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Found 1,334 results
  1. News Article
    An NHS England investigation into claims of a toxic culture at a hospital trust has been described as lacking transparency and undermining trust. The Parliamentary Health Service Ombudsman also said there were "very serious" patient safety issues at University Hospitals Birmingham (UHB). Criticism is contained in letters seen by the BBC between the ombudsman, the trust and NHS England. The inquiries, commissioned by the Birmingham and Solihull Integrated Care Board and the local NHS, were begun in response to an investigation by BBC Newsnight and BBC West Midlands which heard from current and former clinicians from the trust, who accused it of being "mafia-like". One of England's biggest hospital trusts, UHB has been in the spotlight for months after three probes were started following allegations doctors there were threatened for raising safety concerns. The trust denies this and says its "first priority is patient safety". The ombudsman, however, said he was sceptical about the reviews' transparency and independence. His finding of "very serious" patient safety issues at UHB is based on the trust's response to the ombudsman's recommendations and findings, including a case of an avoidable patient death. Read full story Source; BBC News, 14 March 2023
  2. Content Article
    Infiltration is when fluid or intravenous drugs administered to a patient (which are given to patients into a vein through a cannula or other device) inadvertently leak into the tissue surrounding a vein by mistake. Extravasation is when infiltration occurs but the drugs involved are called vesicants which can damage the tissue and  cause serious harm to the patient. The National Infusion and Vascular Access Society (NIVAS) are leading a campaign to improve awareness of infiltration and  extravasation and reduce avoidable harm.  In this interview Andrew Barton, Chair of NIVAS, explains why this is such an important issue and what needs to happen to improve patient safety.  
  3. News Article
    MPs from across the political spectrum have called for a ban on electroconvulsive therapy (ECT) as a treatment for mental illness in England, and want the practice to be subject to an urgent inquiry. MPs told The Independent they have serious concerns that women are disproportionally given electroconvulsive therapy, and argued that patients are not properly notified of the treatment’s potential side effects. Some patients have also reported that they weren’t asked to provide consent before it was administered. Dr Pallavi Devulapalli, a GP, called for the government to undertake an “urgent and comprehensive review” of the treatment as she warned that patients’ wellbeing was “at stake”. The calls come after The Independent previously reported that thousands of women were being given ECT despite concerns that it can cause irreversible brain damage. It comes after Dr Sue Cunliffe, who began receiving ECT in 2004, previously told The Independent that the treatment had “completely destroyed” her life despite a psychiatrist having told her there would be no long-term side effects. Dr Cunliffe, a former children’s doctor, said: “By the end of it, I couldn’t recognise relatives or friends. I couldn’t count money out. I couldn’t do my two times table. I couldn’t navigate anywhere. I couldn’t remember what I’d done from one minute to another.” Read full story Source: The Independent, 12 March 2023
  4. News Article
    Ministers and NHS England have not sufficiently warned the public of the risk to patient harm posed by next week’s junior doctors strike, some of the NHS’s most senior trust chief executives have warned. The senior leaders contacted HSJ with their concerns after a group call between trust leaders and NHSE bosses on Thursday. The chief executives and medical directors, who spoke to HSJ on condition of anonymity, made a series of robust criticisms which focussed on the lack of awareness of danger presented by the junior doctor’s industrial action, a lack of thorough communication of that to the public, and the insistence that trusts negotiate strike agreement with the British Medical Association at a local level. One comment on the chat function stated: ”Public awareness of the impact of this strike seems far lower than for e.g. the ambulance strike, but from a an acute trust perspective this will have a much bigger impact on patient care and safety. Junior doctors’ are not newly qualified students - they are the backbone of day to day medical management in our services. I am concerned we might be giving false assurance about the quality of service we can offer next week.” Read full story (paywalled) Source: HSJ, 10 March 2023
  5. News Article
    A trust spent £460,000 on legal fees trying to fight a patient safety whistleblowing case that it lost, it can be revealed. An employment tribunal judge rejected the idea that a consultant nephrologist had done anything to bring about her dismissal from Portsmouth Hospitals University Trust. Jasna Macanovic was subjected to what the tribunal earlier this year called “a campaign of harassment”, after she warned colleagues that a procedure they were using was harming patients. After relationships broke down in the Wessex Kidney Unit, she was referred to a disciplinary panel at which two board members – the former nursing director and the current medical director – offered her a good reference if she would resign. She refused and was dismissed in March 2018. The judge noted the offer was clear evidence that the disciplinary process was a foregone conclusion. Read full story Source: HSJ, 8 March 2023
  6. Event
    until
    Despite decades of attention to safety, the 2023 New England Journal of Medicine article titled "The Safety of Inpatient Health Care" ushers in a stark reminder that patients continue to experience unacceptably frequent, and often serious, harms while receiving care. This 2023 IHI Patient Safety Awareness Week free webinar features lead author and globally renown safety expert, Dr. David Bates, who will share perspective on the history of harm in health care, key findings, and insights from this recent publication, associated opportunities to improve identification and measurement of events, and methods for anticipating and preventing harm. Whether you’re a health care leader, safety or quality professional, direct care provider, or work in any setting or role in health care, you’ll leave this illuminating discussion with refreshed thinking about what’s essential for a radical reboot of safety and the role that you and your organizations can take to eliminate and prevent harm. Register
  7. News Article
    Former patients of a surgeon who has been struck off say their lives have been ruined by his misconduct. The number of people harmed by Jeremy Parker is unknown but at least 123 are taking legal action. Their lawyer said the scale of harm caused by his malpractice "could be huge". A total of 53 allegations against him were found "proved" including dishonestly adding to the case notes of 14 patients, botching operations, not diagnosing infections, failing to consult colleagues and not obtaining patient consent. The General Medical Council also confirmed a patient had a leg amputated below the right knee after a procedure carried out by Mr Parker went awry. Christian Beadell from Fletchers Solicitors, which is representing former patients in a class action, said East Suffolk and North Essex NHS Trust (ESNEFT) had not answered questions over whether it had initiated a recall process to determine the number patients harmed. "It's difficult to say how many patients have been injured by him," Mr Beadell said. Read full story Source: BBC News, 8 March 2023
  8. News Article
    The government’s response to the East Kent maternity scandal inquiry has been condemned as ‘very disappointing’ by its chair. More than four months on from the inquiry report, ministers this morning issued what they called an “initial response” to it, as a brief written statement to Parliament. It contained few specific proposals, instead saying government was kicking off a series of other reviews, and “working” with various other agencies. Inquiry chair Bill Kirkup, the well-regarded former medic and expert in care failures, told HSJ the response was poor and should have been “wider and deeper”. Dr Kirkup said the response showed government had “not grasped how fundamental” some of the issues outlined in his report were, and “what sort of initiative” was needed to address them. Read full story (paywalled) Source: HSJ, 7 March 2023
  9. Content Article
    Statement from Maria Caulfield, Parliamentary Under Secretary of State (Minister for Mental Health and Women's Health Strategy) on the Government’s initial response to the report of the independent review into the maternity and neonatal services at East Kent University NHS Foundation Trust that was published on the 19 October 2022. NHS England commissioned Dr Bill Kirkup to undertake this review following concerns about the quality and outcomes of care.
  10. Content Article
    In a series of blogs for the hub, Emma Plunkett and Nancy Redfern, part of the Joint Working Group on Fatigue, will highlight the impact staff fatigue has not only on the staff themselves but also on patient safety, and why healthcare needs a robust fatigue risk management system like other safety-critical industries. In their first blog, Emma and Nancy share how they became involved in investigating night shift fatigue after the death of a colleague driving home tired. They discuss how they set up the Joint Working Group on Fatigue and the aims of the #FightFatigue campaign.
  11. News Article
    Source: The Times. 5 March Shared on Twitter @ShaunLintern
  12. News Article
    Patients are being warned of a “shocking gap in cancer care” as new figures reveal that fewer than 3% of England’s NHS trusts met a key waiting-times target last year for cancer patients to be treated within two months of an urgent GP referral. Of 125 hospital trusts in England analysed, only three (2.4%) hit the standard of treating 85% of patients within 62 days after an urgent referral in 2022. Some trusts have not hit the standard for at least eight years. More than 66,000 patients were forced to wait more than two months for their first treatment last year after a referral, the figures reveal. One leading cancer charity said this weekend the cancer care system was not fit for purpose, with “lives left hanging in the balance”. Daisy Cooper, the Lib Dems health spokesperson, said the figures showed that even before the pandemic struck, the number of hospital trusts meeting targets was falling rapidly. “Now the situation is so bad that barely any hospitals are able to provide patients with the treatment they need on time. Ministers have consistently failed to plan ahead or provide adequate funding, while taking patients and NHS staff for granted. There is a shocking gap in cancer care from one area to another,” she said. Read full story Source: The Guardian, 5 March 2023
  13. Content Article
    In this opinion piece, Kath Sansom, founder of Sling the Mesh, looks at why an audit of pelvic mesh outcomes due to be published in April 2023 has again failed to capture the true extent of the harm caused by the procedure. She outlines why the approach taken by the Government and NHS Digital was flawed and why it is so important to understand both the proportion of women who have experienced harm as a result of the procedure, and the nature of their injuries and side effects.
  14. Content Article
    It's now a decade since the Francis Report, which outlined the causes of serious failures in care at Mid Staffordshire NHS Foundation Trust. The report and prior media coverage exposed a wide set of issues surrounding the culture and transparency of health care, and these topics remain of major concern today. In this article for the Nuffield Trust, Shaun Lintern has interviewed Sir Robert Francis KC about the weight of those patient stories and treatment of the NHS's staff, then and now.
  15. Content Article
    In this article, John Tingle, Assistant Professor at the University of Birmingham Law School, discusses recent developments in patient safety in the context of possible reform of the clinical negligence system in the UK.
  16. News Article
    Sam Hindle has 23cm of polypropylene mesh in her body and lives in constant fear that it will become unstable and cause irreversible damage. "You are in your own Battle Royale, strapped to a time bomb, and thinking when is it going to go off," she told the BBC. Sam, 46, is one of hundreds of women in Scotland who have suffered life-changing symptoms since they had a transvaginal mesh implant. After years of campaigning by the women, the Scottish government has promised it will cover the costs of mesh removal at private clinics in the UK and US. But Sam has been waiting more than two years just for a referral to the Complex Mesh Surgical Service in Glasgow to start the process. The Scottish government announced last year that it had signed a contract to allow NHS patients to visit a US expert for mesh removal surgery The contract with Gynaecologic and Reconstructive Surgery of Missouri, where Dr Dionysios Veronikis operates, follows a similar contract agreed with Spire Healthcare in Bristol. The cost of each removal procedure is estimated to be £16,000 to £23,000. But in order to access such treatment, women have to be assessed by the national service in Glasgow. Women like Sam say there are waiting years to just get referred for assessment. With further delays for appointments and then waits for surgery. Read full story Source: BBC News, 2 March 2023
  17. Content Article
    The Harmed Patients Alliance (HPA) was founded to highlight and promote restorative approaches to healthcare harm. To support their campaign for action, HPA carried out a survey of 44 people asking how those harmed by their contact with healthcare felt about the response, and what impacts this had on them. They were also asked what could have been done differently. 
  18. Content Article
    Midurethral tapes (MUTs) were the most common surgical treatment for stress urinary incontinence (SUI) between 2008 and 2017. Transobturator tapes were introduced as a novel way to insert MUTs. Some women have experienced life-changing complications, and opt to undergo a total excision of transobturator tape (TETOT). This study, published in Neurourology and Urodynamics, aims to report clinical outcomes of all women who underwent TETOT in a specialist mesh centre.
  19. News Article
    Mental health trusts are exploring wider use of CCTV to review incidents of seclusion or restraint in response to high-profile abuse scandals, HSJ has learned. All providers of mental health, learning disability and autism services were ordered to review safety and asked to feed back to NHS England’s national team. The request was made in a letter from national director Claire Murdoch sent in response to abuse allegations aired by BBC Panorama and Channel 4’s Dispatches. The review is taking place alongside NHSE’s launch of a £36m three-year quality programme. This aims to identify providers and systems needing support, commission a culture and leadership development programme for all trusts, and produce a new model for safe inpatient care. Results of trust-level reviews, seen by HSJ, show at least five providers aim to use CCTV more “pro-actively”, as a tool for boosting safety. Read full story (paywalled) Source: HSJ, 27 February 2023
  20. Content Article
    The Healthcare Safety Investigation Branch (HSIB) have published a third interim report for this investigation which focuses on staff wellbeing across the urgent and emergency care systems and the impact that this has on patient safety.
  21. News Article
    Nearly half of NHS patients with a learning disability or autism are still being kept inappropriately in hospitals, several years into a key programme to reduce inpatient care, a national review reveals. The newly published review by NHS England suggests 41% of inpatients, assessed over an eight-month period to May 2022, should be receiving care in the community. Reasons given for continued hospital care in the NHSE review included lack of suitable accommodation, with 19% having needs which could be delivered by community services; delays in moving individuals into the community with appropriate aftercare; legal barriers, with one region citing “ongoing concerns for public safety” as a barrier for discharge; and no clear care plans. In some cases, individuals were placed in psychiatric intensive care units on a long-term basis, because “there was nowhere else to go”, while another instance cited a 20-year stay in hospital. Other key themes included concerns about staff culture, particularly “institutionalisation” and suggestions that discharge delays were not being sufficiently addressed. The report adds: “While the process around discharge can be time consuming, staff may perpetuate this by accepting such delays as necessary or inevitable.” Read full story (paywalled) Source: HSJ, 22 February 2023
  22. Content Article
    This report details the findings of a thematic review of Safe and wellbeing reviews (SWRs) between October 2021 and May 2022. SWRs are undertaken for children, young people and adults that are autistic and/or have a learning disability who are being cared for in a mental health inpatient setting.  SWRs are part of the NHS response to the safeguarding adults review concerning the tragic deaths of Joanna, Jon, and Ben at Cawston Park Hospital, who were each detained for a long period of time and did not receive appropriate care.
  23. News Article
    Prostate cancer screening may be a step closer after a study suggested that harms linked to testing have reduced thanks to advances in medical technology. Screening for prostate cancer has been heavily debated in medical circles due to potential harms including side effects from biopsies and unnecessary testing for those with no clinically significant cancer. A new study set out to examine whether the “seesaw has been tipped” in favour of screening. Researchers from Prostate Cancer UK combined the results of the latest clinical trials and real-world data on the “prostate cancer screening pathway” to examine the risk-to-harm benefit. Prostate Cancer UK said that on average 67%t fewer men experienced harm during the diagnostic process with the newer techniques compared with older methods. Prostate Cancer UK said the UK National Screening Committee, which makes recommendations to the Government, is to re-examine prostate cancer screening. Dr Matthew Hobbs, lead researcher on the analysis and director of research at Prostate Cancer UK, said: “We’ve known for some time now that testing more men reduces prostate cancer deaths, but there have always been concerns about how many men would be harmed to achieve this. “However, our evidence shows that screening may now be a lot safer than previously thought. That’s why we are so pleased that the committee is going to review the evidence once more. Read full story Source: The Independent, 23 February 2023
  24. Content Article
    Electronic prescribing (ePrescribing) systems allow healthcare professionals to enter prescriptions and manage medicines using a computer. Sheikh and colleagues set out to find out how these ePrescribing systems are chosen, set up and used in English hospitals. Given that these systems are designed to improve medication safety, we looked at whether or not these systems affected the number of prescribing errors made (mistakes such as ordering the wrong dose of medication). They also tried to see whether or not the systems were good value for money (or more cost-effective). Finally, they made recommendations to help hospitals choose, set up and use ePrescribing systems.
  25. News Article
    Children's services could be forced to close at a hospital that is accused of leaving young patients traumatised and sick through poor care. The care regulator said it had taken action to "ensure people are safe" on Skylark ward at Kettering General Hospital (KGH) in Northamptonshire. Thirteen parents with serious concerns after their children died or became seriously ill have spoken to the BBC. A BBC Look East investigation has heard allegations spanning more than 20 years about the treatment of patients on Skylark ward, a 26-bed children's unit. The BBC discovered: An independent report found staff left a 12-year-old boy - who died at KGH in December 2019 - for four hours suffering seizures, and suggests little effort was made to obtain critical care support. In April 2019, nurses allegedly dragged a "traumatised" four-year-old girl down a corridor in agony, insisting that she could walk. Medics are accused of refusing to carry out an MRI scan, which would have detected a dangerous cyst on her spine. Mothers claim to have been threatened with safeguarding referrals, with one stating a referral was made against her after she complained her son was struggling to breathe, while another likened it to blackmail. Read full story Source: BBC News, 20 February 2023
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