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Showing results for tags 'Patient death'.
Found 1,491 results
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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 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 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 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 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 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 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 ArticleINQUEST's groundbreaking evidence-based report is based on our work with families of those who have died in mental health settings and related policy work. It identifies three key themes: 1. The number of deaths and issues relating to their reporting and monitoring. 2. The lack of an independent system of pre-inquest investigation as compared to other deaths in detention. 3. The lack of a robust mechanism for ensuring post-death accountability and learning.
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Sorry needn’t be the hardest word
Patient Safety Learning posted an article in Complaints
Nick Wright co-founder of the Apology Clause campaign wrote an article on why organisations need to say sorry The law supports apologies. The Compensation Act 2006 says “an apology, an offer of treatment or another redress, shall not itself amount to an admission of negligence or breach of statutory duty”. However, too many organisations put their fear of legal ramifications over what they see as their moral obligations. They fear if they apologise properly they will leave themselves open to legal action. That refusal to do the right thing can have serious and lasting impact on victims. A clear apology can lift the burden that victims very often carry for a long time after a trauma. It can enable them to move on. To stop blaming themselves. To stop re-living the most agonising moment. To rebuild. -
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 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. -
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Coroner’s inquests: A guide for learners (Health Education England)
Claire Cox posted an article in Inquests
Being called as a witness at an inquest is an infrequent event. It can however cause much anxiety and uncertainty. This guide is written to give advice to learners on how to prepare for an inquest and what support is available. -
Content ArticleSir Stephen Moss, Patient Safety Learning Trustee, is the former Chairman of Mid Staffordshire Hospitals NHS Trust, following their damming Healthcare Commission report of 2009. In this interview with Patient Safety Learning, Sir Stephen tells us about lessons learnt and what more needs to be achieved to make the NHS one of the safest healthcare systems in the world. View video (15 minutes)
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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 ArticleBetween 2005 and 2008 conditions of appalling care were able to flourish in the main hospital serving the people of Stafford and its surrounding area. During this period this hospital was managed by a Board which succeeded in leading its Trust (the Mid Staffordshire General Hospital NHS Trust) to foundation trust (FT) status. The Board was one which had largely replaced its predecessor because of concerns about the then NHS Trust’s performance. In preparation for its application for FT status, the Trust had been scrutinised by the local Strategic Health Authority (SHA) and the Department of Health (DH). Local scrutiny committees and public involvement groups detected no systemic failings. In the end, the truth was uncovered in part by attention being paid to the true implications of its mortality rates, but mainly because of the persistent complaints made by a very determined group of patients and those close to them. This group wanted to know why they and their loved ones had been failed so badly. The report was laid before Parliament in response to a legislative requirement.
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Content ArticleThe lack of follow-up or communication of unexpected significant findings can have a serious or life-threatening impact on patients. This was seen in the reference case that informed this Healthcare Safety Investigation Branch (HSIB) investigation. In this event, a 76-year old woman had a chest X-ray showing a possible lung cancer which was not followed up and resulted in a delayed diagnosis. The patient died just over two months after her diagnosis.
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Content ArticleA framework to support ambulance trusts in England to learn from deaths in their care.
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Content ArticleThis Care Quality Commission (CQC) report focuses on why avoidable harm remains a persistent problem within healthcare.
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Content ArticleA protocol for liaison and effective communications between the NHS, Association of Chief Police Officers (replaced in 2015 by a new body, the National Police Chiefs' Council) and Health and Safety Executive (HSE). Although now archived in The National Archives, much of the protocol is still relevant today. The protocol took effect in circumstances of unexpected death or serious untoward harm requiring investigation by the police, or the police and the HSE jointly. The protocol sets out the general principles for the NHS, police and HSE to observe when liaising with one another. It focused on investigations in NHS Trusts, although the principles and practices it promotes should apply to other locations where healthcare is provided and the NHS is required to investigate under its performance management and other duties.
