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Found 1,338 results
  1. News Article
    Ministers are to invest millions in making Britain's maternity wards safer, it was announced on Wednesday after The Independent exposed a series of cases in which mothers and babies had suffered avoidable harm during childbirth. The new money, almost £10m, was announced as part of the spending review unveiled by Rishi Sunak, the chancellor, in the Commons and will deliver new pilots of what the Treasury called “cutting-edge training” to improve practice during childbirth. Significant failings in maternity safety units across the NHS have devastated families and left some babies needing tens of millions of pounds to look after them in later life. In November last year, The Independent joined with the charity Baby Lifeline to call for a new fund to be set up after exposing the single largest maternity scandal in NHS history at Shrewsbury and Telford Hospitals Trust, where dozens of babies have died or been left with brain damage. The new funding will also cover the final year of the independent investigation into the Shrewsbury trust. Read full story Source: The Independent, 26 November 2020
  2. Content Article
    The use of healthcare complaints to improve quality and safety has been limited by a lack of reliable analysis tools and uncertainty about the insights that can be obtained. The Healthcare Complaints Analysis Tool, developed by Alex Gillespie and Tom W. Reader was used to analyse a benchmark national data set, conceptualise a systematic analysis, and identify the added value of complaint data.
  3. Content Article
    Harm reviews give assurance to patients, patient groups, commissioners and the public as to whether patients have been harmed, or are at risk of harm, as well as helping to avoid future harm to patient. Patients may be harmed not only by clinical treatment, but also as a result of the need to be on a waiting list for clinical treatment, as this may result in deterioration of their physical or mental condition.  Royal Cornwall Hospitals standard operating procedure (SOP) identifies a standardised approach to harm reviews for all specialities at the Trust that support the Trusts' governance and assurance processes and maintains practice in line with national expectations.
  4. Content Article
    This is a guest post for the Hysterical Women website, by Kath Sansom, founder of the Sling the Mesh campaign. Content warning: mention of self-harm.
  5. Content Article
    Today was the Parliamentary launch event of the Surgical Fires Expert Working Group’s report, 'A case for the prevention and management of surgical fires in the UK', which focuses on the prevention of surgical fires in the NHS This report contains important information on surgical fires and their prevention, to be submitted to the Centre for Perioperative Care (CPOC), in order to make the case for its inclusion on their agenda. In the perioperative setting, a fire may cause injury to both the patient and healthcare professionals. Injuries caused by a surgical fire most commonly occur on the head, face, neck and upper chest. The prevention of surgical fires, which can occur on or in a patient while in the operating theatre, is an urgent and serious patient safety issue in UK hospitals.  A Short Life Working Group (SLWG) for the prevention of surgical fires was established in May 2019, following an initial discussion in December 2018 on the issue of surgical fires in the UK. The group of experts from healthcare organisations and bodies across the UK convened four times in 2019 with the aim of compiling this document, in order to recommend surgical fires for a Never Event classification. The group conducted a literature review of best practice and evidence, in the UK and internationally, which informed the development of a number of considerations that could address the issue of surgical fires. This report contains information surrounding the scale of the problem of surgical fires in the UK, in addition to reported experiences of these incidences by both healthcare professionals and patients. It also includes prevention and management materials, and mandatory training that should be consistently delivered to hospital staff, and concludes with recommendations moving forward, in order to ensure the prevention of surgical fires in UK hospitals.
  6. News Article
    Several patients were harmed after leaders at an acute trust failed to act on multiple concerns being raised about a surgeon, documents obtained by HSJ suggest. The documents reveal a catalogue of governance and safety concerns over the trauma and orthopaedics department at University Hospitals of Morecambe Bay Foundation Trust in the last three years. They include an external review which described the process for investigating clinical incidents as akin to “marking your own homework” and found the T&O department at Royal Lancaster Infirmary driven by “internecine squabbles”. It comes as the trust, which is widely known for a patient safety scandal within its maternity department, also faces a major investigation into whistleblowing concerns over its urology services. Read full story (paywalled) Source: HSJ, 17 November 2020
  7. Content Article
    Party leaders have written an open letter to Boris Johnson asking him to ensure recommendations made by Baroness Cumberlege are put in place. It's more than three months since her review found three treatments - mesh, primodos and sodium valproate - ruined thousands of lives. 
  8. News Article
    Lawyers have begun legal action on behalf of 200 UK women against the makers of a sterilisation device, after claims of illness and pain. The device, a small coil called Essure, was implanted to prevent pregnancies. Manufacturer Bayer has already set aside more than $1.6bn (£1.2bn) to settle claims from almost 40,000 women in the US. It has withdrawn the device from the market for commercial reasons but says it stands by its safety and efficacy. The metal coil was inserted into the fallopian tube to cause scarring, blocking the tube and preventing pregnancy. Introduced in 2002, it was promoted as an easy, non-surgical procedure - a new era in sterilisation. But many women who had the device fitted have now either had hysterectomies or are waiting for procedures to remove the device. Tracey Pitcher, who lives in Hampshire, felt she had completed her family and did not want any more children. Her doctor strongly encouraged her to have an Essure device fitted, she says. But after it had been, she began to feel very unwell. "I just started to have heavy periods, migraines, which I had only ever had when I was pregnant so they were hormonal," she says. "My back was so painful I'd wake up crying in the middle of the night with pains in my hips and my back." Tracey says she battled to persuade doctors to take her symptoms seriously. But the only information she received was from a Facebook group. "... there's nobody there, there's no support apart from people that we've found ourselves, no-one will listen, because it's just 'women's things'." Read full story Source: BBC News, 15 November 2020
  9. Content Article
    In this blog by the British Society of Criminology, Sharon Hartles critically examines the journey so far towards the implementation of the remaining eight recommendations set out in the landmark publication of the Medicines and Medical Devices Safety Review First Do No Harm report in July 2020.
  10. Content Article
    Identifying improvements in maternity care to help reduce the risk of delays in crucial interventions during labour when a baby is suspected to be unwell is the focus of this latest Healthcare Safety Investigation Branch (HSIB) report. The report was compiled after a review of 289 of our maternity investigations into intrapartum stillbirths, neonatal deaths and potential severe brain injuries. In 14.9% of the cases the delay was a contributory factor. The review identified issues such as inadequate staffing, poor infrastructure and high workload as contributory factors to the delays. Evidence from national reports confirms that such delays are a recognised patient safety risk. 
  11. News Article
    A nurse is due in court charged with eight counts of murder following an investigation into baby deaths at the Countess of Chester hospital neonatal unit in Cheshire. Lucy Letby, 30, is due to appear at Warrington magistrates court on Thursday. She was arrested for a third time on Tuesday as part of the investigation into the hospital, which began in 2017. A force spokesman said: “The Crown Prosecution Service has authorised Cheshire police to charge a healthcare professional with murder in connection with an ongoing investigation into a number of baby deaths at the Countess of Chester hospital.” He said Letby was facing eight charges of murder and 10 charges of attempted murder relating to the period from June 2015 to June 2016. On Tuesday, police said parents of all the babies involved were being kept fully updated on developments and were being supported by officers. Read full story Source: The Guardian, 11 November 2020
  12. News Article
    Study finds 54 days after discharge, 69% of patients still had fatigue, and 53% were suffering from persistent breathlessness. Almost seven out of 10 patients hospitalised due to coronavirus still suffer from debilitating symptoms more than seven weeks after being discharged, according to a new study. Researchers from the University College London (UCL) division of medicine, in collaboration with with clinicians at the Royal Free London (RFL) and UCL, followed 384 patients who had tested positive and had been treated at Barnet Hospital, the Royal Free Hospital or UCLH. Collectively the average length of stay in hospital was 6.5 days. The team found that 54 days after discharge, 69% of patients were still experiencing fatigue, and 53% were suffering from persistent breathlessness. They also found that 34% still had a cough and 15% reported depression. In addition 38% of chest radiographs (X-rays) remained abnormal and 9% were getting worse. Dr Swapna Mandal, an honorary clinical associate professor at UCL division of medicine, said the data shows so-called long COVID is a real phenomenon and that further research is needed to understand how the symptoms of COVID-19 can be treated over an extended period. She said: "Patients whose COVID-19 illness is serious enough for them to require hospital care often continue to suffer significant symptoms for many weeks after their discharge." Read full story Source: Sky News, 11 November 2020
  13. Content Article
    The NHS is full of dedicated staff who, at a one-to-one level with patients, offer deeply personal and compassionate care. But too often the system as a whole seems institutionally deaf to the patient voice. This report from the Patient Experience Library explores the reasons for that. It shows how the NHS – at an institutional and cultural level – fails to take patient experience evidence seriously enough. It calls for a few simple and entirely feasible steps that would strengthen evidence-based practice and ensure that the patient voice is better heard.
  14. Content Article
    Elderly people in care homes in Cornwall were abused and neglected while failings led to reports of concerns not being investigated, a new Safeguarding Adults Review has found. The Morleigh Group, which operated seven homes in Cornwall and has since shut down, was exposed in a BBC Panorama investigation in 2016. A new Safeguarding Adults Review which was commissioned as a result of the TV show has been published making a number of recommendations to all agencies which were involved in the case. The review was completed in April 2019 but has only just been made public - Rob Rotchell, Cornwall Council Cabinet member for adult social care said that this was due to the number of agencies being involved.
  15. Content Article
    The Cornwall and Isles of Scilly Safeguarding Adults Review into The Morleigh Group has found elderly people in care homes in Cornwall were abused and neglected while failings led to reports of concerns not being investigated. The Morleigh Group operated seven homes in Cornwall and has since shut down. The review was completed in April 2019 but has only just been made public - Rob Rotchell, Cornwall Council Cabinet member for adult social care said that this was due to the number of agencies being involved.
  16. News Article
    Hospital hotspots for COVID-19 have been highlighted in a new report by safety investigators. The report by the Healthcare Safety Investigation Branch (HSIB) makes a series of observations to help the health service reduce the spread of coronavirus in healthcare settings. Hospital hotspots for COVID-19 included the central nurses’ stations and areas where computers and medical notes were shared, the HSIB found. The investigation was initiated after a Sage report in May which found that 20% of hospital patients were reporting symptoms of Covid-19 seven days following admission – suggesting that their infection may have been acquired in hospital. In response to the report, NHS England and NHS Improvement confirmed they would publish nosocomial – another term for hospital acquired infections – transmission rates from trusts, the HSIB said. Read full story Source: Express and Star, 28 October 2020
  17. Content Article
    In this podcast from The Health Foundation, Chief Executive Dr Jennifer Dixon talks to Jeremy Hunt about his tenure as the longest-serving health secretary. Jeremy speaks about his passion for patient safety, a topic which became his professional focus following the Mid-Staffs investigations. He highlights the importance of the patient safety agenda and the need to learn from past experiences. With the challenges of the COVID-19 pandemic holding the world’s attention, what would Hunt have done differently? And what are the key lessons for government as we enter a new phase of the pandemic?
  18. Content Article
    This report seeks to inform the six-month review of the Coronavirus legislation required by the Coronavirus Act 2020 along with any future response to a “second wave” of the virus later this year. The report begins by setting out the legislative framework in play, then focuses on the following themes and rights: Human rights impact of the lockdown (Articles 8, 9, 10 and 11 ECHR) The right to life, including both the substantive and procedural duties on government (Articles 2 and 3 ECHR) and the right to health which has been (partially) incorporated within the positive obligation to secure the right to life. Issues in relation to detention settings (Articles 5, 8, 3 and 2 ECHR) Contact tracing and privacy rights (Articles 8 and 14 ECHR) Access to justice (Articles 6 and 2 ECHR) Children’s rights —the right to education (Article 2 of Protocol 1 ECHR) and the right to family life (Article 8 ECHR) The report also reflects on the challenge of ensuring the emergency legislation required in response to the outbreak was subject to appropriate parliamentary scrutiny and review. Follow the link below to read the full report including conclusions and recommendations.
  19. News Article
    Minority ethnic people in UK were ‘overexposed, under protected, stigmatised and overlooked’, new review finds. Structural racism led to the disproportionate impact of the coronavirus pandemic on black, Asian and minority ethnic (BAME) communities, a review by Doreen Lawrence has concluded. The report, commissioned by Labour, contradicts the government’s adviser on ethnicity, Dr Raghib Ali, who last week dismissed claims that inequalities within government, health, employment and the education system help to explain why COVID-19 killed disproportionately more people from minority ethnic communities. Lady Lawrence’s review found BAME people are over-represented in public-facing industries where they cannot work from home, are more likely to live in overcrowded housing and have been put at risk by the government’s alleged failure to facilitate Covid-secure workplaces. She demanded that the government set out an urgent winter plan to tackle the disproportionate impact of Covid on BAME people and ensure comprehensive ethnicity data is collected across the NHS and social care. The report, entitled An Avoidable Crisis, also criticises politicians for demonising minorities, such as when Donald Trump used the phrase “the Chinese virus”. The report, which is based on submissions and conversations over Zoom featuring “heart-wrenching stories” as well as quantitative data, issued the following 20 recommendations: Set out an urgent plan for tackling the disproportionate impact of Covid on ethnic minorities Implement a national strategy to tackle health inequalities Suspend ‘no recourse to public funds’ during Covid Conduct a review of the impact of NRPF on public health and health inequalities Ensure Covid-19 cases from the workplace are properly recorded Strengthen Covid-19 risk assessments Improve access to PPE in all high-risk workplaces Give targeted support to people who are struggling to self-isolate Ensure protection and an end to discrimination for renters Raise the local housing allowance and address the root causes of homelessness Urgently conduct equality impact assessments on the government’s Covid support schemes Plan to prevent the stigmatisation of communities during Covid-19 Urgently legislate to tackle online harms Collect and publish better ethnicity data Implement a race equality strategy Ensure all policies and programmes help tackle structural inequality Introduce mandatory ethnicity pay gap reporting End the ‘hostile environment’ Reform the curriculum Take action to close the attainment gap Read full story Source: The Guardian, 28 October 2020
  20. Content Article
    Across the world, people are suffering from life-altering and serious chronic pain conditions caused by surgical mesh complications.Mesh Down Under are a New Zealand based campaign group whose mission is to:raise awareness amongst New Zealanders about the complications that are not rare with the use of surgical mesh. provide information to enable anyone considering having surgical mesh surgery, particularly women having pelvic floor or bladder sling repairs, to be fully informed before consenting to this surgery.shout out to our health professionals and government bodies so that patient stories are no longer 'news to them' but an acknowledged public health issue that needs to be addressed.highlight the importance of reporting adverse events associated with medical devices.Follow the link below to find out more.
  21. News Article
    In ‘Invisible Women: Exposing Data Bias in a World Designed For Men’ author Caroline Criado Perez writes about Rachael, a woman who suffered years of severe and incapacitating pain during her period. It takes, on average, eight years for women in the UK to obtain a diagnoses of endometriosis. In fact, for over a decade, there has been no improvement in diagnostic times for women living with the debilitating condition. You might think, given the difficulty so many women experience in having their symptoms translated into a diagnosis, that endometriosis is a rare condition that doctors perhaps don’t encounter all that often. Yet it is something that affects one in ten women – so what is going wrong? Read the full article here in The Scotsman
  22. News Article
    The Care Quality Commission (CQC) has called for ‘ministerial ownership’ to end the ‘inhumane’ care of patients with learning difficulties and autism in hospital – after finding some cases where people had been held in long-term segregation for more than 10 years. Following its second review into the uses of restraint and segregation on people with a learning difficulty, autism and mental health problems, the CQC has warned it “cannot be confident that their human rights are upheld, let alone be confident that they are supported to live fulfilling lives”. The review was ordered by health and social care secretary Matt Hancock in late 2018 in response to mounting concerns about the quality of care in these areas. According to the report, published today, inspectors found examples people being in long-term segregation for at least 13 years, and in hospital for up to 25 years. It also found evidence showing the proportion of children from a black or black British background subjected to prolonged seclusion on child and adolescent mental health wards was almost four times that of other ethnicities. Looking at care received in hospital the CQC found many care plans were “generic” and “meaningless” and patients did not have access to any therapeutic care. Reviewers also found people’s physical healthcare needs were overlooked. One women was left in pain for several months due to her provider failing to get medical treatment. The regulator also reviewed the use of restrictive practices within community settings. While it found higher quality care, and the use of restrictive practices was less common, it said there was no national reporting system for this sector. Read full story (paywalled) Source: HSJ, 22 October 2020
  23. Content Article
    Restorative practices involve inclusive democratic dialogue between all those affected by healthcare harm. They are guided by concern to address harms, meet needs, restore trust, and promote repair or healing for all involved. In this webinar recording from the Canadian Patient Safety Institute, participants explore New Zealand's approach to healing after healthcare harm from surgical mesh and ask: What was the impetus for a restorative approach?  What inspired the choice of a relationship-centric and reconciliatory model?  How did restorative practices support the co-design process between consumer advocates and Ministry of Health representatives? How do restorative approaches support New Zealand's commitment to Te Tiriti o Waitangi- The treaty that determines the partnership between the Crown and indigenous peoples?
  24. Content Article
    This blog sets out a timeline of the major landmarks for transvaginal surgical mesh since its first approval in 1996.
  25. News Article
    When the pain in her shoulders and weakness in her right leg started two years ago, Giovanna Ippolito thought it was just part of getting older — that's until the 46-year-old's doctor ordered an X-ray that showed a five-centimetre long, broken needle embedded in her spine. It was a medical error that took more than a decade to discover — after medical staff at the time failed to report it. Exactly when the needle was left in Ippolito's spine is unclear, but she says she's only had something injected into her back twice — during the birth of her son in 2002 and her daughter in 2004. Ippolito says she believes the needle broke off when medical staff at Mackenzie Richmond Hill Hospital in nearby Richmond Hill (called York Central Hospital at the time) administered a spinal block or an epidural during one of the births. She's now locked in a battle with the hospital for answers and accountability. But experts say, with a system that's stacked against Canadians harmed by medical errors, it's likely no one will have to take responsibility. More than 132,000 patients experienced some kind of medical harm — something both preventable and serious enough to require treatment or a longer hospital stay — in 2018-19, according to the Canadian Institute for Health Information, an independent, not-for-profit organization that collects information on the country's health systems. Read full story Source: CBC, 5 October 2020
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