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Found 543 results
  1. News Article
    The government faces a rebellion with at least 30 Tories backing an amendment to extend interim payouts to more victims of the infected blood scandal. Up to 30,000 people were given contaminated blood products in the 1970s and 80s. Thousands have died. A Labour amendment will be brought on Monday calling for a new body to be set up to administer compensation. More than 100 MPs, including Tories Sir Robert Buckland, Sir Edward Leigh and David Davis, are backing the move. In a letter sent to Chancellor Jeremy Hunt, shadow chancellor Rachel Reeves called the scandal "one of the most appalling tragedies in our country's recent history." She added: "Blood infected with hepatitis C and HIV has stolen life, denied opportunities and harmed livelihoods." She praised Theresa May, who set up the Infected Blood Inquiry when she was prime minister in 2017. But she warned: "For the victims, time matters. It is estimated that every four days someone affected by infected blood dies." The chancellor, himself a former health secretary, told the inquiry in July that the government accepted the moral case for compensation. But he said no final decisions could be made before the inquiry publishes its findings - now expected in March next year. In August 2022, the government agreed to make the first interim compensation payments of £100,000 each to about 4,000 surviving victims and bereaved widows. But inquiry chairman Sir Brian Langstaff, said in April this year that the parents and children of victims should also receive compensation and also called for a full compensation scheme to be set up immediately. The Commons Speaker will decide on Monday which amendments to the bill MPs will vote on. But the government has said it will not be supporting the amendment. A Department of Health spokesperson said: "We are deeply sympathetic to the strength of feeling on this and understand the need for action. However, it would not be right to pre-empt the findings of the final report into infected blood." Read full story Source: BBC News, 3 December 2023
  2. Content Article
    The first 14 minutes of this programme are focused on a Newsnight investigation into allegations of cover-up, avoidable harm and patient deaths relating to University Hospitals Sussex NHS Foundation Trust. At the time of broadcast, Sussex Police were investigating 105 claims of alleged medical negligence at the Trust.
  3. Content Article
    Presentation slides from Session 1 of the SEHTA 2023 International MedTech Expo & Conference. This session was on patient voice engagement. Presentations can be downloaded below.
  4. News Article
    The public inquiry into the Lucy Letby murders will seek changes to NHS services and culture next year despite the fact that formal hearings are likely to be delayed until the autumn. Inquiry chair Lady Justice Thirlwall will issue an update message later today. In it she will stress the inquiry will “look for necessary changes to be made to the system of neonatal care in this country in real time and at the earliest opportunity, avoiding delays in making meaningful change”. HSJ understands Lady Thirlwall will look to agree on some changes, based on the inquiry’s evidence gathering and discussions with the sector before it begins oral hearings – which are unlikely to start for at least a year due to ongoing legal action. Lady Thirlwall will say the legal constraints mean its early work will focus on the experience of families who were named in the cases already heard; and “on the effectiveness of NHS management, culture, governance structures and processes, as well as on the external scrutiny and professional regulation supposed to keep babies in hospital safe and well looked after”. She said, “I want this to be a searching and active inquiry in the sense that it will look for necessary changes to be made to the system of neonatal care in this country in real time and at the earliest opportunity, avoiding delays in making meaningful change”. Read full story (paywalled) Source: HSJ, 22 November 2023
  5. Content Article
    You have the right to make a complaint about any aspect of NHS care, treatment or service The information on this NHS page will guide you through the NHS complaints process, as well as the core requirements for NHS complaints handling.
  6. News Article
    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
  7. News Article
    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
  8. News Article
    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
  9. Content Article
    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.
  10. News Article
    A 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
  11. Content Article
    The 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.
  12. News Article
    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
  13. News Article
    The 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
  14. News Article
    Some 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
  15. Content Article
    Trevor 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
  16. News Article
    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
  17. News Article
    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
  18. News Article
    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
  19. News Article
    The WHO-hosted global conference on patient safety and patient engagement concluded yesterday with agreement across a broad range of stakeholders on a first-ever Patient safety rights charter. It outlines the core rights of all patients in the context of safety of healthcare and seeks to assist governments and other stakeholders to ensure that the voices of patients are heard and their right to safe health care is protected. “Patient safety is a collective responsibility. Health systems must work hand-in-hand with patients, families, and communities, so that patients can be informed advocates in their own care, and every person can receive the safe, dignified, and compassionate care they deserve,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “Because if it’s not safe, it’s not care.” "Our health systems are stronger, our work is empowered, and our care is safer when patients and families are alongside us,” said Sir Liam Donaldson, WHO Patient Safety Envoy. “The journey to eliminate avoidable harm in health care has been a long one, and the stories of courage and compassion from patients and families who have suffered harm are pivotal to driving change and learning to be even safer." The global conference on patient engagement for patient safety was the key event to mark World Patient Safety Day (WPSD) which will be observed on 17 September under the theme “Engaging patients for patient safety”. Meaningful involvement of patients, families and caregivers in the provision of health care, and their experiences and perspectives, can contribute to enhancing health care safety and quality, saving lives and reducing costs, and the WPSD aims to promote and accelerate better patient and family engagement in the design and delivery of safe health services. At the conference, held on 12 and 13 September, WHO unveiled two new resources to support key stakeholders in implementing involvement of patients, families and caregivers in the provision of health care. Drawing on the power of patient stories, which is one of the most effective mechanisms for driving improvements in patient safety, a storytelling toolkit will guide patients and families through the process of sharing their experiences, especially those related to harmful events within health care. The Global Knowledge Sharing Platform, created as part of a strategic partnership with SingHealth Institute for Patient Safety and Quality Singapore, supports the exchange of global resources, best practices, tools and resources related to patient safety, acknowledging the pivotal role of knowledge sharing in advancing safety. “Patient engagement and empowerment is at the core of the Global Patient Safety Action Plan 2021–2030. It is one of the most powerful tools to improve patient safety and the quality of care, but it remains an untapped resource in many countries, and the weakest link in the implementation of patient safety measures and strategies. With this World Patient Safety Day and the focus on patient engagement, we want to change that”, said Dr Neelam Dhingra, head of the WHO Patient Safety Flagship. Read full story Source: WHO, 14 September 2023
  20. News Article
    The government has backed Martha’s rule, a campaign to give families and patients the right to a second assessment if they feel their concerns are not being taken seriously. Health secretary Steve Barclay said ministers are “committed” to implementing the rule, insisting the case for it is “compelling”. Martha Mills died after developing sepsis while under the care of King’s College Hospital NHS Foundation Trust in south London. Mr Barclay said the case set out by Ms Mills, was “compelling”. “For everyone that has heard it, it is an absolutely heartbreaking case,” he told the BBC. Mr Barclay said: “I’m determined that we ensure we learn the lessons from it and very keen to learn from best international practice.” Mr Barclay said there are “international lessons”, particularly from Ryan’s Rule in Australia, giving patients a direct line to a second opinion. “And I particularly want to give much more credence to the voice of patients,” Mr Barclay said. He added: “I think a key part of this measure is ensuring that patients feel heard and can get a second opinion.” Read full story Source: The Independent, 14 September 2023
  21. News Article
    A new regional centre which promotes the reporting of suspected safety concerns associated with healthcare products has been launched in Northern Ireland. The Yellow Card centre for Northern Ireland will bring together a dedicated team to increase awareness, educate, and promote reporting of suspected adverse events to the Medicines and Healthcare products Regulatory Agency (MHRA) Yellow Card scheme. The Yellow Card scheme provides a mechanism for patients, care givers and healthcare staff to report suspected safety concerns associated with healthcare products. Speaking at the launch of the new service, Northern Ireland Chief Pharmaceutical Officer Professor Cathy Harrison said: “Collecting and monitoring information on possible adverse effects of medications and healthcare products is vital to ensuring patient safety. "It is fitting that the launch of the Yellow Card centre for Northern Ireland coincides with World Patient Safety Day on 17 September, with this year’s theme of "Engaging patients for patient safety". "The Yellow Card scheme puts the patient voice at its heart. By voluntarily reporting issues, patients, families and care givers can play a crucial role in their own care, and the safety of healthcare as a whole. I welcome the launch of the new regional centre and would encourage anyone who has suspected safety concerns to report them.” Read full story Source: Department of Health (Northern Ireland), 13 September 2023
  22. Content Article
    Sepsis 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
  23. Content Article
    NHS 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
  24. Content Article
    As 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.
  25. Content Article
    We have had quite an eventful few weeks in the NHS in England, much of it not very pretty. There have been reports of a consultant dismissed from a Trust for raising concerns about safety, and, following a well-reported series of events, an experienced and essential clinician leaving the workforce. Then there were the events in Manchester where a nurse has been convicted of murdering seven children and the attempted murder of another six children. This despite the raising of concerns by not one, not two but seven senior clinicians. They faced the now repeatedly seen series of actions where they were not believed, faced counteraccusations and threatened with being reported to their regulators. Now we have the inevitable fall out, an incoming inquiry and, no doubt, the same or very similar themes to the many inquiries that have happened in the past. There has been much discussion about these events on social media, mostly focused on Lucy Letby, about patient safety, the actions that people should have taken and reasons why they did not. However, in this blog, I am choosing to look at things from a slightly different perspective, that of the Patient Safety Incident Response Framework (PSIRF). 
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