern". Read full story (paywalled) Source: The Herald, 10 December 2022
  20. News Article
    The deputy chair of NHS England has said it should be as ‘demanding’ of medical cover in obstetrics and neonatal care as it is for emergency departments, to improve safety in the wake of repeated care scandals. Sir Andrew Morris, who was the long-serving chief executive officer of the well-regarded Frimley Health Foundation Trust, said the service would “expect a consultant to be on duty in an emergency department [from] 8am till 10pm, or midnight, seven days a week”. Speaking at NHS England’s public board meeting yesterday, Sir Andrew said: “We haven’t set that similar expectation out for [maternity care]. I know we’re saying we’re expecting that two ward rounds are undertaken, each day, seven days a week, but that is very different to the service I think is appropriate for this type of semi-emergency operation, that most trusts run. “I’d like us to be as demanding of organisations [in relation to obstetrics and neonatal] as we are for the emergency department.” Read full story (paywalled) Source: HSJ, 1 December 2022
  21. Content Article
    This survey by In-FACT (Independent Fetal Anti Convulsant Trust) is intended to provide patients, no matter what anti-epileptic drug (AED) they are prescribed or what condition the AED is prescribed for, the opportunity to report problems and worries about taking their medication during pregnancy. The results will be used to inform In-FACT's ongoing work to improve medication safety and their engagement with the Medicines and Healthcare products Regulatory Agency (MHRA).
  22. Content Article
    Please help the Campaign Against Painful Hysteroscopy uncover the circumstances, quantify the contributing factors, and evidence the consequences of painful and distressing hysteroscopies. The survey is anonymous. The results will be put in the public domain to be used to help improve hysteroscopy services for future patients.
  23. Content Article
    This is the transcript of a Westminster Hall debate in the House of Commons on Black Maternal Health Awareness Week 2022, dedicated to raising awareness about disparities in maternal outcomes.
  24. News Article
    More than a third of the 3143 counties in the US are maternity “deserts” without a hospital or birth centre that offers obstetric care and without any obstetric providers—and the situation is getting worse, says a report from the March of Dimes organisation. Maternity deserts have increased by 2% since the 2020 report, said the organisation which seeks to improve the health of women and babies. Care is diminishing where it is needed most—especially in rural areas. It affects nearly seven million women of childbearing age and about half a million babies. Read full story (paywalled) Source: BMJ, 17 October 2022
  25. Content Article
    This video by Joyce Harper, Professor of Reproductive Science at the Institute for Women's Health at University College London, highlights short-term and long-term menopause symptoms, outlines their causes and suggests ways that women can deal with them. Her key message is that everyone should understand these symptoms and anyone suffering should go to see their health professional—no one should have to put up with symptoms that affect their life.
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