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Showing results for tags 'Patient death'.
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Content ArticleSmoking or a naked flame could cause patients’ dressings or clothing to catch fire when being treated with paraffin-based emollient that is in contact with the dressing or clothing. The Medicines and Healthcare products Regulatory Agency (MHRA) provided this update for healthcare professionals.
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Bottle of Lies by Katherine Eban
Patient Safety Learning posted an article in Recommended books and literature
The troubles of Indian pharma companies abroad raise questions about the domestic drug regulator. Although Bottle of Lies, a book about the quality problems plaguing generic drugs, focuses on medicines intended for American consumers, the real and continuing victims of the failings described in the book are consumers in developing countries, including Indians. In May 2013, soon after the erstwhile Ranbaxy Laboratories admitted in an American court to selling adulterated drugs, journalist Katherine Eban published a gripping 10,000-word account of the saga in Fortune magazine. But the story left Eban wondering if Ranbaxy was an isolated case. Could there be more rotten eggs, she asked, given the United States Food & Drugs Administration’s (FDA) lax policing of overseas manufacturers? Bottle of Lies is the result of the multi-year investigation that followed. -
Content ArticleA Parliamentary and Health Service Ombudsman (PHSO) report of an investigation that found that Averil Hart's tragic death from anorexia would have been avoided if the NHS had cared for her appropriately. Ignoring the alarms: How NHS eating disorder services are failing patients highlights five areas of focus to improve eating disorder services.
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Content ArticleIn this interview with Nick Robinson from the BBC, Jeremy Hunt (then Foreign Secretary) speaks passionately about patient safety and the statistics surrounding avoidable patient deaths. Listen from 9:30 for this section. They veer away from the topic but return to it at 12:20 where he speaks about the importance of learning from mistakes in healthcare.
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Content ArticleAction Against Medical Accidents (AvMa) is a UK charity for patient safety and justice. AvMA supports people affected by avoidable harm in healthcare; to help them achieve justice; and to promote better patient safety for all.
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Content ArticleThe Citizens Advice provides advice on how to take legal action to get compensation for clinical negligence.
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Content ArticleLaw firm Bevan Brittan summarises the new Guidance for registered medical practitioners on Notification of Deaths Regulations 2019 that came into force on 1 October 2019: When to notify a death? How to notify? What is the significance? Training on the regulations.
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Content ArticleGov.uk has produced guidance for registered medical practitioners on meeting their duties under the Notification of Deaths Regulations 2019. The Notification of Deaths Regulations 2019 came into force on 1 October 2019. A copy of the Regulations can be found on the legislation website.
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Content ArticleThe RCNi (the publishing company of the Royal College of Nursing) have brought together a selection of their most popular articles on the topic of sepsis from across their journals to inform your practice. Sepsis remains a significant cause of death – it is estimated that 44,000 people die from ‘the silent killer’ every year. RCNi has a wide range of resources available to help nurses improve diagnosis and early management of the condition.
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Content ArticleFollowing the inquest into the death of former patient Amy Allan and the subsequent Preventing Future Deaths report given to Great Ormond Street Hospital for Children, Chief Executive Matthew Shaw would like to outline how the hospital is learning from this and what action has been taken to address the concerns that have been raised.
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Why investigate? The patient's perspective
Joanne Hughes posted an article in Investigations and complaints
A brief, heartfelt piece presented purely from the harmed patient's perspective and urging those involved in making decisions about whether or not to investigate to consider the impact of a good investigation on the ability of the harmed patient and their family to heal... Well received on twitter and described by a number of patients as 'you've said what I feel'. A reminder that a crucial purpose of the investigation is to give a harmed patient and their family a full explanation to help them understand, process and share for learning their experience. All necessary to their recovery. All necessary to their own 'safety' following an incident (we know poor responses cause additional suffering to those already harmed). The author also highlighted (via twitter) how much of this blog relates to the needs of staff involved in incidents too...- Posted
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Content ArticleThe Parliamentary and Health Service Ombudsman (PHSO) was set up by Parliament to provide an independent complaint handling service for complaints that have not been resolved by the NHS in England and UK government departments. This report look at how a man died after excessive wait for cancer treatment.
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Content ArticleOn 17 September 2019, we contributed to the first-ever World Patient Safety Day by releasing three short videos, with information about our thinking and proposed action to address unsafe care. Leadership for patient safety Patient safety is a purpose of health and social care Shared learning for patient safety
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Content ArticleHelen Haskell, co-chair of the WHO Patients for Patient Safety Advisory Group, brings the patient leader perspective to her take on World Patient Safety Day in this essay published in the BMJ.
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Content ArticleThe Parliamentary and Health Service Ombudsman (PHSO) has published a report following investigations into the deaths of two vulnerable young men. They found a series of significant failings in their mental health care and treatment. The PHSO are publishing the report and recommendations to alert parliament to systemic problems in care and treatment of patients with acute mental health problems at former North Essex Partnership University NHS Foundation Trust. NHS Improvement has agreed to establish a review in line with our recommendations and will share any learning it identifies across the NHS as needed. The North Essex Partnership University NHS Foundation Trust (now merged into the Essex Partnership University NHS Foundation Trust) has accepted the recommendations and are committed to continuing to work the PHSO to put things right. It is important the NHS understands why this happened and what lessons can be learned to prevent it happening again.
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Content ArticleNo one should be harmed while receiving healthcare. And yet globally, at least five patients die every minute because of unsafe care. The World Health Organization (WHO) will focus global attention on patient safety and launch a campaign in solidarity with patients on the very first World Patient Safety Day on 17 September 2019. Watch the WHO Director General’s statement calling for patients, healthcare workers, policy makers to “Speak up for Patient Safety!”.
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Content ArticleConnor Sparrowhawk died in July 2013 while he was in the care of Southern Health NHS Foundation Trust. An independent report concluded that Connor’s death was preventable and that there were significant failings in his care and treatment. Following publication of this report in February 2014, Oxfordshire Safeguarding Adults Board and NHS England (South) commissioned a second report in June 2014 to find out whether there were wider commissioning, leadership or management issues that could have contributed to the inadequate care that Connor received.
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Content ArticleA new medical examiner system is being rolled-out across England and Wales to provide greater scrutiny of deaths. The system will also offer a point of contact for bereaved families to raise concerns about the care provided prior to the death of a loved one. Acute trusts in England and local health boards in Wales have been asked to begin setting up medical examiner offices to initially focus on the certification of all deaths that occur in their own organisation. The purpose of the medical examiner system is to: provide greater safeguards for the public by ensuring proper scrutiny of all non-coronial deaths ensure the appropriate direction of deaths to the coroner provide a better service for the bereaved and an opportunity for them to raise any concerns to a doctor not involved in the care of the deceased improve the quality of death certification improve the quality of mortality data.
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Patient Stories: Paul's Story (10 March 2013)
Claire Cox posted an article in Patient stories
In 2007, when Paul Richards was diagnosed with non-Hodgkin lymphoma, his family were stunned by the news. This powerful film from Patient Stories is based on the testimony of Lisa, Paul’s wife, who gives a moving account of the events that led to Paul’s death and explores the effects on their family. -
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Patient Stories: Beth's story (27 December 2013)
Claire Cox posted an article in Patient stories
A moving and challenging short film about the Bowen family following the tragic death of five year old Bethany during ‘routine’ surgery and subsequent sudden death of father Richard aged 31, following the trauma of his daughter’s death and the ‘torture’ of the inquest. -
Content ArticlePulmonary embolism resulting from deep vein thrombosis, collectively referred to as venous thromboembolism, is the most common preventable cause of hospital death in the US. Pharmacologic methods to prevent venous thromboembolism are safe, effective, cost-effective, and advocated by authoritative guidelines, yet large prospective studies continue to demonstrate that these preventive methods are significantly underused.
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Content ArticleThis document sets out the policy statement and procedure for reporting, reviewing and investigating deaths of people who have been in receipt of services from the Southern Health NHS Foundation Trust. The policy demonstrates how Southern Health NHS Foundation Trust will quality monitor the process and provide the Board with assurance that deaths are being reviewed and learning/improvement is taking place to benefit future patients.
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Content ArticleLewis Blackman, a healthy 15-year-old boy, died in 2000 after an elective surgery. In this video, Lewis' mother Helen Haskell, President of Mothers Against Medical Error and member of the Institute for Healthcare Improvement (IHI) Board of Directors, explains why communication isn’t always the norm after adverse events and why this dynamic is changing.
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Content ArticleProfessor Don Berwick, an international expert in patient safety, was asked by the UK Prime Minister to carry out a review following the publication of the Francis Report into the breakdown of care at Mid Staffordshire Hospitals.
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Bawa-Garba - Implications and the BMA's response (April 2018)
Claire Cox posted an article in Systems
This is the British Medical Association's (BMA) response to the Bawa-Garba case. Dr Bawa-Garba was taken to the High Court, where a ruling on the 4th November 2015 deemed her guilty of manslaughter of six year old Jack Adcock on the grounds of gross negligence.
