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Showing results for tags 'Patient / family involvement'.
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News ArticleParents affected by serious failings in maternity units at a Welsh health board will be told of the findings of an independent investigation this autumn. Ten more cases at units run by Cwm Taf Morgannwg in the south Wales valleys have been found by a review, bringing the total number to 160. Maternity services at hospitals in Merthyr Tydfil and Llantrisant were placed in special measures last year. Failings at the maternity units were discovered after an investigation by two Royal Colleges, which found mothers faced "distressing experiences and poor care" between 2016 and 2018. The services at the Royal Glamorgan Hospital in Llantrisant and Prince Charles Hospital in Merthyr Tydfil were also found to be "extremely dysfunctional" and under extreme pressure. A number of recommendations were set to make the service safe for pregnant women and those giving birth at the hospitals. The Welsh Government then appointed the Independent Maternity Services Oversight Panel (IMSOP) to look back at cases, including neonatal deaths. Mick Giannasi, the chairman of IMSOP, said: "In the early autumn, we will start writing to mothers to say we have reviewed your care and this is what we found. "That will be quite distressing for the women because they will have to revisit all those things again. "But it's going to be a difficult period for staff as well because we know that the Royal Colleges review was very difficult for staff - some of the messages that they had to hear were very challenging and those things may be played out again." Read full story Source: BBC News, 28 September 2020
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News Article
Families launch court case in bid for public inquiry into deaths
Patient Safety Learning posted a news article in News
The Department of Health and Social Care (DHSC) is facing being taken to court over an inquiry it launched into the deaths of dozens of mental health patients in Essex. Last year, the government said it would commission an independent inquiry into at least 36 inpatient deaths in Essex, which had taken place over the last two decades. However, more than 70 families are calling for a full statutory public inquiry, which can compel witnesses to give evidence. They have lodged judicial review proceedings at the High Court against the government to that effect. The DHSC said it could not comment on ongoing legal proceedings. The current inquiry was launched in response to a highly critical report from the Parliamentary Health Service Ombudsman, published in June 2019, into the deaths of two patients at North Essex Partnership University Foundation Trust, which has since merged to form Essex Partnership University FT. There has also been an investigation by Essex Police into 25 of the deaths. This concluded in 2018, when the force said there had been “clear and basic” care failings, but there was not enough evidence to prosecute the trust for corporate manslaughter. Read full story (paywalled) Source: HSJ, 11 May 2021 -
News ArticleCampaigners have started legal action against the government over guidance that bans care home residents in England aged 65 and over from taking trips outside the home. John's Campaign, of residents and their loved ones, says the ban is unlawful. They are also challenging the requirement for residents to self-isolate for 14 days after such visits. The government said its guidance provides a "range of opportunities" for visitors to spend time with loved ones. Nearly all residents have now had at least one dose of the vaccine, and care homes have been cautiously reopening, allowing indoor visits with designated family or friends. But the government guidance, updated on 8 March, says trips to see family or friends "should only be considered" for under-65s while national Covid restrictions apply because they increase the risk of bringing Covid into a home. Visits out for residents, whatever their age, "should be supported in exceptional circumstances such as a visit to a friend or relative at the end of their life", it adds - but on returning to the home, the resident must self-isolate for two weeks. The legal letter sent to the Department of Health and Social Care by John's Campaign says the decision whether someone can go on a visit outside a care home should be based on individual risk assessments. Read full story Source: BBC News, 2 April 2021
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News Article
Bereaved families call for judge-led public inquiry into UK Covid response
Patient Safety Learning posted a news article in News
The COVID-19 Bereaved Families for Justice group has told Downing Street it wants a statutory public inquiry led by a senior judge to “determine a definitive, official, evidence-based narrative of what did and did not happen, independent of political influence” during the pandemic. The group considers it potentially cathartic and wants the families’ grief heard. Frontline health workers also want a wide-ranging inquiry to provide a platform for their experiences, while minority ethnic leaders believe an inquiry can only determine what went wrong if wider societal inequalities relating to work, health and housing are investigated. But while there is no dissent about the need for an inquiry, others fear this remit might be too broad – and fear lessons have to be learned now so the UK can properly protect itself from any future health emergency. Sir John Bell, the regius professor of medicine at Oxford University, and Lord O’Donnell, head of the civil service under Tony Blair, Gordon Brown and David Cameron, want a different model more narrowly focused on determining future actions. Ultimately the decision will be for Boris Johnson, who has significant latitude to set the terms and scope of any inquiry, including selection of its chair. Read full story Source: The Guardian, 16 March 2021 -
News Article
Jeremy Hunt’s safety programme has stalled, say bereaved families
Patient Safety Learning posted a news article in News
Bereaved families have been left feeling like their efforts to improve patient safety have been ‘in vain’ as progress of a government programme instigated by Jeremy Hunt appears to have ‘stalled’. The Learning from Deaths programme board, which was set up in 2017 to develop guidance for trusts working with families on investigations of deaths, has not met since June 2019. Josephine Ocloo and David Smith, two bereaved family members who were on the board, have written to HSJ, saying the programme’s progress has “stalled”. They added many of the issues it was set up to consider have not yet been addressed, including the need for a national inquiry into unresolved historical cases, the independence of the NHS’ investigatory systems, lack of effectiveness of the duty of candour, and the disproportionate impact on ethnic minorities and those with mental ill-health or learning disabilities. They said: “We now have serious concerns that what these families went through [in November 2017] in recalling — and effectively reliving — their experiences, in order to ensure the terrible things that happened to them could not happen to others, was in vain… “If [the issues] are not to be addressed by the new board, the families will have every right to feel betrayed and to feel as if they have been used as pawns in a political game. Once again, harmed and let down by a system that has used us and then cast us aside.” Read full story (paywalled) Source: HSJ, 26 February 2021 -
News Article
Watchdog forced to hand over NHS staff names in safety failure cases
Patient Safety Learning posted a news article in News
A national safety watchdog has been forced to release almost 100 pieces of evidence, including names of NHS staff, after being ordered to by courts. A freedom of information request, submitted by HSJ, has revealed the Healthcare Safety Investigation Branch (HSIB) has been required to release 93 interviews with staff, family members and external experts, along with their identities, over the last two years. The interviews, which relate to HSIB investigations involving hospital trusts across England, were released to coroner’s courts through eight separate orders dating from February 2019. A further four court orders compelled HSIB to release other information to coroners, including reports into trusts, findings of internal panel reviews, and evidence from external experts. The orders were made under the Coroners and Justice Act 2009. When HSJ asked whether any NHS staff or family members were named in open court, HSIB said it was “not able to comment on specific instances”, but added that all those whose evidence was shared with the coroners were notified in advance. Read full story (paywalled) Source: HSJ, 23 February 2021 -
News Article
NHS urged to back plan to help patients harmed by mistakes
Patient Safety Learning posted a news article in News
Patients and families who suffer avoidable harm as a result of mistakes in the NHS should be given targeted help and support to recover. Campaign group the Harmed Patients Alliance and patient safety charity Action against Medical Accidents (AvMA) believe the NHS needs to develop a specific harmed patient pathway to care for families affected by errors in their care. They are hoping to define what the pathway will look like in partnership with families, patients and NHS trusts with the idea of piloting an approach in the NHS and getting it adopted nationally. There are more than two million safety incidents reported in the NHS every year, with more than 10,000 incidents resulting in severe harm and death. Read full story Source: The Independent, 11 February 2021 -
News Article
Gosport hospital deaths: Families 'need Hillsborough-style inquests'
Patient Safety Learning posted a news article in News
Relatives of patients who died after receiving "dangerous" levels of painkillers at Gosport War Memorial Hospital have called for new inquests. An inquiry found 456 patients died after being given opiate drugs at the hospital between 1987 and 2001, but no charges have ever been brought. Four families told the BBC they have requested judge-led "Hillsborough-style" hearings with a jury. The Attorney General's Office said it was reviewing the application. Police began a fresh inquiry in 2019 into 700 deaths after the Gosport Independent Review Panel found there was a "disregard for human life" at the hospital in Hampshire. Coroner-led inquests in 2009 found drugs administered at the hospital contributed to five deaths. However, lawyers representing some of the families told the BBC more wide-ranging inquests similar to those that examined the events of the Hillsborough disaster should be undertaken. Read full story Source: BBC News, 5 February 2021- Posted
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News Article
COVID-19 bereaved families group hopes PM will 'take us seriously' at meeting
Patient Safety Learning posted a news article in News
The co-founder of a coronavirus bereaved families group has said he hopes Boris Johnson will "at long last... take us seriously" when he meets them at Number 10 today. Matt Fowler said it is vital the prime minister understand the need to start a public inquiry as soon as possible. Mr Johnson will meet members of the Covid-19 Bereaved Families for Justice group today - more than a year after promising to meet people whose loved ones had died. They will share how their family members caught the disease and died, and repeat calls for a public inquiry to get priority. The group plans to raise issues with the PM such as the disproportionate effect of COVID on some ethnic groups, transmission of the disease on public transport and in the workplace, the impact of late lockdowns, and failures to learn from the first wave. Boris Johnson previously said the inquiry would start in spring 2022. Read full story Source: Sky News, 28 September 2021 -
News Article
Contaminated blood inquiry: Matt Hancock to give evidence
Patient Safety Learning posted a news article in News
The health secretary will face questions about compensation for victims of the contaminated blood scandal on Friday afternoon. Matt Hancock will give evidence at a public inquiry into what's been called the worst NHS treatment disaster. Around 3,000 people have died after being given blood containing HIV and hepatitis C in the 1970s and 1980s. Ministers announced a public inquiry into the scandal in 2017 after decades of campaigning by victims and their families. Nearly 5,000 people with the blood disorder haemophilia were infected with potentially fatal viruses after being given a clotting agent called Factor VIII. Much of the drug was imported from the US, where prisoners and other at-risk groups were often paid to donate the plasma used to make it. Victims included dozens of young haemophiliacs at a boarding school in Hampshire who died after contracting HIV as a result. Tens of thousands more victims may have been exposed to viral hepatitis through blood transfusions after an operation or childbirth. Read full story Source: BBC News, 21 May 2021 -
EventThis masterclass will cover the new guidance and provide participants with an in-depth knowledge of what needs to be done to comply with the duty of candour; clarify ‘grey areas’ and provide advice on dealing with difficult situations which may arise. It will provide participants with an understanding of good practice in implementing the duty and, in particular doing so in a meaningful way with empathy, to not only comply, but to work with patients and loved ones in a way that puts the emotional experience at the heart of communication. Anyone with responsibility for implementing the duty of candour should attend, whether as a health or social care professional or at an organisational level, be it in the NHS, private healthcare or social care. Health and social care professionals; staff with responsibility for quality, safety, clinical governance, safety investigations, complaints or CQC compliance, patient experience and executive teams would benefit from attending. See flyer attached below: Implementing the Duty of Candour with Empathy generic leaflet.pdf For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/duty-of-candour or click on the title above or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for a discount code.
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EventThis conference focuses on patient involvement and partnership for patient safety including implementing the New National Framework for involving patients in patient safety, and developing the role of the Patient Safety Partner (PSP) in your organisation or service. The National Framework for involving patients in patient safety was released by NHS England in June 2021. This conference will enable you to: Network with colleagues who are working to involve patients in improving patient safety. Reflect on patient perspective. Understand how to implement the June 2021 National Framework for Involving Patients in Patient Safety. Improve the way you recruit, work with and support Patient Safety Partners. Develop your skills in embedding compassion and empathy into patient partnership. Understand how you can improve patient partnership and involvement after serious incidents. Identify key strategies for support patients, their families and carers to be directly involved in their own or their loved one’s safety. Learn from case studies demonstrating patient partnership for patients safety in action. Examine methods of involving patients to improve patient safety in high risk areas. Self assess and reflect on your own practice. Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register hub members receive a 20% discount. Email info@pslhub,org for discount code.
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EventuntilPatient Academy for Innovation and Research (PAIR Academy) and the International Alliance of Patients’ Organizations (IAPO) are launching a series of webinars to introduce the Strategic Framework of the Global Patient Safety Challenge - Medication Without Harm. This is the first webinar of the series and will take place at 17.00 IST (11.30 GMT). The theme is "An approach towards medication safety for patients and family." Register for the webinar
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EventuntilAre you interested in storytelling health? Do you want to use narrative as the basis for improvement? Do you want to work with people and hear about their experiences of care? Are you curious about storytelling? If so, come along to the NHS/Hope storytelling festival which is taking place between 9 and 23 March. You will find out about filmmaking, arts therapy, live performance, storytelling for quality improvement, staff stories, digital stories, how volunteers can capture stories, and hear from the author of a book about storytelling in health and how patient leaders are shaping our programme of digital storytelling. You will also hear how stories are being used across systems as a learning tool. There will also be the opportunity to take part in online training where you can gain a contribution to your CPD and gain some essential knowledge about a broad range of storytelling methods. Each session takes place between 6pm and 7.30pm and details can be found here.
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EventuntilThe COVID-19 pandemic has exposed huge problems with the way Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions are made, understood and communicated with people with learning disabilities and their families and carers. There have been reports of unlawful blanket decision-making and of DNACPR orders noted without discussion with the people involved. This webinar will focus on some of the questions that have been raised over the past year. What exactly is DNACPR? Why are the terms DNR or DNAR unhelpful, confusing and potentially dangerous? In what circumstances is CPR not a good option, and DNACPR therefore appropriate? How should those decisions be made? Who should be involved? What if the person lacks capacity for a DNACPR decision – how can we make decisions based on best interest? Register
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EventThink back to 2006 and recall what you knew about patient safety, and patients as partners in safety. Now, pause for a second to reflect on where we are now, in 2021. Then, imagine what you want patient safety to look like in 15 years – 2036 to be specific. Join the Canadian Patient Safety Insitute in exploring how patients, families and communities have helped shape patient safety in the past 15 years, and contribute your thoughts on how we can accelerate safety efforts together in the next 15 years. In celebration of Patients for Patient Safety Canada's 15th anniversary, we will share our journey so far, our successes, and our dream: "EVERY PATIENT SAFE". Register
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Event“Improving patient experience is not simple. As well as effective leadership and a receptive culture, trusts need a whole systems approach to collecting, analysing, using and learning from patient feedback for quality improvement. Without such an approach it is almost impossible to track, measure and drive quality improvement.” NHS England and Improvement 2019 Convenzis are excited to share details of our 1st Virtual NHS Patient Experience Conference to date, this live and interactive session will focus on key findings from the 2019 British Social Attitudes survey and discuss how the 2020 COVID-19 outbreak affected patient satisfaction and assurance. Register
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Content ArticlePrevious research has shown that visitors can decrease the risk of patient harm; however, the potential to increase the risk of patient harm has been understudied. Sanchez et al. queried the Pennsylvania Patient Safety Reporting System database to identify event reports that described visitor behaviours contributing to either a decreased or increased risk of patient harm. The study provides insight into which visitor behaviours are contributing to a decreased risk of patient harm and adds to the literature by identifying behaviours that can increase the risk of patient harm, across multiple event types.
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Content ArticleThe duty of candour is a general duty to be open and transparent with people receiving care from you. It applies to every health and social care provider that CQC regulates. The duty of candour requires registered providers and registered managers (known as ‘registered persons’) to act in an open and transparent way with people receiving care or treatment from them. The regulation also defines ‘notifiable safety incidents’ and specifies how registered persons must apply the duty of candour if these incidents occur. This document from the Care Quality Commission (CQC) gives the background to the duty of candour and explains the statutory and professional duties of candour.
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Content ArticleInvestigation of a complaint against the Belfast Health and Social Care Trust A Trust’s failure to perform an examination of a patient on admission to hospital meant he was not assessed by medical staff against this baseline during his time on the ward.
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Content ArticleA restorative just culture has become a core aspiration for many organisations in healthcare and elsewhere. Whereas ‘just culture’ is the topic of some residual conceptual debate (e.g. retributive policies organised around rules, violations and consequences are ‘sold’ as just culture), the evidence base on, and business case for, restorative practice has been growing and is generating increasing, global interest. In the wake of an incident, restorative practices ask who are impacted, what their needs are and whose obligation it is to meet those needs. Restorative practices aim to involve participants from the entire community in the resolution and repair of harms. This book from Sidney Dekker, Amanda Oates and Joseph Rafferty offers organisation leaders and stakeholders a practical guide to the experiences of implementing and evaluating restorative practices and creating a sustainable just, restorative culture. It contains the perspectives from leaders, theoreticians, regulators, employees and patient representatives.
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Content ArticleBenjamin King lived 5-days before parents, Jamie Thomas King and Tamara Podemski, had to pull him off life support. Benjamin's parents share their experience, the value of sharing their story with the media and what changes have happened in UK hospitals since to ensure this won't happen to any other family. The panel discusses the role of human factors and system design and how it can be embraced to ramp up patient safety improvement. Human factors experts across healthcare and aviation will discuss this issue alongside patient advocates who have lost loved ones where the application of principles and methodologies of human factors engineering may have saved their loved ones lives. Hear from the leadership at Christus Muguerza Hospital Sur in Monterrey, Mexico, about their work to become an HRO Champion.
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Content Article
Family Integrated Care (FICare) is an approach to neonatal care which aims to involve parents as equal partners in the care of their babies while in the Neonatal Intensive Care Unit (NICU). FICare aims to minimise separation, support parent-child bonding and promote parental decision-making. In this blog, Katie Cullum, Lead Nurse for Innovation and Quality Improvement at East of England Neonatal Operational Delivery Network, talks about the proven benefits of Family Integrated Care and why all NICUs should be implementing the model to improve outcomes. -
Content ArticleThis study by Sir Robert Francis QC looks at options for a framework for compensation for the victims of the infected blood tragedy. Sir Robert will give evidence about his work to the Infected Blood Inquiry in July. Before then, it is important that the Inquiry, and recognised legal representatives of its infected and affected core participants, have an opportunity to consider his work.
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Content ArticlePresentation from Peter Walsh, CEO of Action against Medical Accidents (AvMA), on a 'Harmed Patient Pathway' launched jointly by AvMA and the Harmed Patient Alliance in February 2021.
