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Found 285 results
  1. Content Article
    People are given this Guide when someone close to them has died and their death has been reported to the coroner or if they have been called as a witness at an inquest. The coroner is involved in the death because the coroner needs to make enquiries to find out what happened and how the person died. For most people, the inquest process is new. Preparing for an inquest can be difficult, and some find it hard to find their way through the legal processes on top of the distress caused by the death. This guide, from the Ministry of Justice, is designed to help bereaved families understand the coroner process.
  2. Content Article
    Sarah Seddon's son (Thomas) was stillborn in May 2017. The lack of candour following Thomas’ death and the conduct of the serious incident investigation impacted significantly on Sarah and her family. The local investigation was followed by a Fitness to Practise (FtP) investigation where Sarah experienced how damaging, dehumanising and traumatic FtP processes can be for patients who are required to be witnesses. Here she reflects on the impact of being a witness in a Fitness to Practise (FtP) hearing had on her.
  3. Content Article
    Mouth Care Matters have launched a video – Supporting Patients in Hospital Who Are Resistant to Mouth Care. As part of their work with trusts in England, care resistant behaviour was the number one barrier to providing mouth care. They have developed a video is to explain why a patient may be resistant towards mouth care, and some ways that may help manage this. This video is aimed at all healthcare professionals. Covering techniques, use of distraction and products, we hope after watching this video you will have picked up many new tips towards delivering better care, to a patient who may at first be resistant to mouth care.
  4. Content Article
    Everyday across the NHS, patients, their supporters and the professionals caring for them deal with the aftermath of healthcare harm and, on rare occasions, wrongdoing. Every healthcare system in the world confronts exactly the same problem, but none deal well with the aftermath of harm. In this article published in the Journal of Patient Safety and Risk Management, Anderson-Wallace and Shale introduce a set of standards that aims to make the consequences less devastating for everyone.
  5. Content Article
    This study, published in the BMJ Open, aims to examine individual, situational and organisational aspects that influence psychological impact and recovery of a patient safety incident on physicians, nurses and midwives.
  6. Content Article
    This paper, published by Science Daily, highlights how a multidisciplinary group of leaders established consensus-driven research agenda designed to create a path forward to inform approaches that better support harmed patients and families.
  7. Content Article
    At the second annual Patient Safety Learning conference, held on 2 October 2019, we interviewed Evelyn Prodger, Head of Community Services at Martlets Hospice, on her experience at the conference and her thoughts on the launch of the hub.
  8. Content Article
    The Australian Open Disclosure Framework provides a nationally consistent basis for open disclosure in Australian healthcare. The framework is designed to enable health service organisations and clinicians to communicate openly with patients when healthcare does not go to plan.
  9. Content Article
    Published in Acta Paediatrica, the parents of a baby who was born prematurely and died, share their experiences of the communication and choices given to them before the birth.
  10. Content Article
    AvMA was originally established in 1982 as Action for the Victims of Medical Accidents following public reaction to the television play Minor Complications by AvMA’s founder Peter Ransley. The name was changed in 2003 to Action against Medical Accidents. Since its inception, AvMA has provided advice and support to over 100,000 people affected by medical accidents, and succeeded in bringing about massive changes to the way that the legal system deals with clinical negligence and in moving patient safety higher up the agenda in the UK.
  11. Content Article
    Jo Wailling is a registered nurse and research associate with the Diana Unwin Chair in Restorative Justice, Victoria University of Wellington. Jo presented on restorative practice at the Commission’s mental health and addiction (MHA) quality improvement programme workshop held in Wellington on 26 June for mental health and addiction leaders. This blog is a continuation of that presentation.
  12. Content Article
    The nature and consequences of patient and family emotional harm stemming from preventable medical error, such as losing a loved one or surviving serious medical injury, is poorly understood. Patients and families, clinicians, social scientists, lawyers, and foundation/policy leaders were brought together to establish research priorities for this issue. I recommend that all those involved in 'engagement with harmed patients and families' read this and in particular, commit to making sure they are doing the '20 things organisations can do now' that is listed in table 3. This paper was published in the Joint Commission Journal on Quality and Patient Safety. Register for free to view the full article. 
  13. Content Article
    The National Falls Prevention Coordination Group has identified resources to address Covid-19 related falls and fracture issues including advice for patients on keeping active following hospital discharge. The advice leaflet has been designed for patients who are discharged home with no community rehabilitation and can be download via the Chartered Society of Physiotherapy link below. It explains why muscle wasting occurs with prolonged bed rest or inactivity and why it is important to be active when discharged home from hospital. 
  14. Content Article
    People with chronic obstructive pulmonary disease (COPD) are at increased risk from coronavirus. Patient Safety Collaboratives are temporarily pausing their work to actively promote the COPD discharge bundle, however they will remain available to provide any support that organisations require. There are more updates and resources for COPD via this webpage.
  15. Content Article
    The Communication and Optimal Resolution (CANDOR) process is an evidence-based approach developed through support and testing by the US Agency for Healthcare Quality and Research. The CANDOR program aids healthcare institutions and practitioners to effectively respond when accidental, unexpected harm befalls patients in their care. The CANDOR toolkit contains information to help organisations implement the program. It covers topics such as event reporting and analysis, disclosure response and organisational learning. Further reading - The 'seven pillars' response to patient safety incidents: effects on medical liability processes and outcomes (December 2016)
  16. Content Article
    Helping patients and their families cope during a terminal illness is fundamental to good health care and that depends on professionals and the people in their care having access to the right information at the right time to support them. The Professional Record Standards Body (PRSB) has published the crisis care standard to support better coordination of treatment in primary,acute and community care, as well as hospices, care homes, and social services. The standard will also help patients to avoid unnecessary admissions and procedures.
  17. Content Article
    Sarah O'Neill, Family Liaison Manager, Solent NHS Trust, presented at the recent Bevan Brittan seminar on the role of family liaison. The presentation slides are attached.
  18. Content Article
    This moving video accompanied by a poem by Molly Case, speaks of the last 1000 days of a persons life, most of which is often spent in hospital. This is part of the #EndPjParalysis campaign and was commissioned by Prof Jane Cummings, Chief Nursing Officer for England,
  19. Content Article
    Venous thromboembolism (VTE) is responsible for over 25,000 deaths a year in the UK, including 10% of hospital inpatient deaths. A House of Commons report in 2005 led to the development of guidance by the National Patient Safety Agency (NPSA), the National Institute for Health and Clinical Excellence (NICE) and the Chief Medical Officer, for the safe use of anticoagulants and other measures to prevent VTE (deep vein thrombosis and pulmonary embolism). VTE prevention is a patient safety priority for the National Health Service (NHS).
  20. Content Article
    Thrombosis UK is a charity and a leader in: Identifying, Informing & Partnering the NHS, healthcare providers and individuals to work to improve prevention of venous thromboembolism (VTE) and the management and care of unavoidable VTE events. This short video explains how a blood clot might form, what the risks are and how they might be treated.
  21. Content Article
    Learn about anthithrombotics, what they are, the different types and how they work in this short video.
  22. Content Article
    INQUEST is a charity providing expertise on state related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians. Their specialist casework includes deaths in police and prison custody, immigration detention, mental health settings and deaths involving multi-agency failings or where wider issues of state and corporate accountability are in question. What is the Family Reference Group? The INQUEST Family Reference Group is made up of people directly affected by a contentious death (i.e. in detention/custody, where a state body is involved, or where the facts are disputed). It supports and contributes to INQUEST's work from a family perspective. The reference group brings together a range of experiences, taking into consideration race and gender perspectives, types of deaths across custody, immigration detention and mental health care.
  23. Content Article
    The INQUEST Skills and Support Toolkit is a resource for families and friends dealing with the aftermath of a death in custody and detention. The skills toolkit has been directed by the thoughts and experiences of INQUEST’s family reference group. The group includes a number of families whose relative has died in police custody or following police contact, prison custody, an immigration removal centre and a psychiatric setting.
  24. Content Article
    This poster has been developed by Dr Antonia Field-Smith and Dr Louise Robinson from the Palliative Care Team at West Middlesex Hospital. It provides a guide for communicating with relatives with compassion during the Covid-19 pandemic.
  25. Content Article
    Guidance from the Ministry of Justice and Her Majesty’s Prison and Probation Service about visiting prisons during the coronavirus outbreak.
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