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Showing results for tags 'Patient / family involvement'.
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News ArticleAcross 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
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News ArticleA 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
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News Article
Review launched into East Kent NHS trust after baby deaths
Patient Safety Learning posted a news article in News
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 -
News Article
Justice is being denied to too many families
Patient Safety Learning posted a news article in News
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 -
News ArticleToday 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
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News Article
Hundreds of families come forward in Shropshire maternity scandal
Patient Safety Learning posted a news article in News
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 -
Content ArticleIn 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.
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Content ArticlePreventable 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.
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Content ArticleThe 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.
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Content ArticleMartin 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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Content ArticleDr Tejal Gandhi, has been a leader in patient and workforce safety for more than 20 years. Dr. Gandhi talked with Patient Safety Beat following publication of her essay, “Don’t Go to the Hospital Alone: Ensuring Safe, Highly Reliable Patient Visitation,” in the Joint Commission Journal on Quality and Patient Safey.
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Content Article“Don't go to the hospital alone” has been the advice that safety experts have promoted for many years as a way that patients can help protect themselves. Family members provide an important safety net for patients in the hospital, and across the entire continuum of care—another slice of the Swiss cheese in our defenses against errors. As safety professionals, we hate to have to rely on that safety net, knowing that not all patients and families are able to provide it. Yet, given what we know about the frequency of medical errors, we still recommend it because families provide an additional cross-check of our care. But the COVID-19 pandemic has stripped away the layer of protection provided by families. At the start of the pandemic, visitation was heavily curtailed or stopped entirely due to the risks of spreading the virus. These decisions were not made lightly—concerns about protecting patients and the workforce drove them. Risks of visitation have included risks of infection to visitors and staff, particularly when not enough personal protective equipment (PPE) was available, and added strain on nurses to manage the presence of visitors and visitors’ compliance with PPE protocols. These infection concerns have not borne out, especially after adequate PPE supplies became available.1.,2. Those decisions at the start of the pandemic were necessary, given the uncertainties and the PPE shortages. However, now is the time to learn from that experience and reassess the risks and benefits of limited visitation. Further reading It’s time to rename the ‘visitor’: reflections from a relative Visiting restrictions and the impact on patients and their families: a relative's perspective Q&A: Dr. Tejal Gandhi on refocusing COVID visitation policies through a safety lens
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Content ArticleIn March 2015, Bill Kirkup published his report on avoidable harm in maternity services at the Morecambe Bay NHS Trust. His introduction carried a warning: “It is vital that the lessons, now plain to see, are learnt... by other Trusts, which must not believe that ‘it could not happen here.’” With the publication of the Ockenden report, we now know that one of those other Trusts was the Shrewsbury and Telford NHS Hospital Trust. “For more than two decades,” Donna Ockenden wrote, “they [famiies] have tried to raise concerns but were brushed aside, ignored and not listened to.” But why should patients and families have had to show that kind of courage in the first place? Instead of seeing patient feedback as a foundation stone of high quality, evidence based care, healthcare providers too often see it as a threat writes Miles Sibley in this BMJ Editorial.
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Content ArticleThis duty of candour animation offers guidance on the importance of being open and honest. Being open and honest with patients and those close to them is always the right thing to do and is often referred to as the duty of candour. NHS Resolution have produced a short animation to help those working in health and social care to better understand the similarities and differences that exist between the professional and statutory duties of candour. The 8-minute animation also offers guidance on how they can be fulfilled effectively.
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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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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 ArticleProviding high quality care and treatment for patients coming to the end of their lives is likely to involve making difficult and emotionally challenging decisions. This guidance from the General Medical Council provides a framework to support doctors in meeting the needs of each patient as they come towards the end of their life.
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Content ArticlePeople affected by health conditions bring insights and wisdom to transform healthcare – ‘jewels from the caves of suffering'. Yet traditional patient and public engagement relies on (child–parent) feedback or (adolescent–parent) ‘representative' approaches that fail to value this expertise and buffers patients' influence. This editorial from David Gilbert outlines the emergence of ‘patient leadership' and work in the Sussex Musculoskeletal Partnership, its patient director (the first such role in the National Health Service) and a group of patient/carer partners, who are becoming equal partners in decision-making helping to reframe problems, generate insight, shift dynamics and change practice within improvement and governance work.
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Content Article
Animation - The 'D' word (10 March 2022)
Patient-Safety-Learning posted an article in End of life care
This short animated video looks at the importance of clear, compassionate communication in healthcare, particularly when discussing end-of-life care and death with patients. -
Content ArticleAll health and care professionals have an ethical responsibility to be open and honest with service users and their employers when things go wrong with a person’s care. This is otherwise known as the professional duty of candour. Learn more about the Duty of Candour on the Health and Care Professions Council website.
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Content Article
UK Covid-19 Public Inquiry (10 March 2022)
Patient Safety Learning posted an article in Covid-19 Inquiry
This is the independent public inquiry to examine the UK’s preparedness and response to the Covid-19 pandemic, and to learn lessons for the future. The Inquiry has been established under the Inquiries Act 2005. This means that the Chair will have the power to compel the production of documents and call witnesses to give evidence on oath. The Chair has been appointed and will set out her vision for the Inquiry’s work in the coming months. The Inquiry has received the draft Terms of Reference from the Cabinet Office, and will open a public consultation tomorrow, Friday 11 March. The consultation will remain open for four weeks, and will be available online. See the UK COVID-19 Inquiry: draft terms of reference. -
Content Article
Binge Eating Disorder GP Leaflet
Patient Safety Learning posted an article in Eating disorders
This leaflet from Beat Eating Disorders is designed for people with binge eating disorder to bring to a GP appointment, to help them get a quick referral from their GP to an eating disorders specialist. It has guidance for the person with binge eating disorder, and a tear-off section for the GP. -
Content Article
Eating disorders: a guide for friends and family
Patient Safety Learning posted an article in Eating disorders
This booklet from Beat Eating Disorders is for anyone supporting someone with an eating disorder. It covers information about eating disorders and treatment, and offers guidance on how you might approach the subject if you’re worried about someone you know and how to support them after diagnosis, as well as looking after yourself. It also suggests further useful resources. -
Content ArticleEmployers have a duty of care to support doctors when they are faced with an abusive patient or their guardians/relatives. This guidance from the British Medical Association (BMA) gives background information and steps that all employers and healthcare workers should take when discrimination against a healthcare worker occurs.
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Content ArticleThis report by Bliss, the UK’s leading charity for babies born premature or sick, found that young parents are often underprepared and under-supported when their babies are in neonatal care. Research by Bliss found that more than half of young parents felt they were not as involved in caregiving or decision-making as they wanted to be when their baby was born premature or sick. It also highlighted contradictory messages that young mothers are given throughout their pregnancy that their youth will be a protective factor, despite an increased risk of prematurity and neonatal mortality for babies born to mothers aged under 20. This myth leaves many young parents feeling unprepared, enhancing their feelings of shock and disbelief if their babies are born unwell.
