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Content ArticleThe Care Quality Commission (CQC) were commissioned by the Department for Health and Social Care to conduct a special review of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions taken during the COVID-19 pandemic. This interim report sets out the progress of our review so far and our expectations around DNACPR.
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News Article
‘Do not resuscitate’ orders caused potentially avoidable deaths, regulator finds
Patient Safety Learning posted a news article in News
Do-not-resuscitate orders were wrongly allocated to some care home residents during the COVID-19 pandemic, causing potentially avoidable deaths, the first phase of a review by England’s Care Quality Commission (CQC) has found. The regulator warned that some of the “inappropriate” do not attempt cardiopulmonary resuscitation (DNACPR) notices applied in the spring may still be in place and called on all care providers to check with the person concerned that they consent. The review was prompted by concerns about the blanket application of the orders in care homes in the early part of the pandemic, amid then prevalent fears that NHS hospitals would be overwhelmed. The CQC received 40 submissions from the public, mostly about DNACPR orders that had been put in place without consulting with the person or their family. These included reports of all the residents of one care home being given a DNACPR notice, and of the notices routinely being applied to anyone infected with Covid. Some people reported that they did not even know a DNACPR order had been placed on their relative until they were quite unwell. “There is evidence of unacceptable and inappropriate DNACPRs being made at the start of the pandemic,” the interim report found, adding that the practice may have caused “potentially avoidable death”. Read full story Source: The Guardian, 3 December 2020 -
News Article
Demand for public inquiry into NHS mental health deaths to be debated by MPs
Patient Safety Learning posted a news article in News
A mother fighting for a public inquiry into the death of her son and more than 20 other patients at an NHS mental health hospital in Essex has won a debate in parliament after more than 100,000 people backed her campaign. On Monday, MPs in the House of Commons will debate Melanie Leahy’s petition calling for a public inquiry into the death of her son Matthew in 2012, as well as 24 other patients who died at The Linden Centre, a secure mental health unit in Chelmsford, Essex, since 2000. The centre is run by Essex Partnership University NHS Trust which has been heavily criticised by regulators over the case. A review by the health service ombudsman found 19 serious failings in his care and the NHS response to his mother’s concerns. This included staff changing records after his death to suggest he had a full care plan in place when he didn’t. Matthew was detained under the Mental Health Act but was found hanged in his room seven days later. He had made allegations of being raped at the centre, but this was not taken seriously by staff nor properly investigated by the NHS. The trust has admitted Matthew’s care fell below acceptable standards. In November, it pleaded guilty to health and safety failings linked to 11 deaths of patients in 11 years. Read full story Source: The Independent, 29 November 2020 -
News ArticleThe chairman of an inquiry that has confirmed a 20-year cover-up over the avoidable death of a baby has warned there are other families who may have suffered a similar ordeal. Publishing the findings of his investigation into the 2001 death of Elizabeth Dixon, Dr Bill Kirkup said he wanted to see action taken to prevent harmed families having to battle for years to get answers. Dr Kirkup, who has been involved in multiple high-profile investigations of NHS failures in recent years, said: “There has been considerable difficulty in establishing investigations, where events are regarded as historic. I don't like the term historic investigations. I think that these things remain current for the people who've suffered harm, until they're resolved, it’s not historic for them. “There has been significant reluctance to look at a variety of cases. Mr and Mrs Dixon were courageous and very persistent and they were given help by others and were successful in securing the investigation and it worries me that other people haven't been. “I do think we should look at how we can establish a proper mechanism that will make sure that such cases are heard." “It's impossible to rule out there being other people who are in a similar position. In fact, I know of some who are. I think it's as important for them that they get heard, and that they get things that should have been looked at from the start looked at now, if that's the best that we can do.” Read full story Source: The Independent, 27 November 2020
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Event
Deteriorating Patient Summit
Patient Safety Learning posted an event in Community Calendar
The Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include National Developments including the recent recommendations from the Royal College of Physicians on NEWS2 and COVID-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis and COVID-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. Follow the conference on Twitter #deterioratingpatient Register -
News ArticleThe Department of Health and Social Care (DHSC) has been criticised by the national health ombudsman for the ‘maladministration’ of a 2018 review into the death of a teenage girl under the care of one of England’s top specialist hospitals, HSJ can reveal. The Parliamentary and Health Service Ombudsman (PHSO) came to the conclusion after investigating a DHSC review into the 1996 death of 17-year-old Krista Ocloo which had been requested by her mother. Krista died at home of acute heart failure in December 1996. She had been admitted to the Royal Brompton Hospital with chest pains in January of that year. The PHSO report states her mother was told “there was no cause for concern” and that another appointment would be scheduled in six months. This follow-up appointment did not happen. The young woman’s death was considered by the hospital’s complaints process, an independent panel review and an inquiry into the hospital’s paediatric cardiac services. They concluded the doctor involved was not responsible for Krista’s death – though the paediatric services inquiry criticised the hospital for poor communication. A coroner declined to open an inquest into the case. Civil action against the hospital, brought by Ms Ocloo, found Krista’s death could not have been prevented. However, a High Court judge found that the failure to arrange appropriate follow-up by the RBH was “negligent”. A spokeswoman for PHSO said: “Our investigation found maladministration by the Department for Health and Social Care, which should have been more transparent in its communication. The department’s failure to be open and clear compounded the suffering of a parent who was already grieving the loss of her child.” A DHSC spokeswoman said: “We profoundly regret any distress caused to Ms Ocloo. “[The PHSO] report found that in communicating with Ms Ocloo the department’s actions were – in places – not consistent with relevant guidance. The department has writen to Ms Ocloo to apologise for this and provide further information about the review.” Read full story (paywalled) Source: HSJ, 12 November 2020
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Content ArticleIn this Episode of the 'This Is Nursing' podcast series, Gavin Portier speaks to Amanda McKie, Matron -for Learning Disabilities & Complex Needs Coordinator at Calderdale & Huddersfield NHS Foundation Trust. In this episode Amanda talks about health inequalities, mental capacity, advocacy and high profile key documents such as Death by Indifference, the LeDer Mortality programme and the current case of Oliver McGowan. Learning disabilities is a life long condition and they can present in any areas of health care. In this podcast we discover how important it is to have an understanding an appreciation and insight into the care experience of a person with a learning disability and their parents or carers.
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Content ArticleIn this blog, Patient Safety Learning sets out its response to NHS England and NHS Improvement’s draft Framework for involving patients in patient safety. We commend the intention and share thoughts on our perspective on this important patient safety issue. We make proposals for how to strengthen patient engagement and co-production.
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Content ArticleThis Royal College of Nursing (RCN) publication highlights the specific needs of children and young people undergoing day surgery, outlining pre- and post-operative aspects of care and preparation, parental involvement and facilitating discharge.
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Content Article"Healthcare systems need to act in equal measures to both enable the recovery of patients and families it has harmed, and to protect future patients.... Yet providing what is set out in the Duty of Candour to harmed patients has not been framed as providing care to make sick or injured people better and/or to minimise their pain and suffering." In this blog, Jo Hughes explains why we need to reframe the Duty of Candour and explores what needs to change.
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Content ArticleOn the 12 October 2020, the Care Quality Commission (CQC) announced the launch of a review into the imposition of blanket ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) notices for patients in care homes, primary care and hospitals. This follows revelations earlier in the year that potentially thousands of patients were being placed in care homes with blanket ‘do not attempt resuscitation’ (DNAR) notices in place. This has led to widespread public criticism. This article explores whether a DNACPR notice is valid without the consultation of family members or other representatives of a patient receiving care and, if not, what should be done?
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Content ArticleParents know better than anyone if their child is not behaving as they usually do or seem different in some way. Studies have shown that caregivers are often the first people to spot changes in the health of their child, even when in a clinical environment. You should feel able to raise any concerns if you think something is ‘just not right’ with your child. Great Ormond Street Hospital has produced guidance on what to look out for and how to raise a concern if you are worried about your child when in hospital.
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Content Article
Oliver's Campaign
Patient Safety Learning posted an article in Learning disabilities
Paula McGowan is a Multi Award-winning Activist who following the preventable death of her teenage son Oliver, has dedicated her life to campaigning for equality of Health and Social Care for Learning Disabled people and Autistic people. She is an Ambassador for several charities and organisations. Paula launched a parliamentary petition asking for all doctors and nurses to receive mandatory training in Learning disability and Autism awareness. She ferociously argued that autism must be included. On 22 October 2018, her petition was debated and gained cross party support. As a direct consequence Government announced that all NHS and Social Care Staff would receive The Oliver McGowan Mandatory Training in Learning Disability and Autism. On the Oliver's Campaign website you can find support, resources and blogs. -
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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Content ArticleIn this latest report, the Healthcare Safety Investigation Branch (HSIB) has outlined their approach to working with patients and families with the aim of sharing that learning across the healthcare sector. They have set out their experiences so that other organisations can reflect on how it may be applicable to their work. The report not only covers HSIB's principles and process for effective family engagement, but also how they evaluated the approach using feedback from families involved in investigations. HSIB’s process for effective family engagement has been developed through close collaboration with families who have been involved in investigations. HSIB recognises that there is currently no national framework or process to assist those working with families during investigations. In the report foreword, HSIB’s Chief Investigator, Keith Conradi says: “in the past decade, the healthcare sector has recognised the need to ensure it works with patients and families…however it is also recognised that undertaking family engagement of a high quality can be challenging, particularly when the guidance on how to do it is limited.” The report also highlights some possible future developments, which includes a long-term aim of producing formal family engagement guidance which will be shared externally for organisations to access and use.
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Content ArticleFifteen years after a “moral moment” transformed patient safety here, new systems and a change in culture at John Hopkins Medicine have gone a long way toward eradicating errors.
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Content ArticleThe Patients Association was formed over fifty years ago. Since then, it has listened to patients concerns and spoken out on their behalf. Not long after the Patients Association took up its role, legislation was enacted by the government to establish the Parliamentary and Health Service Ombudsman (PHSO). Both organisations have similar values and agendas, intended to help and support the public, the difference being, one is an independent charity, the other a government body afforded all the power and legislation to act with credibility. However, sadly the Patients Association has no confidence that the PHSO will carry out an independent, fair, open, honest and robust investigation. The Ombudsman is frequently quoted as saying patients who suffer harm or poor care in hospitals are failed by a “toxic cocktail” within the health service, whereby complaints go unheard and lessons unlearned. The Ombudsman states: ”We are the last resort for complaints about the NHS. We listen to individual complaints and where things have gone wrong, help to get them put right.” The Patients Association, in partnership with the families of those who have contributed to this report, challenge that statement. Nearly 50 years after the PHSO was established, it is time for real and robust change, not just promises and more recommendations. The Patients Association have a clear request to the Government and Public Administration Select Committee-read our patients stories, listen to their concerns, consider our conclusions, recommendations and finally, hold the PHSO to account for its action.
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Content Article
IHI's Open School Short: What happened to Josie?
Patient Safety Learning posted an article in Patient-centred care
In 2001, 18-month-old Josie King died of dehydration and a wrongly-administered narcotic at Johns Hopkins Hospital. How did this happen? Her mother, Sorrel King, tells the story and explains how Josie’s death spurred her to work on improving patient safety in hospitals everywhere. -
Content ArticleSorrel King was a 32-year-old mother of four when her eighteen-month-old daughter, Josie, was horribly burned by water from a faulty water heater in the family's new Baltimore home. She was taken to Johns Hopkins--renowned as one of the best hospitals in the world--and Sorrel stayed in the hospital with Josie day-in and day-out until she had almost completely recovered. Just before her discharge, however, she was erroneously injected with methadone, and died soon after. Sorrel's account of her unlikely path from grieving parent to nationally renowned advocate is interwoven with descriptions of her and her family's slow but steady road to recovery, and ends with a deeply affecting description of a ski trip they took recently. The sun is shining, her children are healthy, and they are all profoundly happy--a condition that Sorrel has learned to appreciate all the more for Josie. The book ends with a resource guide for patients, their families, and healthcare providers; it includes information about how to best manage a hospital stay and how to handle a medical error if one does occur.
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Content ArticleThe aim of the project was to introduce and evaluate a Call for Concern (C4C) service that provides patients and relatives with direct access to the Critical Care Outreach (CCO) team, to give patients and relatives more choice about who they can consult with about their care, and facilitate the early recognition of the deteriorating ward patient. The project involved two phases: a six month pilot phase to evaluate the C4C service for feasibility, and its effects on patients, relatives and the health care teams. a three month phase implementing the C4C service onto two surgical wards to test and evaluate the findings of the feasibility phase in preparation for expansion to all hospital wards. Between 1st Sept 2009 and 23rd Sept 2010, the CCO team received 37 C4C referrals representing 0.5% of total CCO activity. Critical deterioration of a patient was prevented in at least two cases, and the service received positive feedback from patients and relatives. In the words of a relative, C4C provided: ‘…a better quality of care…and…reduces the risk of death.’
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Content Article
FIRST: Family Initiated Rapid Safety Team
Claire Cox posted an article in Keeping patients safe
Despite the introduction of rapid response systems and early warning scores, clinical deterioration that is not recognised or responded to early enough prevails in acute care areas. One intervention that aims to address this issue and that is gaining increased attention is patient- and family-initiated escalation of care schemes. This short video by the University of Michigan Health System explains more. -
Content ArticleNorthampton General Hospital NHS Trust has produced this leaflet to help keep patients safe in hospital.
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Content ArticleDespite the introduction of rapid response systems and early warning scores, clinical deterioration that is not recognised or responded to early enough prevails in acute care areas. One intervention that aims to address this issue and that is gaining increased attention is patient-and family-initiated escalation of care schemes. Existing systematic review evidence to date has tended to focus on identifying the impact or effectiveness of these schemes in practice. However, they have not tended to focus on qualitative evidence to consider the experience of deterioration and the factors that may promote or hinder engagement with these schemes in the practice setting. The aim of this review, published in Systemic Reviews, is to explore patients’, relatives’ and healthcare professionals’ experiences of deterioration and their perceptions of the barriers or facilitators to patient and family-initiated escalation of care in acute adult hospital wards.
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Content ArticleThis patient information leaflet produced by Guys and St Thomas' NHS Foundation Trust gives 8 simple steps to keep yourself safe during your stay in hospital. These include; Preventing falls Preventing blood clots Preventing infection Your medicines Pressure ulcers Identification Your concerns Leaving hospital.
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Content Article
Advanced Care Planning (Macintyre)
Claire Cox posted an article in Learning disabilities
Advance Care Planning (ACP) is becoming increasingly important in ensuring that people receive good care and ultimately experience a “good death”. ACP can lead to less aggressive or invasive medical care, better quality of life near death, decreased rates of hospital admission, and people being more likely to receive care that is aligned with their wishes and dignity. It can be a difficult subject to discuss and can be confusing for health and social care professionals, staff and families, due to a lack of knowledge about ACP and a lack of awareness regarding the legal position.
