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Found 544 results
  1. Content Article
    Women should be able to have confidence that they will receive safe, effective, compassionate maternity care that focuses on their individual needs. That is the experience of many people. But too many families still face care that puts the safety and wellbeing of women and babies at risk. This Parliamentary and Health Service Ombudsman (PHSO) report looks at themes from maternity complaints families have brought to us, to shine a light on their experiences and encourage others to let their voices be heard. It shares case summaries and guidance to help families complain and help NHS organisations understand the issues.
  2. Content Article
    This article* is an update from Dr Henrietta Hughes, Patient Safety Commissioner for England.
  3. Content Article
    Research on maternity care often focuses on factors that prevent good communication and collaboration and rarely includes important stakeholders – parents – as co-researchers. To understand how professionals and parents in Dutch maternity care accomplish constructive communication and collaboration, Korstjens et al. examined their interactions in the clinic, looking for “good practice”.
  4. Content Article
    Patient Safety Learning recently interviewed Keith Conradi, former HSIB chief executive, on why healthcare needs to operate as a safety management system. In this interview, we speak to Jono Broad, part of the South West Integrated Personalised Care team at NHS England, to hear his response to this, how patients, families and relatives can get involved, and why we need to really embed patient safety in a management culture and a healthcare management system.
  5. Content Article
    Statement from Maria Caulfield, Parliamentary Under Secretary of State (Minister for Mental Health and Women's Health Strategy) on the Government’s initial response to the report of the independent review into the maternity and neonatal services at East Kent University NHS Foundation Trust that was published on the 19 October 2022. NHS England commissioned Dr Bill Kirkup to undertake this review following concerns about the quality and outcomes of care.
  6. Content Article
    It's now a decade since the Francis Report, which outlined the causes of serious failures in care at Mid Staffordshire NHS Foundation Trust. The report and prior media coverage exposed a wide set of issues surrounding the culture and transparency of health care, and these topics remain of major concern today. In this article for the Nuffield Trust, Shaun Lintern has interviewed Sir Robert Francis KC about the weight of those patient stories and treatment of the NHS's staff, then and now.
  7. Content Article
    The Harmed Patients Alliance (HPA) was founded to highlight and promote restorative approaches to healthcare harm. To support their campaign for action, HPA carried out a survey of 44 people asking how those harmed by their contact with healthcare felt about the response, and what impacts this had on them. They were also asked what could have been done differently. 
  8. Content Article
    This report looks into the circumstances surrounding the deaths of three young adults; Joanna, Jon and Ben. They each had learning disabilities, were patients at Cawston Park Hospital and died within a 27 month period (April 2018 to July 2020). It highlights multiple significant failures in care, including excessive use of restraint and seclusion, overmedication of patients, lack of record keeping and the physical assault of patients. The report also makes a series of recommendations for critical system and strategic change, both at a local and national level.
  9. Content Article
    More and more people are dying at home, rather than in a hospital or hospice. With this trend set to continue, how can commissioners ensure that end-of-life care reflects this and meets the needs of people approaching the end of their lives and their loved ones?   This new report from the King's Fund explores what we know about commissioning end-of-life care, the inequalities experienced by particular groups, and how NHS and social care commissioners in England are measuring and assuring the quality of care people receive.   Drawing on interviews with commissioners, stakeholders and experts in end-of-life care, as well as recently bereaved carers and family members, this report offers reflections and recommendations for those wanting to improve end-of-life care for those dying at home.
  10. Content Article
    GP services are the first point of call for many health issues and the gateway to NHS specialist support.  GP teams are highly skilled and may decide that treatment without specialist care is the best action. But when you need specialist support, such as hospital tests or treatment, you may need a referral from your GP team first. New research from Healthwatch highlights that it can be very hard for some people to get a GP referral to another NHS service. And for 21% of people we spoke to, even when they get referrals, they can be lost, rejected or not followed up on. When services don't process referrals properly, it can cause significant frustration, unnecessary anxiety, and even cause harm to patients.  It can also lead to increased demand for either more GP appointments or help from healthcare teams in other parts of the NHS, putting more pressure on already overstretched services.
  11. News Article
    The NHS could be facing its largest maternity scandal to date as the review into services in Nottingham is now expected to exceed 1,500 cases, The Independent has learned. The probe began in 2021 after this newspaper revealed dozens of babies had died or been left with serious injuries or brain damage as a result of care at NUH, which runs Nottingham’s City Hospital and Queen’s Medical Centre (QMC). But the scope of the investigation has more than doubled, with Nottingham University Hospitals NHS Trust sending more than 1,000 letters to families to contact the independent inquiry, after 700 families previously came forward with their concerns. Of these, the number of families expected to be covered by the probe is more than 1,500 – surpassing the 1,486 examined during the UK’s current largest maternity scandal in Shrewsbury. Read full story Source: The Independent, 30 November 2022
  12. News Article
    Greg Price died of complications after testicular cancer surgery, but a review of his case found missed faxes, follow-ups and botched data-sharing ultimately cost the vibrant 31-year-old Alberta man his life. All the missteps in his case meant it took 407 days from his first complaint for Price — an engineer, pilot, and athlete — to be diagnosed with cancer. He died three months after his doctor said he should see a specialist, and while he was being passed between multiple doctors, his health data often was not. Now, his sister, Teri Price, says too little has changed in medical information-sharing in the decade since her brother's death. This, despite a review of his case — the 2013 Alberta Continuity of Patient Care Study — that recommended life-saving changes to the healthcare system to avoid more experiences like his. So, she's fighting to improve the system that she says not only failed her brother, but keeps failing to change. Price says that Canadians assume that their health information is shared between doctors to keep them safe and studied to improve the system, but often, it's not. And medical front-line staff in Canada say problems persist when it comes to sharing everything from patient information to aggregate medical and staffing data. "Information tends to be broken up between the services that patients attend," said Ewan Affleck, a doctor in the Northwest Territories who has spent his career fighting for better data access, and a member of the expert advisory arm of the Pan-Canadian Health Data Strategy Group. "The cohesion and use of health data in Canada is legislated to fail." Read full story Source: CBC News, 17 November 2022
  13. News Article
    Judges’ notes are regarded as the official record and are made available to employment appeal tribunals, but they are seen as private documents and are not available to the parties. If the judgment that follows a hearing omits substantial elements of oral evidence that support the claimant’s case, the prospects of a successful appeal are hampered without a court record. 'This imbalance irretrievably denies parties the right to prepare adequately an appeal and it is manifestly unfair,' the letter states. Reference to the full record 'is the only way to determine whether the decision made was fair and proper'. Signatories include Sir Adam Ridley, a former senior civil servant at 10 Downing Street and the pioneering cardiologist Jane Somerville of Imperial College, London. A spokesperson for the judiciary said: 'The letter has been received and is being reviewed.' Barrister Sophie Walker, founder of the company Just Transcription, told the Gazette: 'Providing litigants and their legal teams recordings and automated transcripts of the hearing would be a major leap forward for open justice and access to justice.' Read full story Source: The Law Society Gazette, 22 March 2022
  14. News Article
    Care homes and hospitals will be forced to allow visitors under plans being drawn up by the government. Helen Whately, the care minister, said shutting out relatives showed a lack of humanity. Covid-19 rules mean some of the country’s most vulnerable people still cannot have loved ones at their bedside. Whately, who has told of her personal grief and frustration at being barred from visiting her critically ill mother, is now developing laws to give residents and patients a right to receive visitors. Although official visiting restrictions were dropped in the spring in England, there are still widespread reports of care homes and hospitals refusing to let in relatives or imposing stringent conditions that ministers do not believe are justified by public health guidance. Hundreds of care homes still refuse to accept visitors entirely, according to government figures, while others restrict residents to one relative at a time. Campaigners report residents losing weight because their relatives cannot go in to help them at mealtimes amid staff shortages. They also fear residents are being left in bed for long periods because staff know there will be no visitors to check on them. Whately said that she was “determined to fix” the issue, adding: “No one can be in any doubt now how much visits matter”. Read full story (paywalled) Source: The Times, 11 November 2022 Related reading on the hub: Visiting restrictions and the impact on patients and their families: a relative's perspective It’s time to rename the ‘visitor’: reflections from a relative
  15. News Article
    A senior doctor is to be removed from the medical register after she was found to have attempted to cover-up the circumstances of a young girl's death. Paediatrics consultant Dr Heather Steen was found to be unfit to practise after an investigation into the death of nine-year-old Claire Roberts in 1996. A medical tribunal examining the doctor's case ruled that the majority of allegations against her were true. Claire's mother said it was "just the start of getting full justice". "I am angry at Dr Steen for putting us through 26 years of mental torment," said Jennifer Roberts. At the time of Claire's death, her parents were told she had a viral infection that had spread from her stomach to her brain. But in 2018 a public inquiry determined that she had died from an overdose of fluids and medication caused by negligent care at the Royal Belfast Hospital for Sick Children. The inquiry also concluded there had been "cover up" and the girl's death had not been referred to the coroner immediately to "avoid scrutiny". The case was then put to the Medical Practitioners Tribunal Service (MPTS), which rules on doctors' fitness to practise. When the case reached the tribunal stage Dr Steen twice applied to be voluntarily removed from the medical register and was twice refused. Had that been successful the tribunal would have been halted as she would no longer have been a doctor. However the tribunal continued and examined allegations that between October 1996 and May 2006 Dr Steen "knowingly and dishonestly carried out several actions to conceal the true circumstances" of Claire. Read full story Source: BBC News, 11 November 2022
  16. News Article
    Across the country there have been reports of “do not resuscitate” (DNR) orders being imposed on patients with no consultation, as is their legal right, or after a few minutes on the phone as part of a blanket process. Laurence Carr, a former detective chief superintendent for Merseyside Police, is still angry over the actions of doctors at Warrington Hospital who imposed an unlawful “do not resuscitate” order on his sister, Maria, aged 64. She has mental health problems and lacks the capacity to be consulted or make decisions and has been living in a care home for 20 years. As her main relative, Mr Carr found out about the notice on her records only when she was discharged to a different hospital a week later. Maria had been admitted for a urinary tract infection at the end of March. Although she has diabetes and an infection on her leg her condition was not life threatening. Mr Carr said: “My sister has no capacity to effectively be consulted due to her mental illness and would not understand if they did try to explain, so I was furious that I had not been consulted." He later learnt that the reason given by the hospital for imposing the DNR was "multiple comorbitidies". In a statement, Warrington and Halton Teaching Hospitals Foundation Trust said it was fully aware of the law, which was reflected in its policies and regular training. It said: “We did not follow our own policy in this case and have the requisite discussions with the family. The template form which was completed in this case indicates that discussion with the family was ‘awaiting’. Regretfully due to human error this did not occur." Mr Carr and his sister are not alone. National charity Turning Point said it had learnt of 19 inappropriate DNARs from families, while Learning Disability England said almost one-fifth of its members had reported DNARs placed in people’s medical records without consultation during March and April. Read full story Source: The Independent, 14 July 2020
  17. News Article
    A woman whose father died in a care home has launched a judicial review case in the High Court over the government’s “litany of failures” in protecting the vulnerable elderly residents who were most at risk from COVID-19. Cathy Gardner accuses England’s health and social care secretary, Matt Hancock, NHS England, and Public Health England of acting unlawfully in breaching statutory duties to safeguard health and obligations under the European Convention on Human Rights, including the right to life. Her father, Michael Gibson, who had Alzheimer’s disease, died aged 88 of probable COVID-19 related causes on 3 April at Cherwood House Care Centre, near Bicester, Oxfordshire. She claims that before his death the care home had been pressured into taking a hospital patient who had tested positive for the virus but had not had a raised temperature for about 72 hours. “I am appalled that Matt Hancock can give the impression that the government has sought to cast a protective ring over elderly residents of care homes, and right from the start,” Gardner said. “The truth is that there has been at best a casual approach to protecting the residents of care homes. At worst the government has adopted a policy that has caused the death of the most vulnerable in our society.” Read full story Source: BMJ, 15 June 2020
  18. News Article
    The government has announced an independent review into maternity services at an NHS trust where a number of babies have died. “Immediate actions” have also been promised and an independent clinical team has been placed “at the heart” of East Kent Hospitals University NHS Foundation Trust. It comes amid reports that at least seven preventable baby deaths may have occurred at the trust since 2016, including that of Harry Richford. Harry died seven days after his emergency delivery in a “wholly avoidable” tragedy, contributed to by neglect, in November 2017, an inquest found. Speaking in the House of Commons, the health minister Nadine Dorries confirmed the independent review would be carried out by Dr Bill Kirkup, who led the investigation into serious maternity failings at Morecambe Bay. It will look at preventable and avoidable deaths of newborns to ensure the trust learns lessons from each case and will put in place appropriate processes to safeguard families. The review is expected to begin shortly and work in partnership with affected families. Read full story Source: 13 February 2020
  19. News Article
    Harry Richford's death underlines the need for the health secretary to bring back the national maternity safety training fund – and there are other issues that require urgent attention – The Independent reports. Harry Richford had not even been born before the NHS failed him. An inquest has concluded he was neglected by East Kent University Hospitals Trust in yet another maternity scandal to rock the NHS. His parents and grandparents have fought a tireless campaign against a wall of obfuscation and indifference from the NHS. In their pursuit of the truth they have exposed a maternity service that did not just fail Harry, but may have failed dozens of other families. As with the family of baby Kate Stanton-Davies at Shrewsbury and Telford Hospitals Trust, or Joshua Titcombe at the University Hospitals of Morecambe Bay Trust, it has taken a family rather than the system to expose what was going wrong. It is known that there are about 1,000 cases a year of safety incidents in the NHS across England, including baby deaths, stillbirths and children left brain damaged by mistakes. Last week, the charity Baby Lifeline, joined The Independent to call on the Department of Health and Social Care (DHSC) to reinstate the axed maternity safety training fund. This small fund was used to train maternity staff across the country. Despite being shown to be effective, it was inexplicably scrapped after just one year. There are other issues that also need urgent attention. The inquest into Harry’s death, which concluded on Friday, lasted for almost three weeks. Without pro bono lawyers from Advocate, Brick Court Chambers and Arnold & Porter law firm, the family would have faced an uphill struggle. At present, families are not automatically entitled to legal aid at an inquest, yet the NHS employs its own army of lawyers who attend many inquests and can overwhelm bereaved families in a legal battle they are ill-equipped to fight. Even the chief coroner, Mark Lucraft QC, has called for this inequality of legal backing to end, but the government has yet to take action. Read full story Source: The Independent, 26 January 2020
  20. News Article
    Today marks the seventh annual Patient Solidarity Day, where people and organisations across the world rally around one of the key issues facing patients and help to raise awareness of this. The theme this year is ‘Acceleration for Safe Patient-Centred Universal Health Coverage’ with a call to hold leaders accountable for the commitments they have made to ensure safe and patient-centred universal health coverage for all. In a bog released today, Patient Safety Learning's Helen Hughes discusses why patient engagement is essential for a patient-safe future and how we are currently working with Joanne Hughes, founder of Mother’s Instinct, to take action to help patients engage for patient safety. Read blog
  21. News Article
    More than 200 new families have contacted an inquiry into mother and baby deaths at a hospital trust in Shropshire. Investigators were already looking at more than 600 cases where newborns and mothers died or were left injured while in the care of the Shrewsbury and Telford Hospital Trust. One expert says the scandal, spanning decades, may be the tip of the iceberg. Dr Bill Kirkup says it suggests failure might be more widespread in the NHS. The surge in new cases follows the leak of an interim report last week. Read full story Source: BBC News, 27 November 2019
  22. Content Article
    In a wide-ranging Report on NHS litigation reform, the Health and Social Care Committee finds the current system for compensating injured patients in England ‘not fit for purpose’ and urges a radically different system to be adopted. Reforms would introduce an administrative scheme which would establish entitlement to compensation on the basis that correct procedures were not followed and the system failed to perform rather than clinical negligence which relies on proving individual fault. The new system would prioritise learning from mistakes and would reduce costs. Currently, litigation offers the only route by which those harmed can access compensation. MPs say in addition to being grossly expensive and adversarial, the existing system encourages individual blame instead of collective learning. This is a House of Commons Committee report, with recommendations to government. The Government has two months to respond.
  23. Content Article
    Preventable harm continues to occur to critically ill premature babies, despite efforts by hospital neonatal intensive care units (NICUs) to improve processes and reduce harm. This article in the Journal for Healthcare Quality describes the introduction of a robust process improvement (RPI) program at a NICU in a US children's hospital. Leaders, staff, and parents were trained in RPI concepts and tools and given regular mentoring for their improvement initiatives, which focused on central line blood stream infections, very low birth weight infant nutrition and unplanned extubations. The authors conclude that implementing the RPI program resulted in significant and sustainable improvements to reduce harm in the NICU.
  24. Content Article
    The newly released Ockenden report into maternity services at Shrewsbury and Telford NHS trust is at least the fourth similar report in recent years, with two more in progress. Many messages are not new, and these are not isolated findings. Women and families accessing care throughout the UK continue to feel ignored. Many families remain concerned that they are not receiving full and frank investigations and explanations after the death or injury of a mother or baby. Repeated headlines understandably undermine women’s confidence in services when they should be able to trust that they will receive safe, high quality care writes Marian Knight and Susanna Stanford in this BMJ Editorial.
  25. Content Article
    Martin Bromiley is a commercial airline training Captain and founder of The Clinical Human Factors Group. This episode of the Leadership Enigma podcast is deeply personal, inspirational and thought provoking. Martin describes how he turned the loss of his wife after a surgical procedure into a mission to understand and help others embrace the need for non-technical behaviours especially during critical times. He chats about the aviation and healthcare industry in relation to themes such as deference to hierarchy, the checklist manifesto, confident humility and creating an environment where your team and organisation embrace the challenge to 'double their error rate.' Behaviours are the bedrock for living your values and creating a culture that is positive and sustainable.
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