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Content ArticleHertfordshire Partnership University NHS Foundation Trust's Quality Account has been designed to report on the quality of their services in line with regulations. The aim in this report is to describe in a balanced and accessible way of how the Trust provides high-quality clinical care to service users, the local population and commissioners.
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Content Article
In this blog Patient Safety Learning sets out its initial response to the report of the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust (also known as the Ockenden Maternity Review).- Posted
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News Article
Baby deaths inquiry: Shrewsbury NHS trust condemned for ‘repeated failures’
Patient Safety Learning posted a news article in News
A damning report into hundreds of baby deaths has condemned the trust at the centre of the biggest maternity scandal in the history of the NHS for blaming mothers while repeatedly ignoring its own catastrophic blunders for decades. The independent inquiry into maternity practices at Shrewsbury and Telford hospital NHS trust uncovered hundreds of cases in which health officials failed to undertake serious incident investigations, while deaths were dismissed or not investigated appropriately. Instead, grieving families were denied access to reviews of their care and mothers were blamed when their babies died or suffered horrific injuries. A combination of an obsession with natural births over caesarean sections coupled with a shocking lack of staff, training and oversight of maternity wards resulted in a toxic culture in which mothers and babies died needlessly for 20 years while “repeated failures” were ignored again and again. Tragically, it meant some babies were stillborn, dying shortly after birth or being left severely brain damaged, while others suffered horrendous skull fractures or avoidable broken bones. Some babies developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries. The report, led by the maternity expert Donna Ockenden, examined cases involving 1,486 families between 2000 and 2019, and reviewed 1,592 clinical incidents. “Throughout our final report we have highlighted how failures in care were repeated from one incident to the next,” she said. “For example, ineffective monitoring of foetal growth and a culture of reluctance to perform caesarean sections resulted in many babies dying during birth or shortly after their birth. “In many cases, mother and babies were left with lifelong conditions as a result of their care and treatment. The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the trust and a culture of not listening to the families involved. “There was a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths. What is astounding is that for more than two decades these issues have not been challenged internally and the trust was not held to account by external bodies. “This highlights that systemic change is needed locally, and nationally, to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding. Going forward, there can be no excuses.” Read full story Source: The Guardian, 30 March 2022 -
Content ArticleThe Independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust was commissioned in 2017 to assess the quality of investigations relating to newborn, infant and maternal harm at the Trust. When it commenced this review was of 23 families’ cases, but it has subsequently grown to cover cases of maternity care relating to 1,486 families, the majority of which were patients at the Trust between the years 2000 and 2019. Some families had multiple clinical incidents therefore a total of 1,592 clinical incidents involving mothers and babies have been reviewed with the earliest case from 1973 and the latest from 2020.
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Content Article
CORESS reports
Patient Safety Learning posted an article in Surgery
CORESS is an independent charity, which aims to promote safety in surgical practice in the NHS and the private sector. CORESS receives confidential incident reports from surgeons and theatre staff. These reports are analysed by the Advisory Board, who make comments and extract lessons to be learned. Aiming to educate, and avoid blame, CORESS calls on surgeons to recognise a near miss or adverse event, react by taking action to stop it happening and then report the incident to CORESS so that the lessons can be published. Every month CORESS highlight's one of the cases reported for you to consider the issues raised and read the experts comments. -
Content ArticleHealthcare professionals have a duty to be open and honest with patients and people in their care when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress. This is know as the professional duty of candour. This joint guidance from the General Medical Council and Nursing & Midwifery Council provides detailed guidance for healthcare professionals on: being open and honest with patients in your care, and those close to them, when things go wrong. encouraging a learning culture by reporting errors.
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Content ArticleWithin the last two decades, it has been commonly agreed that patient safety and error management in healthcare organizations can best be attained by adopting a systems approach via re-engineering efforts and the introduction of industrial safety technologies and methodologies. This strategy has not delivered the expected result. Based on John Dewey’s pragmatism, in this study Kirstine Z. Pedersen and Jessica Mesman propose another vocabulary for understanding, inquiring into and learning from safety situations in healthcare. Drawing especially on Dewey’s understanding of transaction as the inseparability between human and environment, they develop an analytical approach to patient safety understood as a transactional accomplishment thoroughly dependent on the quality of situated and shared habits and collaborative practices in healthcare. They further illustrate methodologically how a transactional attitude can be situationally practised through video-reflexive ethnography, a method that allows for inquiry into mundane safety practices by letting interprofessional teams see, reflect upon and possibly modify their shared practices and safety habits.
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Crossword counterpoint: glimpses of NHS whistleblowing terrain
Hugh Wilkins posted an article in Whistle blowing
This blog is prompted by a recent newspaper crossword in which one of the clues, quadruplicated, was 'Whistle-blower'. The four answers were, respectively, 'canary', 'snitch', 'telltale' and 'betrayer'. The blog draws attention to negative perceptions of whistleblowers in the eyes of some people. It emphasises how wrong these perceptions are and how damaging this can be, with serious patient safety implications. In this blog I provide a crossword counterpoint (attached below to solve), which seeks to support learning about the realities of hostility against some staff who speak up in the NHS. I will share a follow-up blog which contains the solution to this crossword and seeks to provide further education on this topic where there is so much confusion and misunderstanding. -
Content Article
Learning from Coroner's reports
Patient Safety Learning posted an article in Coroner reports
When a patient dies because of preventable avoidable harm it is crucial that we learn from the event and implement changes to ensure it does not reoccur. Implementing the findings and recommendations of Coroner’s Prevention of Future Deaths (PFD) reports can play a key role in this. This blog reflects on a recent discussion at a Patient Safety Management Network (PSMN) meeting about PFD reports and how their insights can be used for learning and improvement. 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 to patient safety managers, providing information, peer support and safe space for discussion. You can find out about the network here.- Posted
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Content Article
NHS England’s Patient Safety Team will be launching the new Patient Safety Incident Response Framework (PSIRF) in the Spring of 2022, and one of the tools it will recommend to enhance learning from events is After Action Review (AAR). It is likely that each healthcare provider will define its own 'playing field' for AAR as the PSIRF is integrated in daily practice in the months and years ahead, yet this can extend far wider than many assume. In the 12 years since I was trained as an AAR Conductor, I have grown to appreciate its adaptability as well as the many benefits it delivers. The examples of real AARs described here are designed to illustrate some of the many applications. As you will see, these AARs have created opportunities for learning at three levels, all of which contribute to the delivery of safe and effective patient care: the individual, the team and the organisation. -
Content Article
This is the third in our new series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Deinniol tells us about how his role at the Healthcare Safety Investigation Branch (HSIB) helps make healthcare services in the UK safer for both patients and staff. He explains the importance of understanding the complexity of healthcare systems and the pressures that staff within the NHS face. He highlights the need build trust with patients, staff and other stakeholders to find ways forward in improving patient safety. -
Content ArticlePromoting a ‘just culture’ is a key theme in patient safety research and policy, reflecting a growing understanding that patients, their families and healthcare staff involved in safety events can experience feelings of sadness, guilt and anger, and need to be treated fairly and sensitively. There is also growing recognition that a ‘blame culture’ discourages openness and learning. However, there are still significant difficulties in listening to and involving patients and families in organisations' responses to safety incidents, and for healthcare staff, a blame culture often persists. This can lead to a sense of sustained unfairness, unresponsiveness and secondary harm. The authors of this article in BMJ Quality & Safety argue that confusion about safety cultures comes in part from a lack of focused attention on the nature and implications of justice in the field of patient safety. They make suggestions about how to open up a conversation about justice in research and practice.
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Content Article
Blog - Learning from HSIB Covid-19 reports (27 January 2022)
Patient-Safety-Learning posted an article in Blogs
This blog summarises investigations about Covid-19 and its impact on the healthcare system carried out by the Healthcare Safety Investigation Branch (HSIB). It highlights learning from five HSIB reports: COVID-19 transmission in hospitals: management of the risk – a prospective safety investigation Early warning scores to detect deterioration in COVID-19 inpatients Oxygen issues during the COVID-19 pandemic Treating COVID-19 patients using continuous positive airway pressure (CPAP) Personal protective equipment (PPE): care workers delivering homecare during the COVID-19 response -
Content ArticleHealthcare is recognised as a high-risk industry, involving complex systems, vulnerable individuals, and constantly evolving clinical treatments and healthcare products. This is the recording of a webinar hosted by NHS Supply Chain which looked at key patient safety issues in the NHS. It includes examples of learning related to patient safety and assurance priorities for safe healthcare products and services. Speaker panel: Helen Hughes, Chief Executive of Patient Safety Learning Tracey Cammish, NHS Supply Chain Heather Tierney-Moore OBE, NHS Supply Chain Dave Fassam, Healthcare Safety Investigation Branch (HSIB)
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News Article
CQC should not ‘sit in an ivory tower’ when rating ICSs, says preferred chair
Patient Safety Learning posted a news article in News
The Care Quality Commission (CQC) should not ‘sit in an ivory tower and dream up what it thinks good looks like’ when it starts rating integrated care systems, the proposed new chair for the regulator has told MPs. Ian Dilks, the government’s preferred candidate to become the CQC’s new chair, was questioned by the health and social care committee on Tuesday. During the session the committee chair’s Jeremy Hunt asked how Mr Dilks would make the rating of systems “a success”. Mr Hunt said: “We became the first healthcare system in the world to ‘Ofsted rate’ our hospitals. Under your leadership, assuming you take up this role, we will become the first healthcare system in the world to do the same for entire geographical regions of health systems.” Mr Dilks responded: “I don’t think it is up to the CQC to sit in an ivory tower and dream up what it thinks good looks like.” “It will not be in anybody’s interest if the CQC comes up with a whole bunch of ratings and ICSs say, ‘well I don’t know how you got there’.” He added: “I think involving all parties in the development process so that what emerges has a high degree of acceptance.” He was also asked at the session about what he had learnt about improving patient safety while working at NHS Resolution. Mr Dilks said: “I do not think the system is good at learning… it needs some help and encouragement to firstly really understand what’s gone wrong when you have an outcome that isn’t the correct one, and secondly how do you encourage and support the system to do better the next time around.” Read full story (paywalled) Source: HSJ, 23 February 2022 -
Content Article
In this blog, Patient Safety Learning’s Chief Executive, Helen Hughes, reflects on participating in a recent Health Service Journal (HSJ) Patient Safety Congress webinar, held in association with BD, which considered some of the key emerging patient safety issues for 2022.- Posted
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Content ArticleIn this blog, Gwen Nightingale and Katherine Merrifield from The Health Foundation highlight measures to tackle health inequalities that they would like to see included in the government's White Paper on health disparities, due to be published in Spring 2022. They argue that significant investment and ambitious policy are needed to tackle differences in health outcomes. They highlight five areas of focus: Tackle the wider determinants of health head on A new, whole-government approach to improving health Policy ideas backed with immediate investment Meaningfully measuring success Learning from the past
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Content ArticleDr Nick Woodier, HSIB National Investigator, reflects on the challenges associated with joint surgical care of patients and shares learning that can aid the NHS and the private sector as new national agreements come into force.
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Content Article
What is a whistleblower?
Hugh Wilkins posted an article in Whistle blowing
hub topic lead, Hugh Wilkins, explores attitudes towards and repercussions of whistleblowing, with emphasis on healthcare professionals who suffer retaliation after raising patient safety concerns. He draws attention to damaging discrepancies between written policy and actual procedure. Hugh urges all healthcare leaders to welcome the concerns that 'whistleblowers' raise in the public interest and respond positively to them, which would lead to substantial improvements in staff engagement, organisational culture, quality of care and patient safety. *Whilst much of the information in this article is referenced and in the public domain it is not legal advice.- Posted
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Statement from Sajid Javid, Secretary of State for Health and Social Care, to the House on establishing a Special Health Authority for Independent Maternity Investigations. -
Content ArticleThis study in the International Journal of Nursing Studies looked at the role of primary care nurses in coaching patients in shared decision making about their treatment. It evaluated an approach to support nurses in coaching patients, which was found to have a positive impact overall. Nurses became more aware of their own attitudes and learning needs and reported more in-depth discussions with patients. However, nurses struggled to integrate the approach in routine care and highlighted the need to receive support from their practice to implement the new approach.
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Content ArticleOnline patient feedback is becoming increasingly prevalent on an international scale. However, limited research has explored how healthcare organisations implement such feedback. This research from Baines et al. sought to explore how an acute hospital, recently placed into ‘special measures’ by a regulatory body implemented online feedback to support its improvement journey.
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Content ArticleImproving patient safety culture (PSC) is a significant priority for OECD countries as they work to improve healthcare quality and safety—a goal that has increased in importance as countries have faced new safety concerns connected to the COVID-19 pandemic. Findings from this OECD benchmarking work in PSC show that there is significant room for improvement.
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Content Article
A series of failures: a relative's story
Patient Safety Learning posted an article in Keeping patients safe
At the first Patient Safety Management Network (PSMN)* meeting of 2022, we were privileged to hear from a bereaved relative about her shocking experience, which reminded us all of why we do what we do. Claire Cox, one of the PSMN founders, invited Susan (not her real name to protect her confidentiality) to share with us the causes of her relative’s untimely death and the poor and shameful experience when she and her GP started to ask questions. This kicked off a valuable and insightful discussion about how patients are responded to when things go wrong and about honesty and blame, patient and family engagement in decision making when patients are terminally ill, and how we need to ensure that the new Patient Safety Incident Response Framework (PSIRF) guidance embeds good practice informed by the real-life experience of patients and staff.- Posted
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Content ArticlePoster from the Princess Alexandra Hospital on their Learning from deaths project.
