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Content ArticleReports showing that babies and mothers died or were harmed as a result of failures by, and sometimes heartless cruel treatment in, NHS maternity units are becoming worryingly common. Dr Bill Kirkup’s just-published 192-page exposé of an appalling catalogue of failings at East Kent NHS trust between 2009 and 2020 is the second in the last 12 months. As many as 45 babies and 23 mothers in East Kent died avoidably during that time because their care was substandard, his inquiry found. March brought Donna Ockenden’s grim findings about poor maternity care at the Shrewsbury and Telford trust. And Kirkup produced the first detailed exposition of what inadequate care of women and their offspring during childbirth looked like when in 2015 he laid bare “serious and shocking” lapses in care at Morecambe Bay trust. A fourth official inquiry, again being led by Ockenden, is under way into death, brain damage and other horrendous outcomes at the Nottingham trust. Families affected claim that, despite coroners’ findings, close scrutiny of the trust by regulators, media coverage of lapses in care and pressure for change, “babies, mothers and their families continue to be harmed”. No wonder Rob Behrens, the NHS Ombudsman, says: “The phrase ‘never again’ is starting to ring hollow.”
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Content Article'State of Care' is the Care Quality Commission's annual assessment of health care and social care in England. The report looks at the trends, shares examples of good and outstanding care, and highlights where care needs to improve.
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Content Article
In this short blog, Patient Safety Learning sets out its initial response to the publication of the report of the independent investigation into maternity and neonatal services at the East Kent Hospitals NHS Foundation Trust.- Posted
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Content ArticleHarry Richford was born at the Queen Elizabeth the Queen Mother Hospital (QEQM), Margate, Kent on 2/11/17. He died on 9/11/17 at the William Harvey Hospital, Ashford to where he had been transferred. The cause of death was 1a Hypoxic Ischaemic Brain Encephalopathy. There was a narrative conclusion setting out some seven failures in the care of Harry Richford together with a conclusion that his death was contributed to by neglect.
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Content Article
LifeQI: Improvement methods cheatsheet
Patient Safety Learning posted an article in Implementation of improvements
Improving the quality of products or services and maintaining acceptable levels of performance are critical factors in the success of any organisation. There are many improvement methods available which include Six Sigma, Lean Management, Lean Six Sigma, Total Quality Management, Model for Improvement and Kaizen just to mention a couple. These methods have differences in approach and application, normally stemming from the differing focus of the methods. The choice of which improvement method to use can sometimes be divisive. One single method is not necessarily better than another, with their strengths lying in different areas. LifeQI have put together a cheatsheet for you to help you choose the most appropriate one for your project and organisation. This Improvement methods cheatsheet compares the different methods according to multiple aspects which you can use as guidelines to help your decision-making process. Note: You will need to fill in your details to download the cheatsheet. -
Content ArticleDespite the constant pressures and chronic shortages, the number of nurses leaving the NHS had flatlined over recent years. Now our analysis of new data shows there has been a large increase in nurses leaving the NHS, and that this trend is being driven by younger workers. The last year's data (June 2021 - June 2022) saw a 25% increase in the number of NHS nurses leaving their role, with an additional 7,000 leaving compared to the previous year. The largest increase in numbers leaving was seen among the younger nurses, two thirds of leavers were under 45 years of age. In this article, Jonathon Holmes explores why there is a sudden increase in vacancies.
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Content ArticleLooking at health and care through a systems lens reveals a wealth of connections and opportunities to achieve better outcomes, as seen in the case studies within this paper. Systems are also complex and changing, with multiple inputs and feedback loops, and control distributed across multiple stakeholders. This paper is a timely exploration of the strategies, skills, and toolkit for effective working within systems. The paper is particularly focused on local government’s role in health and care systems, though there are learning points relevant to any systems leader.
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Content ArticleIt won’t come as a surprise but more than in 9 in 10 of almost 200 NHS leaders that responded to the latest NHS Confederation survey said that risk to patient safety is going to increase as we approach winter. Almost all of them identified the biggest risks being demand for urgent and emergency care and ambulance waits. And most expect to have to make difficult decisions and compromises around safe staffing ratios and delayed transfers of care. As the health and care sector braces for a challenging winter, three key steps could support systems to manage risk and minimise harm, writes Matthew Taylor, chief executive at NHS Confederation: The need for a robust and honest assessment of harm. The role of systems in minimising harm. The role of the centre in providing a helping hand.
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Content ArticleEverybody has a right to good care. Much attention is rightly focused on the occasions when people experience poor quality care, but it is also important to recognise where care is good and to celebrate the services that are getting it right. Some care providers do things well through innovative new ways of working, or by doing the basics well. Others can learn from them and solutions should be shared across the system. This publication from the Care Quality Commission (CQC) is purposely focused on celebrating good and outstanding care that CQC's inspectors have seen.
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Content ArticleHealthcare has, in many ways, always been a form of ‘learning system’. Driven by a diverse community of stakeholders, including health care professionals, patients and the public, a learning health system (LHS) uses internal and external knowledge to continually learn about and improve patient care. However, while LHSs have huge potential to support service transformation and population health, there is a lack of consensus about what an LHS actually is, and how to get started. This research report from the Health Foundation helps people understand LHSs and how they can be developed. It is the final output of HDR UK’s Better Care Catalyst Programme’s Policy and Insights workstream, which researched the barriers and enablers for implementing LHS approaches in the UK. It also identifies a range of opportunities and actions that can be taken by policymakers and system leaders to advance the LHS agenda across the UK.
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Content ArticleQuality is complex and difficult to define, and institutions and organisations often have their own definitions, measurements and assurance processes. The Care Excellence Framework (CEF), developed and used at University Hospitals of North Midlands NHS Trust, is a unique, integrated framework of measurement, clinical observation, patient and staff interviews and benchmarking. It also has an internal accreditation system that provides assurance from ward to board based on the five Care Quality Commission (CQC) domains and reflects CQC standards. The CEF has been established in its existing form since autumn 2016 and has been used in all areas of the organisation. This article provides an overview of the development and use of the CEF in an acute care setting, demonstrates how the framework acts as an internal accreditation system, and shows how it can encourage staff to undertake effective change and transform care from ordinary to excellent.
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Content ArticleThis QualityWatch report, ‘Focus on: Emergency hospital care for children and young people’, shows changes in patterns of use over time and provides the basis for discussion about the quality of care for children and young people. The report analyses Hospital Episode Statistics from 2006/07 to 2015/16, giving a picture of how children and young people used emergency care at NHS hospitals over the past 10 years, what conditions they needed care for, and what may be happening to care quality in some areas. It finds that some age groups saw significant rises in emergency admissions, and many children were hospitalised for conditions that could be treated in other settings. The report, therefore, also raises questions about where children and young people can access high quality treatment outside the hospital emergency care setting.
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Content ArticleThe number of people waiting for NHS treatment in England has risen rapidly during the Covid-19 pandemic, with more than 6.8 million people waiting for treatment in July 2022. Read the Institute for Fiscal Studies' analysis of NHS waiting lists.
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EventuntilThe story of Alison Bell, and her family's uncovering of the truth about what happened to her in the care of an NHS Trust will be told by her brother Tom. He will describe the nature of the various investigations that were held into Alison's death and the role of the prevailing cultures within the public sector organisations they have dealt with; the NHS, Police, CPS and Regulatory Bodies. This true and ongoing story shines a light on the personal, emotional and financially costly impact that public sector service cultures can have on the lives of their service-users and their own bottom-line. Tom’s lived and current experience will help us to explore the implications for our own practice and the organisations we might seek to influence, manage and lead. Registration
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EventThis free four-week online course from the King's Fund will provide you with a broad understanding of the NHS – its inner workings, how it all fits together and the challenges it typically faces. You will build your knowledge of the health system in England through articles, quizzes and videos with experts from The King’s Fund. Plus you can study each week at a time that suits you. Sign up
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Human Factors for Patient Safety Course
Patient Safety Learning posted an event in Community Calendar
Patient Safety is an essential part of health and social care that aims to reduce avoidable errors and prevent unintended harm. Human Factors looks at the things that can affect the way people work safely and effectively, such as the optimisation of systems and processes, the design of equipment and devices used and the surrounding environment and culture, all of which are key to providing safer, high quality care. New for September 2020, this part-time, three year, distance learning course, from the Centre of Excellence Stafford, focuses specifically on Human Factors within the Health and Social Care sectors with the aim of helping health and social care professionals to improve performance in this area. The PgCert provides you with the skills to apply Human Factors to reduce the risk of incidents occurring, as well as to respond appropriately to health, safety or wellbeing incidents. Through the study of Human Factors, you will be able to demonstrate benefit to everyone involved, including patients, service users, staff, contractors, carers, families and friends. Further information -
Content ArticleIdentifying improvements in maternity care to help reduce the risk of delays in crucial interventions during labour when a baby is suspected to be unwell is the focus of this latest Healthcare Safety Investigation Branch (HSIB) report. The report was compiled after a review of 289 of our maternity investigations into intrapartum stillbirths, neonatal deaths and potential severe brain injuries. In 14.9% of the cases the delay was a contributory factor. The review identified issues such as inadequate staffing, poor infrastructure and high workload as contributory factors to the delays. Evidence from national reports confirms that such delays are a recognised patient safety risk.
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Content ArticleThere are large numbers of patients with olfactory disturbance in the UK and shortfalls in assessment and support amongst mainstream practice in both primary and secondary care leading to significant quality‐of‐life impairment and potential missed diagnoses. The aim of this study from Erskine and Philpott was to determine the key themes which can be identified from the accounts of anosmia sufferers and to identify important areas to target for future research or service development.
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Content ArticleOn 23 September, Improvement Cymru, the all-Wales Improvement service for NHS Wales, hosted an online session with colleagues from Holland to talk about patient flow in hospital.
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Content ArticleSacha Wells-Munro, Maternity Improvement Advisor at NHS Improvement and Professor Tim Draycott, consultant obstetrician and Health Foundation Improvement Science Fellow, present at the Patient Safety Learning Conference the lessons learned from the Morecambe Bay maternity scandal and changes needed to improve the safety of maternity services system wide.
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Content ArticleElderly people in care homes in Cornwall were abused and neglected while failings led to reports of concerns not being investigated, a new Safeguarding Adults Review has found. The Morleigh Group, which operated seven homes in Cornwall and has since shut down, was exposed in a BBC Panorama investigation in 2016. A new Safeguarding Adults Review which was commissioned as a result of the TV show has been published making a number of recommendations to all agencies which were involved in the case. The review was completed in April 2019 but has only just been made public - Rob Rotchell, Cornwall Council Cabinet member for adult social care said that this was due to the number of agencies being involved.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) report charts a four-month patient safety investigation that was launched following concern that patients were contracting COVID-19 after being admitted to hospital. The report references data presented to SAGE in mid-May that suggested around 20% of patients were reporting symptoms seven days after admission. The aim of the investigation was to understand the factors that could contribute to the risk of transmission, how the NHS operates to reduce that risk and where there may be opportunities to reduce that risk even further. The investigation represented the voices of those working across the health service, from strategic national planners to hospital porters. It also captured experiences of patients and families, providing further insight into the challenges of managing the transmission of COVID-19.
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Content ArticleIn the latest Patient Safety Watch newsletter, Jeremy Hunt interviews Aidan Fowler on his role as National Director for Patient Safety, the impact the new health and care bill will have on patient safety, and his personal wish list for the next couple of years. (Interview appears at the end of the newsletter.)
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Content ArticleHealthcare worldwide is faced with a crisis of patient safety: every day, everywhere, patients are injured during the course of their care. Notwithstanding occasional successes in relation to specific harms, safety as a system characteristic has remained elusive. Mary Dixon-Woods and Peter J Pronovost propose that one neglected reason why the safety problem has proved so stubborn is that healthcare suffers from a pathology known in the public administration literature as the problem of many hands. It is a problem that arises in contexts where multiple actors – organisations, individuals, groups – each contribute to effects seen at system level, but it remains difficult to hold any single actor responsible for these effects. Efforts by individual actors, including local quality improvement projects, may have the paradoxical effect of undermining system safety. Many challenges cannot be resolved by individual organisations, since they require whole-sector coordination and action. The authors call for recognition of the problem of many hands and for attention to be given to how it might most optimally be addressed in a healthcare context.
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Content ArticleUrgent action is needed in the NHS to meet a ballooning backlog of procedures put on hold during the pandemic and build a more resilient health care system. This report from Reform, produced jointly with Edge Health, shows the scale of the challenges the NHS faces: 6 million fewer patients were referred to treatment in 2020 than in 2019 • 10 million patients could be on a waitlist by April By April, 52-week waits for care are projected to have risen 12,008% since March 2020 (by December they had already risen by 7139%) Cancellations of diagnostic testing and delayed treatment may lead to 1,660 extra deaths from lung cancer alone.
