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Found 1,489 results
  1. Event
    This national conference looks at the practicalities of serious incident investigation and learning from deaths in mental health services. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) which was published on 16 August 2022. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement, and updates from PSIRF early adopter sites in mental health. The conference will also examine how the new framework will fit with the Royal College of Psychiatrists Care Review Tool for mortality review. Register
  2. Event
    This conference focuses on investigating and learning from deaths in the community/primary care. The conference focuses on the extension of the Medical Examiner role to cover deaths occurring in the community and the role of the GP in working with the Medical Examiner to learn from deaths and to identify constructive learning to improve care for patients. The conference will also focus on implementation of the new Patient Safety Incident Response Framework and learning from a primary care early adopter. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-of-deaths-community or email nicki@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #LearningfromdeathsPC
  3. Community Post
    About 1000 angry nurses and doctors have rallied outside Perth Children’s Hospital in Australia following the death of seven-year-old Aishwarya Aswath, demanding vital improvements to the state’s struggling health system. The Australian Nurses Federation was joined by the Australian Medical Association for the rally, with staff from hospitals across Perth attending. Many people held signs that read “We care about Aishwarya”, “Listen to frontline staff”, “Report the executive — not us” and “Please don’t throw me under the bus”. Aishwarya developed a fever on Good Friday and was taken to Perth Children’s Hospital the next day, but had to wait about two hours in the emergency department before she received treatment. She died soon after from a bacterial infection. An internal report into the tragedy made 11 recommendations — including improvement to the triage process, a clear way for parents to escalate concerns and a review of cultural awareness for staff — but Aishwarya’s parents said the report raised more questions than it answered. The family wants a broader independent inquiry to look at all 21 near-misses in the past 15 months – not just their daughter’s case. Some people have been referred to medical authorities, while Child and Adolescent Health Service chair Debbie Karasinski resigned after the report.' I am encouraged to see the way healthcare staff reacted to this tragedy. Imagine a similar event in England, would nurses protest outside the hospital and stand up to authority like this? I doubt it very much, which is very sad reflection on the prevailing culture and health leadership in England. What do others think? Source: The Australian. 9 July 2021 Picture: Picture: 9 News
  4. Community Post
    We should all strive to keep antibiotics working for our NHS surgeons and future generations, by decreasing antibiotic use in medicine. It is mums themselves who could dramatically decrease antibiotic use, in the only medical specialty where this is possible - in obstetrics - by keeping skin intact; by being informed of the 10cm diameter that 'Aniball' and 'Epi-no Delphine Plus' birth facilitating devices, the mechanical version of Antenatal Perineal Massage, achieve by skin expansion (much like by 'earlobe skin expanders') prior to birth, for back of baby's head. This enables a normal birth for many more babies by shortening birth, with no cutting (episiotomies) or tearing, and much fewer Caesarean sections, as each Caesarean section requires antibiotics to be injected into mum, to kill any bacteria, which might have invaded a skin cell, from being implanted with that skin cell, deep into the wall of the uterus, by the surgeon's knife. There are around 750,000 births in the UK alone and three-quarters of mums are damaged during birth and at risk of developing infection; so a dramatic decrease in antibiotic use is possible. Empowering mums with knowledge; that both the skin and the coats of the pelvic floor muscles, which form the floor of the lower tummy, can be stretched painlessly, in preparation of birth, from the 26th week of pregnancy, so a gentler, kinder birth for both baby and mum becomes possible by decreasing risky obstetric interventions. Muscle can be stretched to 3 times its original length, if stretched painlessly over 6 or more occasions, and still retains its ability to recoil back, contracting to its original length. So there is no damage to mum. Baby's delicate head is not used to achieve this 'birth canal widening', because Antenatal Perineal Massage or Aniball or Epi-no Delphine Plus have already achieved this prior to the start of birth. In birth this stretching is rushed within the last 2 hours of birth, with risk of avulsion of pelvic floor muscle fibres from the pubic bone and risk of skin tearing or the need for episiotomy. The overlying skin will likewise stretch without tearing if done over 6 or more occasions. The maximal opening in the outlet or lower part of the pelvis is 10cm diameter, so 10cm diameter is the goal of the birth aiding devices and 'Antenatal Perineal Massage' or 'Birth Canal Widening' - opening doors for baby maximally. The mother reviews on 'Aniball' and 'Epi-no Delphine Plus' are impressive: Wanda Klaman, a first time mum, gives birth at nearly 42 weeks to a 4.4kg baby, with no need for episiotomy or forceps; Sophie of London, avoids episiotomy, when forceps are used to aid delivery for her baby who lays across her tummy - transverse lay, because the skin at this opening is so stretchy thanks to the birth facilitating devices. Cochrane Collaborate Report on Antenatal Massage https://pubmed.ncbi.nlm.nih.gov/23633325/ https://www.dailymail.co.uk/news/article-7450045/Fears-infections-pandemic-grow-NINETEEN-new-superbugs-discovered-UK.html https://www.mirror.co.uk/news/uk-news/mistakes-maternity-wards-setting-nhs-22702909
  5. Community Post
    See Rob Hackett's video on the hub: Indistinct Chlorhexidine: Patients suffer unnecessarily – the reason is clear Rob highlights the story of Grace Wang. In 2010 Grace Wang was left paralysed after an accidental epidural injection with antiseptic solution (indistinct chlorhexidine – easily mistaken for other colourless solutions). This same error continues to play out again and again throughout the world. Do you have evidence or data from your organisation or healthcare system. Comment below or email: info@pslhub.org We will ensure confidentiality.
  6. Content Article
    Two years after his 13-year-old child died needlessly in hospital, Paul Laity reflects on life without her. Martha Mills died of septic shock due to a series of serious failures in her care after she injured her pancreas in a cycling accident. Her father Paul talks about the ongoing pain of grief, and the additional burden of knowing that Martha's death was preventable, caused by the complacency of her doctors and a culture in the hospital that meant consultants were reluctant to ask expert advice from paediatric ICU. "Martha’s avoidable death was unusual in that the prime causes weren’t overwork or a lack of resources, but complacency, overconfidence and the culture on the ward. What upsets me most was that the consultants – a different one most days – took a punt that she was going to be OK over the weekend. No one assumed responsibility; they hoped for the best rather than playing safe. Was everything done for Martha that could have been done? Emphatically not. It’s very hard to live with this knowledge. But just as hard is the recognition that I, too, didn’t do enough." Further reading ‘We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death (The Guardian, 3 September 2022) Prevention of Future Deaths Report: Martha Mills (28 February 2022)
  7. Content Article
    In this letter, Rob Behrens, the Parliamentary and Health Service Ombudsman, calls on the Secretary of State for Health and Social Care, Steve Barclay MP, to prioritise improving patient safety in the wake of the Lucy Letby trial.
  8. Content Article
    Following the Lucy Letby case, letters to the Times discuss workplace rights and safety in hospitals. Keith Conradi, former chief investigator, Healthcare Safety Investigation Branch, highlights a current NHS workforce too frightened to raise safety concerns, working in a toxic and bullying culture, where the predominance of HR approaches undermine the culture of safety. And Andrew Harris, professor of coronial law, William Harvey Research Institute, Queen Marys University London, writes that there is a duty on medical practitioners to report the circumstances of a death and not to limit disclosure to avoid investigation. In his letter he questions whether medical examiners across the country are acting independently of their trusts and properly notifying such cases.
  9. Content Article
    We now know that Lucy Letby is a murderer, responsible for the deaths of seven babies and the attempted murders of six more. But as unimaginable as her crimes were, this verdict raises as many questions as it answers. Letby was not working in a vacuum. Could the killings at the Countess of Chester Hospital NHS Foundation Trust have been stopped sooner? Did organisational failures cost the lives of babies who could have been protected? The timeline gives us a clue, writes Minh Alexander, a retired consultant psychiatrist and NHS whistleblower, in this Guardian opinion piece. In June 2016, Letby’s hospital trust commissioned a review of neonatal care by the Royal College of Paediatrics and Child Health after “concerns about increasing neonatal mortality”, which oddly did not feature a case-note review. This prevented detailed examination of the deaths, which should have been the prime objective. The college reported “extremely positive relationships” among staff but “remote” relationships with executives. Astonishingly, the college’s report seemingly did not explicitly acknowledge a possibility of deliberate harm. Nevertheless, the college raised concern that not all deaths were followed by postmortem investigations – as they should have been, according to guidelines – and that where postmortems did take place, they did not include systematic blood tests and toxicology. It noted concerns from obstetrics staff about four unexpected deaths. In the coming days, there will be many questions. Why did it take so long for the hospital to refer matters to the police? Were doctors pressured not to persist with their concerns about Letby? How many trust board members knew there was a possibility of deliberate harm but failed to act?
  10. Content Article
    This study in the Journal of Medical Virology aimed to assess the extent and the disparity in excess acute myocardial infarction (AMI)-associated mortality during the pandemic, focusing on the outbreak of the Omicron strain. Using data from the US Centers for Disease Control and Prevention's (CDC's) National Vital Statistics System, the authors found that excess death, defined as the difference between the observed and the predicted mortality rates, was most pronounced for the 25–44 years age group. Excess deaths ranged from 23%–34% for the youngest compared to 13%–18% for the oldest age groups. The trend of mortality suggests that age and sex disparities have persisted even through the Omicron surge, with excess AMI-associated mortality being most pronounced in younger-aged adults.
  11. Content Article
    Publicly available data from the Office for Health Improvement and Disparities (OHID) shows a persistently high number of excess deaths involving cardiovascular disease (CVD) in England since the beginning of the pandemic. This analysis of by the British Heart Foundation looks at this situation in more detail.
  12. Content Article
    On the 20 February 2019 an investigation commenced into the death of Bethan Naomi Harris who was born on the 16 November 2018 at the St George's University Hospitals NHS Foundation Trust. Bethan Naomi Harris died at Shooting Star Hospice on the 26 November 2018. Her mother's pregnancy had been uneventful. After admission to labour ward labour progressed very quickly indeed and Bethan sustained severe brain injury during delivery. Despite best efforts by the neonatal team she succumbed to her injuries. The Investigation concluded at the end of the Inquest on the 19 November 2019. The conclusion of the inquest was that the medical cause of Bethan's death was (1a) hypoxic ischaemic encephalopathy.
  13. Content Article
    Babies would have survived if hospital executives had acted earlier on concerns about the nurse Lucy Letby, a senior doctor who raised the alarm has said. In an exclusive Guardian interview, Dr Stephen Brearey accused the Countess of Chester hospital trust of being “negligent” and failing to properly address concerns he and other doctors raised about Letby as she carried out her killings. Brearey was the first to alert a hospital executive to the fact that Letby was present at unusual deaths and collapses of babies in June 2015. The paediatrician and his consultant colleagues raised concerns multiple times over months before Letby, then 26, was finally removed from the neonatal unit in July 2016. The police were contacted almost a year later, in May 2017. Speaking publicly for the first time, Brearey told the Guardian that executives should have contacted the police in February 2016 when he escalated concerns about Letby and asked for an urgent meeting.
  14. Content Article
    This procedure describes the Trust wide process of retrospective case review that is to be implemented following an in-hospital death. The document outlines roles and responsibilities and provides guidance on the  process of identifying, reviewing, sharing and escalating mortality case reviews.
  15. Content Article
    This policy sets out a framework describing how the Trust and its staff will respond to and learn from deaths that occur under their care.It will provide guidance for all staff involved in the mortality review process ensuring clarity on roles, responsibilities and expectations. Reviewing mortality can help make improvements to the quality of care received by patients at the Trust by identifying care related issues. This enables the identification of learning themes and provides evidence of a high standard of care. Mortality is a fundamental component of clinical effectiveness, one of the three dimensions of quality described by Lord Darzi in High Quality Care for all (2008). The Trusts aims are to: Have continuous improvement of our Hospital Standardised Mortality Ratios (HSMR) and the Trusts Standardised Hospital-Level Mortality Index (SHMI) Achieve a year-on-year reduction in avoidable mortality  Improve learning from mortality reviews Ensure robust and timely governance processes regarding mortality outcomes and reviews Provide assurance of mortality processes in the Trust.
  16. Content Article
    The objective of this study, published in the BMJ, was to determine the proportion of avoidable deaths (due to acts of omission and commission) in acute hospital trusts in England and to determine the association with the trust’s hospital-wide standardised mortality ratio assessed using the two commonly used methods - the hospital standardised mortality ratio (HSMR) and the summary hospital level mortality indicator (SHMI). Authors conclude that reviews of individual deaths should focus on identifying ways of improving the quality of care, whereas the use of standardised mortality ratios should be restricted to assessing the quality of care for conditions with high case fatality for which good quality clinical data exist.
  17. Content Article
    At the time of her death, Heather Findlay, aged 28 years, was in the care of the East London Foundation Trust (ELFT), detained under section 2 of the Mental Health Act at Mile End Hospital. At approximately 3pm on 11 June 2020, she was on s17 escorted leave, standing with a healthcare assistant (HCA) at the front gates of the hospital having a cigarette, when she turned to the HCA, said “I’m sorry I have to do this to you” and ran away. ELFT contacted the Metropolitan Police Service (MPS) at 3.17pm, but by 3.58pm, Ms Findlay had been found by a member of the public in a nearby park. At inquest, the jury came to a conclusion of death by suicide and giving a medical cause of death of: 1a hypoxic ischaemic encephalopathy 1b sodium nitrate toxicity.
  18. Content Article
    Wales' national policy on patient safety incident reporting and management.
  19. Content Article
    A vision for improving the care and support available to families when baby loss occurs before 24 weeks' gestation.
  20. Content Article
    This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the Independent Investigation into East Kent Maternity services.
  21. Community Post
    I’ve just been listening to the 10 o’clock news tonight and it has been covering the report into Paterson, the breast surgeon who may have needlessly operated on thousands on women. One of the recommendations is that patient safety should be a ‘top priority’ across the NHS (again!!). Another interesting recommendation is that the NHS (and private healthcare providers) need to be better at sharing information about medical staff. Currently, medical staff seem to be able to be investigated in one hospital, and then move to another without any of their history following them. Maybe we need some sort of central system, like Doctify for employers? What do you think?
  22. Community Post
    Hi The new Patient Safety Incident Response Framework is due for publication this month for early adopters and as 'introductory guidance' for everyone else: https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/ I wondered if there is anyone who is involved in an organisation that is an early adopter who can share what has happened so far and also would be willing to share any local learning as the new framework is implemented? Also, more generally wondered if anyone has any initial comments on the proposals which were mentioned in the NHS patient safety strategy and any things in particular which they think will bring benefit or could represent significant challenges or issues?
  23. Community Post
    Does anyone have examples of templates they use for reviewing unexpected deaths in the community of patients known to mental health services?
  24. Content Article
    Food allergy affects around 7-8% of children worldwide, or about two children in an average-sized classroom. As children spend at least 20% of their waking hours in school, it is not surprising that data show that 18% of food allergy reactions and 25% of first-time anaphylactic reactions occur at school. This report by the Benedict Blythe Foundations looks at the prevalence and seriousness of allergies in school-aged children, and the devastating consequences when things go wrong at school.
  25. Content Article
    NHS England commissioned a limited scope independent review into patient safety concerns and governance processes related to the North East Ambulance Service. Chaired by Dame Marianne Griffiths DBE, the review considered the facts surrounding a number of individual cases, reviewed the processes surrounding coronial investigations and reviewed the seven previous investigations and reviews undertaken by the ambulance service to determine if they were sufficient to fully understand and resolve issues.
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