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News Article
Martha’s rule must be available 24/7, England’s patient safety commissioner says
Patient Safety Learning posted a news article in News
Patients and their relatives will be able to request a second opinion from senior medics around the clock when the “Martha’s rule” system starts in hospitals in England. The government’s patient safety commissioner, asked by the health secretary, Steve Barclay, to advise on how to implement the change, has said access to a medic’s opinion must operate 24/7. Dr Henrietta Hughes made clear to Barclay in a letter that inpatients and families worried that their loved one’s health is deteriorating should be able to seek a second opinion at any time of day or night. In her letter, which she published on Wednesday, Hughes also said the availability of that service must be widely advertised in hospitals, so patients know they can use it. She told Barclay that all staff in acute and specialist medical NHS trusts in England “must have 24/7 access to a rapid review from a critical care outreach team who they can contact should they have concerns about a patient”. Hughes added: “All patients, their families, carers and advocates must also have access to the same 24/7 rapid review from a critical care outreach team which they can contact via mechanisms advertised around the hospital and more widely if they are worried about the patient’s condition. This is Martha’s rule.” Read full story Source: The Guardian, 3 November 2023 -
News Article
Children's health warning system rolled out by NHS
Patient Safety Learning posted a news article in News
NHS England is rolling out a national early-warning system to help medics spot and treat a deteriorating child patient quickly - and act on parents' concerns. Parents and carers are "at the heart of the new system", NHS chiefs say. Scores for signs such as blood pressure, heart rate and oxygen levels will be tracked on a chart. But if a parent is worried their child is sicker than the chart suggests, care will be rapidly escalated. While similar systems already exist in many hospitals, NHS national medical director, Prof Sir Stephen Powis, said staff and patients alike would welcome the introduction of a standardised system across hospitals. "We know that nobody can spot the signs of a child getting sicker better than their parents, which is why we have ensured that the concerns of families and carers are right at the heart of this new system, with immediate escalation in a child's care if they raise concerns and plans to incorporate the right to a second opinion as the system develops further," he said. The rollout follows the patient safety commissioner, Dr Henrietta Hughes, recommending that Martha's rule is delivered across England's hospitals, giving patients and families the right to an urgent second opinion and rapid review from a critical care team if they are worried about a patient's condition. Read full story Source: BBC News, 3 November 2023 -
News Article
Launch of a new Patient Entrepreneur Programme
Patient Safety Learning posted a news article in News
Are you a patient whose experience has led you to develop a healthcare innovation? Do you want to develop your skills to help scale this innovation? The NHS Clinical Entrepreneur Programme (CEP) is offering a 12-month pilot programme for people who have experience of a long-term health condition and are working on healthcare innovations. The NHS CEP Patient Entrepreneur Programme, ran by Anglia Ruskin University and in collaboration with NHS England’s Patient and Public Involvement (PPI) team, is free, part-time, and open to all patients, or carers with an innovation in healthcare. The programme aims to give individuals the skills and knowledge to develop their innovation, while giving them access to a network of mentors, healthcare experts, and patient support. Applications for this programme will open on the 1 November 2023, with the programme starting March 2024. So, if you are a patient with lived experience of an illness or condition who has developed an innovation to improve patient care, this is your chance to scale your idea with the help of the NHS Clinical Entrepreneur Programme. Find out more -
Content Article
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This blog provides an overview of a Patient Safety Management Network (PSMN) meeting discussion on 27 October 2023. At this meeting, members of the network were joined by Dr Ted Baker, Chair of the Health Services Safety Investigations Body (HSSIB). The PSMN, created in June 2021, is an innovative voluntary network for patient safety managers and everyone working in patient safety. It provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. Find out more about the Network. -
News ArticleA public inquiry into the deaths of at least 2,000 mental health inpatients has been relaunched with new powers. The Essex Mental Health Independent Inquiry was established in 2021 to investigate the deaths of people on mental health wards in the county. The number of initial responses to the inquiry from current and former staff was described as "disappointing". The inquiry has converted to a statutory inquiry meaning witnesses can be forced to give evidence. It is understood the new chairwoman is considering extending the inquiry's timeframe to include deaths from the start of 2000 until the end of 2023. Baroness Kate Lampard, leading the inquiry, said: "I am determined to conduct this inquiry in a fair, thorough and balanced manner. "I am also concerned to ensure that I do not take any longer than necessary - the recommendations from this inquiry are urgent and cannot be delayed." She added: "To be clear from the outset, I will not be compelling families to give evidence. "Evidence from staff, management and organisations will be gathered in a proportionate, fair and appropriate manner." Read full story Source: BBC News, 1 November 2023
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Content ArticleThe Patient Safety Commissioner for England was asked by the UK Government to run a series of policy sprint meetings to set out what would make Martha’s Rule a success in England. Martha’s Rule would mean that if a patient, family member or carer suspected deterioration or a serious concern, they would have the right to easily call for a rapid review or second opinion from an doctor within the same hospital. In this letter to the Secretary of State for Health and Social Care, Steve Barclay MP, the Patient Safety Commissioner outlines the process and outcome of these meetings and a set of recommendations for the implementation of Martha’s Rule.
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News Article
Parents of babies who died or were harmed in NHS care demand inquiry
Patient Safety Learning posted a news article in News
Parents of babies who have died or been harmed as a result of poor care are demanding that ministers order a public inquiry into repeated failings in NHS maternity units. They want Steve Barclay, the health secretary, to set up a judge-led statutory inquiry to investigate recurring problems in maternity services, which cost the NHS in England £2.6bn a year in damages. Babies are still being damaged and dying, despite previous inquiries into maternity scandals at the Morecambe Bay, Shrewsbury and Telford, and East Kent NHS trusts recommending changes. The NHS’s failure to improve maternity safety is so alarming that a public inquiry is needed to finally ensure that women and babies no longer come to harm, the families say. The Maternity Safety Alliance, a group of relatives of newborns who have died due to lapses in NHS childbirth, warned that scandals will continue unless such an inquiry is held. “Our babies are too precious to keep on ignoring the reality that despite a raft of national initiatives and policies implemented in the wake of investigations and reports, systemic issues continue to adversely impact on the care of women and babies. “Far too much avoidable harm continues to devastate lives in circumstances that could and should be avoided. Fundamental reform is needed,” they said in a letter urging Barclay to intervene. Read full story Source: The Guardian, 31 October 2023 -
News ArticleThe parents of a baby boy who died at seven weeks old after a hospital did not give him a routine injection have described the failure as “beyond cruel”. William Moris-Patto was born in July 2020 at Addenbrooke’s hospital in Cambridge, where it was recorded in error that he had received a vitamin K injection – which is needed for blood clotting. The shot is routinely given to newborns to prevent a deficiency that can lead to bleeding. His parents, Naomi and Alexander Moris-Patto, 33-year-old scientists from Chatteris, Cambridgeshire, want to raise awareness about the importance of the vitamin after a coroner concluded William would not have died had the hospital administered the injection. On Friday, the coroner Lorna Skinner KC described the omission as “a gross failure in medical care amounting to neglect”. Alexander Moris-Patto, a researcher at the University of Cambridge who recently co-founded William Oak Diagnostics to test for deficiencies in babies, said: “What’s come out of the inquest for me is that the systems they [the trust] put in place to try to prevent this happening again are not satisfactory.” He stressed the importance of the vitamin K injection, adding that about 1% of the UK population opt out of it. “We want people to know more about it, to understand how critical it can be, and for hospitals to take seriously the responsibility they have in those first precious hours of a baby’s life,” he said. Read full story Source: The Guardian, 29 October 2023
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News ArticleSome care home residents may have been "neglected and left to starve" during the pandemic, Scotland's Covid Inquiry is expected to hear. Lawyers representing bereaved relatives said they also anticipate the inquiry will hear some people were forced into agreeing to "do not resuscitate" plans. Shelagh McCall KC told the inquiry that evidence to be led would "point to a systemic failure of the model of care". The public inquiry is investigating Scotland's response to the pandemic. Ms McCall is representing Bereaved Relatives Group Skye, a group of bereaved relatives and care workers from Skye and five other health board areas of Scotland. In her opening statement, she told the public inquiry that families wanted to know why Covid was allowed to enter care homes and "spread like wildfire" during the pandemic. She added: "As well as revealing the suffering of individuals and their families, we anticipate the evidence in these hearings will point to a systemic failure of the model for the delivery of care in Scotland, for its regulation and inspection. "We anticipate the inquiry will hear that people were pressured to agree to do not resuscitate notices, that people were not resuscitated even though no such notice was in place, that residents may have been neglected and left to starve and that families are not sure they were told the truth about their relative's death." Read full story Source: BBC News, 25 October 2023
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Content ArticleTrevor Stevens daughter, Tobi, took her own life in December 2020 whilst in the care of the Norfolk and Suffolk NHS Foundation Trust. Trevor recently attended the HSJ Patient Safety Congress. In this blog, he reflects on his experience at the Congress. Related reading on the hub: Time for a reset on safety? Highlights from day one of the HSJ Patient Safety Congress
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News Article
Sepsis killing too many as lessons not learned, warns NHS watchdog
Patient Safety Learning posted a news article in News
Sepsis is still killing too many patients due to the same hospital failings that occurred a decade ago, a damning report by the NHS ombudsman has warned. Avoidable mistakes include delays in spotting and treating the condition, poor communication between health staff, sub-standard record keeping and missed opportunities for follow-up care, according to Rob Behrens, the parliamentary and health service ombudsman (PHSO). Despite some progress since a previous report on sepsis by the ombudsman in 2013, lessons are not being learned and repeated mistakes are putting people at risk, Behrens said. Major improvements are urgently needed to avoid more fatalities, he added. “I’ve heard some harrowing stories about sepsis through our investigations, and it frustrates and saddens me that the same mistakes we highlighted 10 years ago are still occurring,” said Behrens. “It is clear that lessons are not being learned. Losing a life through sepsis should not be an inevitability.” Melissa Mead, whose one-year-old son, William, died from sepsis in 2014 after concerns were dismissed by doctors, said: “I think this report, nine years on from William’s death, really lays bare the incidences of sepsis cases.” Mead, who peer-reviewed the study, added: “Too many lives are being lost in preventable circumstances.” Read full story Source: The Guardian, 25 October 2023 Further reading on the hub: Top picks: Six resources about sepsis -
Content ArticleSepsis is a life-threatening reaction to an infection. It can affect anyone of any age. It happens when your immune system overreacts to an infection and starts to damage your body’s own tissues and organs. Sepsis is sometimes called septicaemia or blood poisoning. According to the UK Sepsis Trust, 48,000 people in the UK die of sepsis every year. This number can and should be reduced. It is often treatable if caught quickly. This report from the Parliamentary and Health Service Ombudsman(PHSO) looks at some of the sepsis complaints people have brought to PHSO, to shine a light on their experiences and encourage others to let their voices be heard. It shares case summaries and guidance to help people complain and help NHS organisations understand and learn from the issues raised Further reading on the hub: Top picks: Six resources about sepsis
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Content ArticleNHS England wants to find out how people would choose to tell the NHS about things that go wrong in healthcare, to help the NHS do things better. NHS England wants to hear from people of all ages and backgrounds, who use all kinds of NHS services. They want to know how people would choose to give feedback if something went wrong in their care, or in the care of someone they look after, so the NHS can learn. NHS England will use what you tell them to help design a new online service to make care better. Click on the link below to find out more and take the survey. Closing date: 31 December 2023
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Content ArticleHistorically, patient safety efforts have focused mostly on measuring and responding to harm. However, safety is much more than the absence of harm. Instead, patient safety includes looking at the whole system: its past, present and future in all its complexity. Healthcare Excellence Canada and Patients for Patient Safety Canada held many conversations with users of the health system, people who work in healthcare and safety scientists. The ideas collected suggest a new way of approaching patient safety – where everyone can contribute to creating safe conditions and where harm is more than physical. This discussion guide summarises what has been learned so far and captured in this key statement: Everyone contributes to patient safety. Together we must learn and act to create safer care and reduce all forms of healthcare harm.
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Content ArticleOn 29 September 2023, a group of NHS staff and Experts by Experience joined a Teams meeting to help the National Patient Safety team in NHS England (NHSE) to answer two important questions. 1. Is it a good idea to keep asking NHS staff to record the level of psychological harm experienced by patients and service users, after a patient safety incident? 2. If so, how we can help make sure this is done as well and accurately as possible? Here is the write up of the workshop.
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Content ArticleHealthcare is starting to embrace a shift towards Just Culture. In England, the new Patient Safety Incident Response Framework (PSIRF) prioritises respect, compassion, and systemic improvements. The potential benefits of this, and other initiatives, are significant, as Suzette Woodward reports
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Content ArticleWhen a patient is deteriorating but no one is listening, Martha’s rule will guarantee a second opinion. Martha’s mother, Merope Mills, calls for doctors and nurses to embrace its implementation.
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News Article
Patient declared dead woke up in hospital
Patient Safety Learning posted a news article in News
An ambulance trust has apologised after a patient who was declared "dead" later woke up in hospital. As first reported by The Northern Echo, the individual was taken by paramedics to Darlington Memorial Hospital on Friday. The newspaper reported they had been declared dead following an incident earlier that day. The North East Ambulance Service (NEAS) apologised to the patient's family and said an inquiry had begun. The patient has not been identified or their current condition revealed. NEAS director of paramedicine Andrew Hodge said: "As soon as we were made aware of this incident, we opened an investigation and contacted the patient's family. "We are deeply sorry for the distress that this has caused them. "A full review of this incident is being undertaken and we are unable to comment any further at this stage. "The colleagues involved are being supported appropriately and we will not be commenting further about any individuals at this point." Read full story Source: BBC News, 17 October 2023 -
EventuntilThe Learn from Patient Safety Events (LFPSE) service is the NHS's new system for the recording and analysis of patient safety events. Very little research had been done before to understand the best ways to make sure patients, service users and their families can give their views on safety incidents, for the whole NHS to learn from. Learning from patients’ experiences and how they feel about the care they have received is known to be a very good way to make healthcare services better. However, getting the right information from people in the right way, and making sure the right NHS staff see it and can act on it, is difficult to do. This Show and Tell outlines the research completed to understand how we can do this better through the introduction of the LFPSE service. Audience: This is a publicly open event for anyone interested in understanding the work that NHS England has completed into understanding the best ways to make sure patients, service users and their families can give their views on safety incidents, for the whole NHS to learn from. Speakers: Lucie Mussett Patient Safety Lead & Senior Product Manager for the Learn from patient safety events (LFPSE) service Hope Bristow – Senior User Centred Designer (Informed Solutions) Natasha Hughes – User Researcher (Informed Solutions) Register
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Content ArticleAs part of the development of the new Learn from Patient Safety Events (LFPSE) service, this report from NHS England summarises the outcome of Discovery Phase research which considered how best patients, service users and their families can give their views on safety incidents, for the whole NHS to learn from.
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EventuntilThis two-day King's Fund conference aims to explore how the current strain on services makes listening to people more difficult but even more important, at a time when public satisfaction with the NHS is at an all-time low. Join us to hear about how you can make sure building in the user voice is routine and core to the business of the health and care system, not just ‘a nice to have’. Conference sessions will: discuss how the NHS and social care cannot deliver quality unless listening to patients and carers, and acting on their feedback, lies at the heart of its culture. provide learning on how to listen well and what meaningful engagement with people and communities looks like. Gain insight into the findings from the Fund’s project on understanding integration with the HOPE (Heads of Patient Experience) network by working with six sites on an action learning piece. Learn about how health and social care decision-makers cannot overcome challenges and answer long-term questions alone - such as how the system will address the deep inequalities and how it can adapt to provide the joined-up, efficient care that people want and gives them more control – public input is crucial. Join peers to share learning on grasping this opportunity to finish building a culture where listening to patients, service-users, and communities is everyone's business. Register
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Content ArticleMuch has been written recently about Martha’s rule—the proposal to allow patients in hospitals in England and their families the right to demand an urgent second opinion if their condition is deteriorating. In this BMJ opinion piece, Helen Haskell outlines some principles for creating an effective family activated system, including breadth, urgency, continuity, independence and feedback.
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Content Article
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Richard von Abendorff, an outgoing member of the Advisory Panel of the Healthcare Safety Investigation Branch (HSIB), has written an open letter to incoming Directors on what the new Health Services Safety Investigations Body (HSSIB) needs to address urgently and openly to become an exemplary investigatory safety learning service and, more vitally, how it must not contribute to compounded harm to patients and families. The full letter is attached at the end of this page.- Posted
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News Article
'I'll keep fighting for dad over botched dentistry'
Patient Safety Learning posted a news article in News
The daughter of a man who took his own life after experiencing years of pain linked to botched dental surgery said she had "lost faith in the system". Clive Worthington, from Harlow, Essex, travelled to Hungary for dental implants in 2008. Several follow-up procedures from the same dentist back in the UK over the next seven years were unsuccessful. The government said it was addressing a so-called loophole which meant the 81-year-old missed out on compensation. Last week, an inquest concluded Mr Worthington's death in 2022 was a suicide. Senior Essex coroner Lincoln Brookes said the "long-term consequences" of Mr Worthington's unsuccessful dental surgery "impacted significantly on his mental health and ability to cope with daily life". In 2017, the General Dental Council (GDC) found Dr Eszter Gömbös, who was employed by Perfect Profiles, at fault for the work. Mr Worthington was awarded £117,378 in damages and legal costs at Chelmsford County Court in November 2019 - one of the highest pay-outs for dental negligence in the UK. But the insurer which covered Dr Gömbös - the Dental Defence Union (DDU) - argued "discretionary indemnity" and refused to pay. Read full story Source: BBC News, 12 October 2023 Related hub content “I’ve been mocked, scolded and gaslighted”: a harmed patient’s experience of orthodontic treatment A patient harmed by orthodontic treatment shares their story We want to hear from patients with experience of NHS and/or private orthodontists and dentists in any healthcare setting, including community practices and hospitals. Did the orthodontist/dentist give you the treatment and support you needed? If you had ongoing problems, how did the orthodontist/dentist and other healthcare professionals respond? Have you tried to make a complaint? Share your experience of orthodontist and dentistry services -
Content ArticleIt is essential that the voices of people from diverse communities are heard and acted upon because we will only be effective in improving patient safety for everyone if we include these groups. This blog from the Patient Safety Commissioner Dr Henrietta Hughes outlines the importance of listening to patients and staff from diverse communities to identify and act on patient safety issues – and how to make this happen.
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