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Showing results for tags 'Patient death'.
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Content ArticleToo little, too late, says Scally, Jacobson and Abbasi in this BMJ Editorial on the government's response to COVID-19. The UK government and its advisers were confident that they were “well prepared” when COVID-19 swept East Asia. The four-pronged plan of 3 March to contain, delay, research, and mitigate was supported by all UK countries and backed, they claimed, by science. With over 30 000 hospital and community deaths by 12 May, where did the plan go wrong? What was the role of public health in the biggest public health crisis since the Spanish flu of 1918? And what now needs to be done?
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Content ArticleThis pay-walled article, published in The Sunday Times, highlights patient safety concerns identified in relation to West Suffolk hospital, with specific reference to two incidences of avoidable patient harm. In the case of Daniel Parsons, a drugs error caused an adverse affect on the functioning of Daniel's heart and led to his death. The coroner for the inquest concluded that Daniel's death could have been avoided if doctors had heeded the early warning signs of anaphylaxis. The second incident highlighted by the authors is that of Paul Farmer, who was left blind and with severe brain damage following avoidable harm. Concerns raised within the article include: Prioritisation of reputation management (an 'outstanding' status) over patient safety Reluctance to investigate Unfair reprisal for staff raising patient safety concerns Lack of response from Health Secretary Matt Hancock. Further reading: Bullying executives left West Suffolk Hospital staff ‘sobbing, shaking, rocking in despair’ (March 2020)
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Capnography: No Trace = Wrong Place
Patient Safety Learning posted an article in High risk areas
The Royal College of Anaesthetists (RCoA) and the Difficult Airway Society (DAS) have collaborated to create the video resource Capnography: No Trace = Wrong Place. Presented by Professor Tim Cook, the video shares the important message that during cardiac arrest, if a capnography trace is completely flat, oesophogeal intubation should be assumed until proven otherwise. -
Content ArticleThe Marmot Review into health inequalities in England was published on 11 February 2010. It proposes an evidence based strategy to address the social determinants of health, the conditions in which people are born, grow, live, work and age and which can lead to health inequalities.
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Content ArticleAvoidable unsafe care kills and harms thousands of people in the UK each year. When a person dies as a result of a preventable error it is vital that we learn from these tragic events and take action to ensure that this does not reoccur. Coroners' Prevention of Future Deaths (PFD reports) are a crucial resource for this and should be used to make healthcare safer. Are we utilising these to their full extent to improve our safety practice and to achieve their aim, to prevent future deaths?
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Content ArticleMatt Darling was worried when his 15-month-old daughter, Jem Darling, began to show signs of brain cancer. When his worst fears were confirmed, Matt took on the role of an advocate for his daughter. While in the hospital, Matt witnessed firsthand the harm that is caused by a fragmented information environment in hospitals, spurring his development of the world's first safety critical clinical workflow engine. In this short film, produced by The Patient Safety Movement (Australian based), Matt tells his story.
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James Titcombe: The complexity of failure (2 October 2018)
PatientSafetyLearning Team posted an article in Culture
When James Titcombe is hit by the biggest tragedy imaginable to any parent, he and his wife need to confront a tragedy on a bigger scale still: the structural learning disabilities of the organisation that robbed them of their child. The ‘complexity of failure’ video documents the struggle to get the largest employer of the land to account for what was lost. Behind the bureaucracy and posturing, the lies and denials, it discovers a humanity and a richly facetted suffering by many others. It drives a determined James Titcombe to change how we learn from failure forever. -
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NHS Resolution videos: How to prepare for an inquest
PatientSafetyLearning Team posted an article in Legal matters
The purpose of these three films is to share insights about inquests and support all staff working in the NHS who are called to give evidence, so that they can prepare well following the death of a patient in their care. They are intended to be used as a stand-alone product by those called to be a witness as well as integrated as a part of full inquest training package. -
Content ArticleMedication errors may cause harm, including death, and increase use of health care services. This project aims to summarise the evidence on the burden of medication error, namely the number of errors occurring in the NHS in England, the costs of those errors to the NHS and the health losses due to medication error. This involves two systematic reviews, one on the incidence and prevalence of medication errors, and the other on the costs of health burden associated with errors. Additionally, economic modelling estimates the number of errors occurring in the NHS in England each year, their costs and health consequences.
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Content ArticleThis is the response form the Parliamentary Under-Secretary of State for Health and Social Care, Nadine Dorries MP, to an urgent question from Sir Roger Gale MP on maternity care failings at the East Kent Hospitals University NHS Foundation Trust. It was followed by questions from MPs in the chamber and Ms Dorries’ responses.
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Content ArticleEmergency abdominal surgery (EAS) refers to high-risk intra-abdominal surgical procedures undertaken for acute gastrointestinal pathology. The relationship between hospital or surgeon volume and mortality of patients undergoing EAS is poorly understood. This study, published in BMJ Open, examined this relationship at the national level.
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Content ArticleBMJ Quality & Safety, was to determine the association between daily levels of registered nurse (RN) and nursing assistant staffing and hospital mortality.
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Content ArticlePeter Duffy, consultant surgeon writes of his 35 years of experience on the front-line of the NHS. Charting his career pathway from auxiliary nurse and unskilled operating theatre orderly, he takes us through his progress to senior consultant surgeon and head of department. In 2015, and after blowing the whistle on a series of near misses, he reluctantly reported an avoidable death, cover-up and ongoing surgical risk-taking to the Care Quality Commission. Within months he was out of work and unemployed. Via avoidable deaths and errors, cover-ups, misuse of public funds, bullying, abuse and victimisation the author charts out in searing detail his demotion, punishments and exile from both family and NHS and the subsequent brutal legal process that followed his illegal dismissal.
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Content ArticleIn this podcast, Peter Duffy, Consultant Urologist, addresses University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT). He speaks of the significant and damaging challenges faced by himself and others who raise concerns about patient safety, including bullying, harassment and abuse. He argues that whistleblowers are suffering personally and professionally when they speak up on behalf of patients. Duffy states: "There remain safety critical issues that the governors need to hold the Board to account over, if the Board is to regain the full confidence of staff and patients".
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Family reference group: INQUEST
Claire Cox posted an article in Patient stories
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. -
Content ArticleThe Care Quality Commission is the independent regulator of health and adult social care in England. We make sure that health and social care services provide people with safe, effective, compassionate, high quality care and we encourage care services to improve. Their role: They register health and adult social care providers. They monitor and inspect services to see whether they are safe, effective, caring, responsive and well-led, and we publish what we find, including quality ratings. They use our legal powers to take action where we identify poor care. They speak independently, publishing regional and national views of the major quality issues in health and social care, and encouraging improvement by highlighting good practice.
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INQUEST: Skills and support toolkit
Claire Cox posted an article in Prison setting
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. -
Content ArticleThe Talking about dying report seeks to offer advice and support for any doctor on holding conversations with patients much earlier after the diagnosis of a progressive or terminal condition, including frailty. The report identified that the timely, honest conversations about their future that patients want are not happening. Yet, these proactive discussions are fundamental to effective clinical management plans, part of being a medical professional and align with the aspirations of the Royal College of Physicians's Future Hospital Commission report. The Talking about dying report begins to highlight and challenge professional reluctance to engage in conversations with patients about uncertainty, treatment ceilings, resuscitation status and death. It offers some ‘mythbusters’ to get physicians thinking and we offer signposts to tools and educational resources to support physicians and other healthcare professionals.
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RCOG: Each Baby Counts 2019 progress report
Patient Safety Learning posted an article in Maternity
Each Baby Counts is a national quality improvement programme led by the Royal College of Obstetricians and Gynaecologists (RCOG) to reduce the number of babies who die, or are left severely disabled, as a result of incidents occurring during term labour. The Each Baby Counts programme brings together the results of local investigations into stillbirths, neonatal deaths and brain injuries occurring during term labour to understand the bigger picture, share the lessons learned and prevent babies from dying or suffering brain injuries in the future. This report presents key findings and recommendations based on the analysis of data relating to the care given to mothers and babies throughout the UK, to ensure each baby receives the safest possible care during labour. -
Content ArticleIn this article, published by Birmingham City University, Criminologists Professor Elizabeth Yardley, Professor David Wilson and Emma Kelly discuss the report found that 450 patients died after being given powerful painkillers inappropriately at Gosport War Memorial Hospital. "To kill multiple people requires not just the presence of a determined killer but the absence of protectors and guardians. When no one is looking out for the interests of the vulnerable, the vulnerable become the victims. Within organisations, failed protectors and guardians find strength in each other, denying responsibility, eschewing accountability and playing ping-pong until (they hope) people will just go away and stop demanding answers."
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GOSH response to error: a blog by Joanne Hughes
Claire Cox posted an article in Keeping patients safe
In this blog, Joanne Hughes, founder of Mother's Instinct and hub topic leader, gives her response to the recent news that childrens' deaths at Great Ormond Street Hospital (GOSH) have not been investigated properly. Amid claims GOSH put reputation above patient care, former health secretary, Jeremy Hunt, urged it to consider a possible "profound cultural problem". Joanne's daughter, Jasmine, died in 2011 following failures in her care. Soon after Joanne set up Mother’s Instinct with the ambition to provide a source of support specifically for families whose children die following medical error, and a platform to share their stories and experiences for learning to improve patient safety for children, patient engagement in patient safety, and care of avoidably bereaved parents. -
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Medscape: Novel coronavirus (articles)
Claire Cox posted an article in Guidance
This is a collection of articles, news and alerts on coronavirus published on Medscape. -
Content ArticleCharts comparing COVID-19 deaths across countries are appearing daily in our newsfeeds. Done well, these international comparisons can help us to understand how different national strategies and policies have affected the spread and severity of COVID-19 outbreaks. But sometimes what is presented in these neat charts is not quite as straightforward as it seems, and can draw misleading conclusions. Excess deaths is a better measure than COVID-19 deaths of the pandemic’s total mortality. It measures the additional deaths in a given time period compared to the number usually expected, and does not depend on how COVID-19 deaths are recorded. This report, written by Holly Krelle, Claudia Barclay and Charles Tallack, summarises some of the ways of comparing countries to help use make sense of data on deaths.
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Content ArticleThe COVID-19 pandemic has affected some sections of the population more than others, and there are growing concerns that the UK’s minority ethnic groups are being disproportionately affected. Following evidence that minority groups are over-represented in hospitalisations and deaths from the virus, Public Health England has launched an inquiry into the issue. In the short term, ethnic inequalities are likely to manifest from the COVID-19 crisis in two main ways: through exposure to infection and health risks, including mortality; through exposure to loss of income. This report brings together evidence on the unequal health and economic impacts of COVID-19 on people in minority ethnic groups in the UK, presenting information on risk factors for each of the largest minority ethnic groups in England and Wales: white other, Indian, Pakistani, Bangladeshi, black African and black Caribbean. The analysis focuses on a limited but crucial set of risk factors in terms of both infection risk and economic vulnerability in the short term.
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Content ArticleRoger Kline, Research Fellow at Middlesex University, highlights the three principles NHS organisations should take forward immediately to avoid unecessary staff deaths.
