Jump to content

Search the hub

Showing results for tags 'Patient harmed'.

More search options

  • Search By Tags

    Start to type the tag you want to use, then select from the list.

  • Search By Author

Content Type


Forums

  • All
    • Commissioning, service provision and innovation in health and care
    • Coronavirus (COVID-19)
    • Culture
    • Improving patient safety
    • Investigations, risk management and legal issues
    • Leadership for patient safety
    • Organisations linked to patient safety (UK and beyond)
    • Patient engagement
    • Patient safety in health and care
    • Patient Safety Learning
    • Professionalising patient safety
    • Research, data and insight
    • Miscellaneous

Categories

  • Commissioning, service provision and innovation in health and care
    • Commissioning and funding patient safety
    • Digital health and care service provision
    • Health records and plans
    • Innovation programmes in health and care
    • Climate change/sustainability
  • Coronavirus (COVID-19)
    • Blogs
    • Data, research and statistics
    • Frontline insights during the pandemic
    • Good practice and useful resources
    • Guidance
    • Mental health
    • Exit strategies
    • Patient recovery
    • Questions around Government governance
  • Culture
    • Bullying and fear
    • Good practice
    • Occupational health and safety
    • Safety culture programmes
    • Second victim
    • Speak Up Guardians
    • Staff safety
    • Whistle blowing
  • Improving patient safety
    • Clinical governance and audits
    • Design for safety
    • Disasters averted/near misses
    • Equipment and facilities
    • Error traps
    • Health inequalities
    • Human factors (improving human performance in care delivery)
    • Improving systems of care
    • Implementation of improvements
    • International development and humanitarian
    • Safety stories
    • Stories from the front line
    • Workforce and resources
  • Investigations, risk management and legal issues
    • Investigations and complaints
    • Risk management and legal issues
  • Leadership for patient safety
    • Business case for patient safety
    • Boards
    • Clinical leadership
    • Exec teams
    • Inquiries
    • International reports
    • National/Governmental
    • Patient Safety Commissioner
    • Quality and safety reports
    • Techniques
    • Other
  • Organisations linked to patient safety (UK and beyond)
    • Government and ALB direction and guidance
    • International patient safety
    • Regulators and their regulations
  • Patient engagement
    • Consent and privacy
    • Harmed care patient pathways/post-incident pathways
    • How to engage for patient safety
    • Keeping patients safe
    • Patient-centred care
    • Patient Safety Partners
    • Patient stories
  • Patient safety in health and care
    • Care settings
    • Conditions
    • Diagnosis
    • High risk areas
    • Learning disabilities
    • Medication
    • Mental health
    • Men's health
    • Patient management
    • Social care
    • Transitions of care
    • Women's health
  • Patient Safety Learning
    • Patient Safety Learning campaigns
    • Patient Safety Learning documents
    • Patient Safety Standards
    • 2-minute Tuesdays
    • Patient Safety Learning Annual Conference 2019
    • Patient Safety Learning Annual Conference 2018
    • Patient Safety Learning Awards 2019
    • Patient Safety Learning Interviews
    • Patient Safety Learning webinars
  • Professionalising patient safety
    • Accreditation for patient safety
    • Competency framework
    • Medical students
    • Patient safety standards
    • Training & education
  • Research, data and insight
    • Data and insight
    • Research
  • Miscellaneous

News

  • News

Categories

  • Files

Calendars

  • Community Calendar

Find results in...

Find results that contain...


Date Created

  • Start
    End

Last updated

  • Start
    End

Filter by number of...

Joined

  • Start

    End

Group

First name

Last name

Country

Join a private group (if appropriate)

About me

Organisation

Role

Found 1,344 results
  1. Content Article
    On 18 August 2023, Lucy Letby was found guilty of murdering seven babies and convicted of trying to kill six other infants at the Countess of Chester Hospital. Looking ahead to the forthcoming independent inquiry into this case, Patient Safety Learning, reflecting on the inquiries of the past, sets out some key patient safety themes and issues that should be considered as part of this.
  2. News Article
    At least 20 patients have suffered harm due to their follow-up appointments not being booked at a hospital department where people ‘continue to come to harm’, according to an internal review. Torbay and South Devon Foundation Trust is reviewing its ophthalmology service after 22 people were harmed following “system failures” with their follow-up appointments. The trust’s initial investigation, obtained by HSJ with the Freedom of Information Act, warned there were “potentially” other patients affected by the failures who had not yet been identified. In response, the trust said its ophthalmology department had already “undertaken a significant amount of work to address a large proportion of the actions arising from the review”, including building another operating theatre and recruiting more staff. Read full story (paywalled) Source: HSJ, 21 August 2023
  3. 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.
  4. News Article
    Patients whose lives were damaged by surgery for bowel problems are calling for a long-awaited report to be published. More than 200 patients underwent mesh bowel operations in Bristol that they might not have needed. The surgery was carried out by Tony Dixon at Southmead Hospital and the private Spire Hospital, in Redland. A review by North Bristol NHS Trust was published in May 2022, but patients are still waiting to hear from Spire. Jill Smith, 69, from Westbury-on-Trym, paid privately to go to Spire. She said she is still in severe pain following her surgery. "Emotionally it has affected me big time. It is just horrible," she said. "The stress and panic I get going anywhere, is, 'will I have an accident or something?'." Read full story Source: BBC News, 18 August 2023
  5. News Article
    A teaching trust has had its maternity services downgraded to ‘inadequate’ after inspectors found stillbirths and massive haemorrhages were not being treated as ‘serious incidents’. Maternity services at St George’s University Hospitals Foundation Trust in south London were previously inspected in 2016, when they were assessed as “good”. The Care Quality Commission (CQC) said serious incident declaration meetings at St George’s were regularly classing serious incidents as “adverse incidents”, meaning executives were not informed and there were missed opportunities for learning and development. Inspectors also found incidents such as severe perineal tears, emergency hysterectomy, and birth injuries were rated as causing low or no harm when a higher level would have been appropriate, or and sometimes downgraded from a higher rating. Carolyn Jenkinson, CQC’s deputy director of secondary and specialist healthcare, said: “We saw areas where significant and urgent improvements are needed to ensure safe care is provided to women, people using this service, and their babies. “Both staff and people using the service were being let down by leaders who failed to respond quickly, resulting in care that was unsafe, and in the delivery suite, also chaotic.” Read full story (paywalled) Source: HSJ, 17 August 2023
  6. Content Article
    The Maternity Survey 2022, run by Ipsos on behalf of the Care Quality Commission, looked at the experiences of women and other pregnant people who had a live birth in early 2022. In this article Anita Jefferson from Ipsos looks at the results of this and considers what they tell us about experiences of maternity services.
  7. News Article
    An 11-year-old boy suffered permanent brain damage after birth because of negligence by hospital midwives who then fabricated notes, a high court judge has ruled. Jayden Astley’s challenges in life include deafness, motor impairments, cognitive difficulties and behavioural difficulties, his lawyers said. After a five-day trial at the high court in Liverpool, Mr Justice Spencer ruled that staff at the Royal Preston hospital in Lancashire were negligent in their treatment of Jayden in 2012. The brain injury was caused by prolonged umbilical cord compression that resulted in acute profound hypoxia – lack of oxygen – sustained during the management of the birth, the court found. Midwives failed to accurately monitor Jayden’s heart rate when he was born and failed to identify his bradycardic, or slow, heart rate during delivery. The judge also found that some entries in notes were fabricated. In his judgment Spencer said it was agreed that all permanent damage to Jayden’s brain would have been avoided if he had been delivered three minutes earlier. Read full story Source: The Guardian, 2 August 2023
  8. News Article
    Every day Sharon Smith has to take a strong morphine tablet to dull the excruciating pain she has lived with for more than a decade. “I am in chronic pain every day. It’s affected our whole family and I’ve lost all my independence,” said Smith, from Leigh, Greater Manchester. Over four years from 2009, she endured three operations on her spine at Salford Royal Hospital, which as an NHS trust was once fêted as England’s safest. But the hospital had a dark secret: an incompetent leading surgeon who, an independent review would later find, had already “contributed” to the death of a girl in 2007. Now a wider investigation has confirmed that dozens of other patients who went under John Bradley Williamson’s knife were harmed or received poor care. Read full story (paywalled) Source: The Times, 30 July 2023
  9. Content Article
    In 2021, a multi-professional staff support group was established under the Northern Care Alliance NHS Foundation Trust’s Freedom to Speak Up process which raised new questions and concerns around the probity and clinical standards of a Consultant Spinal Surgeon (“Consultant Spinal Surgeon A”) whilst they were employed at Salford Royal NHS Foundation Trust (now part of the Northern Care Alliance NHS Foundation Trust) (“the Trust”). As a result, the Trust commissioned the Spinal Patient Safety Look Back Review (“SPSLBR”) and Investigation Group to evaluate these concerns, including obtaining independent expert advice.In January 2022, the Trust commenced the SPSLBR to investigate and manage patient safety concerns raised in respect of Consultant Spinal Surgeon A who was employed at Salford Royal NHS Foundation Trust (now part of the Northern Care Alliance NHS Foundation Trust) between 1991 and January 2015. This report outlines the investigation carried out by the SPSLBR Investigation Group on behalf of the Trust to investigate and manage potential Serious Incidents (“SI”) caused by the errors and omissions attributable to clinics, surgery and/or consultations undertaken by Consultant Spinal Surgeon A within the scope identified in the Terms of Reference. 
  10. Content Article
    The Duty of Candour for Wales statutory guidance.
  11. Content Article
    Wales' national policy on patient safety incident reporting and management.
  12. Content Article
    This investigation aims to improve patient safety by supporting healthcare staff in a surgical setting to select and insert the appropriate type of implant (vascular graft) for haemodialysis treatment. The Healthcare and Safety Investigation Branch (HSIB) explored the factors that affect the ability of staff to safely select and insert vascular grafts for haemodialysis treatment. The national investigation focused on: The identification of factors within the healthcare system as a whole that influence patient safety risks associated with the selection and insertion of vascular grafts in an operating theatre environment. Exploration, using a systems approach, of the design of labelling and packaging used for the different types of vascular grafts for patients on haemodialysis treatment. Exploration of the impact on operating theatre teams of staff redeployment and repurposing of working environments in response to the COVID-19 pandemic.
  13. News Article
    Rishi Sunak says the government will wait for the Infected Blood Inquiry's final report before responding to questions around victim compensation. Bereaved families heckled the prime minister when he told the inquiry the government would act as "quickly as possible". Mr Sunak told the inquiry people infected and affected by the scandal had "suffered for decades" and he wanted a resolution to "this appalling tragedy". But although policy work was progressing and the government in a position to move quickly, the work had "not been concluded". He indicated there was a range of complicated issues to work through. "If it was a simple matter, no-one would have called for an inquiry," Mr Sunak said. Campaign group Factor 8 said Mr Sunak had offered "neither new information not commitments" to the victims and bereaved families, which felt "like a betrayal". Haemophilia Society chief executive Kate Burt said: "This final delay is demeaning, insulting and immensely damaging. "We urge the prime minister to find the will to do the right thing and finally deliver compensation which recognises the suffering that has been caused." Read full story Source: BBC News, 26 July 2023
  14. News Article
    Health officials waited six months to speak to the surgeon Sam Eljamel after a complaint was made about his conduct that eventually led to his suspension. Eljamel, who was head of neurosurgery at NHS Tayside in Dundee between 1995 and 2013, harmed dozens of patients before being suspended in 2013. Even as NHS Tayside commissioned an external review into Eljamel’s conduct, the surgeon was not suspended. Instead, the health board allowed him to continue practising as long as he was monitored. However, a letter sent to Eljamel by NHS Tayside’s clinical director, dated June 21, 2013, reveals that the surgeon was able to negotiate the extent of his own supervision. It was during this period of supervision that Jules Rose attended Ninewells Hospital to have a brain tumour removed by the surgeon. He performed two surgeries on her, in August and December, and she later discovered that he had removed her tear gland instead of the tumour. Since then she has founded and run the Patient’s Action Group, representing 126 of Eljamel’s patients calling for a public inquiry into how he was able to harm so many patients at NHS Tayside. Read full story (paywalled) Source: The Times, 25 July 2023
  15. Content Article
    This blog from Matthew Bacon, CEO of TCC-CASEMIX Ltd, looks at why a multi-factorial dataset is needed to create holistic understanding of medical device performance and is the only effective means for determining the multi-factorial causes of failure.
  16. News Article
    Just one-fifth of staff at a trust engulfed in an abuse scandal expressed confidence in the executive team, according to the Care Quality Commission (CQC), which has downgraded the trust and its leadership team to ‘inadequate’. The CQC inspected Greater Manchester Mental Health Trust following NHS England launching a review into the trust in November 2022 after BBC Panorama exposed abuse and care failings at the medium-secure Edenfield Centre. The two inspections, made between January and March 2023, which assessed inpatient services and whether the organisation was well-led, also saw the trust served with a warning notice due to continued concerns over safety and quality of care, including failure to manage ligature risks on inpatient wards. Inspectors identified more than 1,000 ligature incidents on adult acute and psychiatric intensive care wards in a six-month period. In the year to January, four deaths had occurred by use of ligature on wards which the CQC said “demonstrated that actions to mitigate ligature risks and incidents by clinical and operational management had not been effective”. Read full story (paywalled) Source: HSJ, 21 July 2023
  17. 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.
  18. Content Article
    This constructive commentary reflects on two recent related publications, the Healthcare Safety Investigation Branch (HSIB) report, Variations in the delivery of palliative care services to adults, and an article from Sarcoma UK, Family insights from Dermot’s experience of sarcoma care. Drawing from these publications, Richard, brother-in-law of Dermot, gives a family perspective, calling for a more open discussion around how we can improve palliative care and sarcoma services, and why we must listen and act upon family and patient experience and insight.
  19. Content Article
    In 2020, the Independent Medicines and Medical Devices Safety Review (IMMDS), chaired by Baroness Cumberlege, highlighted the avoidable harm caused by both pelvic and sodium valproate. It also set out the devastating impact on people’s lives when patients’ voices go unheard. The Minister for Mental Health and Women’s Health Strategy, Maria Caulfield MP, asked the Patient Safety Commissioner (PSC) to explore redress options for those who have been harmed by pelvic mesh and sodium valproate. The work will focus on what a suitable redress scheme for those affected should look like, to meet the needs of those affected. The PSC will publish a public report of this work. Once the project is complete, the Government will consider the report and set out next steps. The project will engage with patients through: meeting patients and their representative organisations. an online survey to gather views, which will be launched in due course.
  20. News Article
    Just one in five staff who were approached in a trust’s internal inquiry – prompted by an undercover broadcast raising serious care concerns – engaged with the process, a report has revealed. Essex Partnership University Foundation Trust said it took “immediate action” to investigate issues highlighted in a Channel 4 Dispatches programme into two acute mental health wards last year. This included speaking to staff identified as a high priority in the investigation. However, a new Care Quality Commission report has revealed, of the 61 staff members the trust approached, only 12 engaged with the process. Read full story (paywalled) Source: HSJ, 19 July 2023
  21. Content Article
    Three years since Baroness Cumberlege published her damming First Do No Harm report and a new report will look into financial redress for women injured by pelvic mesh. The latest project, announced this week by Patient Safety Commissioner Dr Henrietta Hughes, will involve talking to patient groups and individuals to ask women what they want. The government will then make a decision on next steps. While it is tiring to see a report, following a report after a report, it is a step forwards from when the government refused to offer financial redress, instead promising to toughen regulations and systems to improve patient safety.
  22. News Article
    Concerns codeine-based cough syrup could be addictive and have serious health consequences have led the UK medicines safety regulator to consider stopping its sale over the counter. The Medicines and Healthcare products Regulatory Agency (MHRA) is asking the public for their views on changing codeine linctus - which is a syrup with the active ingredient codeine phosphate and is used to treat a dry cough - to a prescription-only medicine. This comes in the wake of multiple reports to the regulator that the medicine is instead being used recreationally for its opioid effects. Since 2018, the MHRA has received 116 reports of recreational drug abuse of, dependence on, and/or withdrawal from codeine medicines, including codeine linctus. Dr Alison Cave, MHRA Chief Safety Officer, said this can have a severe impact on people’s health. She said: “Codeine linctus is an effective medicine, but as it is an opioid, its misuse and abuse can have major health consequences.” Pharmacists are also “significantly” concerned, especially about the overdose risk. Read full story Source: The Independent, 18 July 2023
  23. Content Article
    At a recent Patient Safety Management Network meeting, Hester Wain, Head of Patient Safety Policy at NHS England, and Dr Matt Hill, Consultant Anaesthetist, University Hospitals Plymouth NHS Trust & National Clinical Advisor on Safety Culture at NHS England, presented slides on patient safety culture. Download the presentation slides from the attachment below.
  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
    This webpage explains the approach of the Parliamentary and Health Service Ombudsman (PHSO) to financial remedy relating to complaints against organisations. Where someone believes they have experienced an injustice or hardship because an organisation has not acted properly, or has given a poor service and not put things right, PHSO makes recommendations on the amount of compensation based on its severity of injustice scale. The scale contains six different levels of injustice that a complaint could fall into, which increase in severity. Each level is then linked to a range of the financial amounts the PHSO would usually recommend in those circumstances.
×
×
  • Create New...

Important Information

We have placed cookies on your device to help make this website better. You can adjust your cookie settings, otherwise we'll assume you're okay to continue.

 Accept Cookies  Reject Cookies