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Showing results for tags 'Patient harmed'.
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Content ArticleIn April 2017, Ian Paterson, a surgeon in the West Midlands, was convicted of wounding with intent, and imprisoned. He had harmed patients in his care. The scale of his malpractice shocked the country. There was outrage too that the healthcare system had not prevented this and kept patients safe. At the time of his trial, Paterson was described as having breached his patients’ trust and abused his power. In December 2017, the Government commissioned this independent Inquiry to investigate Paterson’s malpractice and to make recommendations to improve patient safety. This report presents the Inquiry’s methodology, findings and recommendations. More importantly, it tells the story of the human cost of Paterson’s malpractice and the healthcare system’s failure to stop him, and something of the enduring impact this has had on the lives of so many people.
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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. -
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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. -
Content Article
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 ArticleSir Liam Donaldson's presentation slide at the High Level Forum, Africa Patient Safety Initiative, Cape Town, South Africa 24- 25 October 2019.
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Content ArticleAs the coronavirus pandemic focuses medical attention on treating affected patients and protecting others from infection, how do we best care for people with non–Covid-related disease? In her article in the New England Journal of Medicine, Lisa Rosenbaum discusses the impact the pandemic is having and how we help those people who are afraid to seek care.
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Content ArticleRecording now available for the ISQUA webinar. Dr David Bates reflects on achievements and challenges in patient safety since the publication of To Err is Human: Building a Safer Health System.
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Content ArticleA blog from Peter Walsh, Chief Executive at Action against Medical Accidents (AvMA) on the current pandemic.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) has been investigating East Kent Hospitals University NHS Foundation Trust since July 2018 after a series of baby deaths. The report discusses 24 maternity investigations undertaken since July 2018, including the deaths of three babies and two mothers. It said: “These investigations have enabled HSIB to identify recurrent safety risks around several key themes of clinical care in the trust’s maternity services.”
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Content ArticleIn a blog for the Healthcare Financial Management Association (HFMA), Patient Safety Learning’s Chief Executive Helen Hughes highlights both the human and financial costs associated with the persistence of avoidable harm in healthcare. She outlines how Finance directors should play a key role in improving patient safety and argues that they have an essential corporate leadership role to ensure healthcare is both effective and safe.
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News ArticleSickle cell patients are being put at risk because of a chronic shortage of specialist nurses to treat them, a damning new report has found. 'The Difference Between Life and Death', a new study by the Sickle Cell Society, found that there are not enough sickle cell workers to deliver a good standard of care. One patient called Abi Adeturinmo told researchers that previous traumatic experiences caused by delays in receiving pain relief medication and poor care meant she “tries not to go to the hospital when in sickle cell crisis unless it is life-threatening”. Another patient, Araba Mensah, whose daughter has sickle cell disorder, said there was a lack of “hands-on” nursing, and said patients who have difficulties feeding themselves or with personal hygiene were “left to suffer unattended”. John James, CEO of the Sickle Cell Society, said: “While there are undoubtedly workforce challenges across all parts of the health system, the evidence in this report suggests that sickle cell is disproportionately impacted as a result of the legacy of neglect of sickle cell care. “On behalf of everyone affected by sickle cell, we are urging NHS England to take action now to ensure all sickle cell patients have access to the specialist care they are entitled to.” Read full story Source: The Independent, 24 November 2023
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Content ArticleIn this blog, Dr Ahmed Khalafalla looks at the war in Sudan and its disastrous consequences for the health system. He outlines his observations about the impacts of war and conflict on patient safety, from shortages of medical equipment to disruptions to vital primary care services.
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Content ArticleThe Department for Health and Social Care has launched an investigation into allegations made by 22 former patients of mental health units run by private firm The Huntercombe Group. The group ran at least six children’s mental health hospitals between 2012 and 2022. In this Independent article, young women who were subject to humiliating and sometimes abusive treatment talk about their time as inpatients. Some of the experiences they recount are harrowing: "I would get awoken by staff members restraining me out of bed and dragging me down to the de-escalation room to force-feed me." "Patients were left naked in their rooms under anti-ligature blankets because they wouldn’t buy anti-ligature clothing." "I distinctly remember someone saying ‘if you hit me again, I’ll hit you back ten times harder because there are no cameras in here and you can’t cry to [name of nurse] about it’."
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Content ArticleIn this BMJ opinion piece, Iona Heath reviews a new book by Penelope Campling, who worked as an NHS psychiatrist and psychotherapist for 40 years. Don't Turn Away tells the story of "an increasingly brutal turning away from the most abused and damaged people who struggle to survive within our complacent society." The article argues that over the past few decades, our society has failed to listen to and support the most vulnerable people, with mental health systems focusing on exclusion criteria and keeping people out of the system.
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Content ArticleIn this blog, Debbie Ivanova, Deputy Chief Inspector — People with a learning disability and autistic people, and Jemima Burnage, Deputy Chief Inspector and Mental Health Lead, update on progress since the Care Quality Commission’s (CQC) 'Out of Sight' report published in October 2020. Their blog discusses the findings of the authors' 'Restraint, segregation and seclusion review: Progress report' published in December 2021.
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Content ArticleThis resource by the mental health charity Mind is for people who want to change the practice of restraint in mental health services and end reliance on force, particularly on adult mental health wards. It is mainly aimed at people who use mental health services, carers, advocates and campaigners. It provides information about restraint, people’s experiences, official guidance, good practice and campaigners’ stories.
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Content ArticlePeople with developmental disability have higher healthcare needs and lower life expectancy compared with the general population. Poor quality of care resulting from interpersonal and systemic discrimination may further entrench existing inequalities.
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Content ArticleThis 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.
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Content ArticleSTOMP stands for stopping over medication of people with a learning disability, autism or both with psychotropic medicines. It is a national project involving many different organisations which are helping to stop the over use of these medicines. STOMP is about helping people to stay well and have a good quality of life. Psychotropic medicines affect how the brain works and include medicines for psychosis, depression, anxiety, sleep problems and epilepsy. Sometimes they are also given to people because their behaviour is seen as challenging. People with a learning disability, autism or both are more likely to be given these medicines than other people. These medicines are right for some people. They can help people stay safe and well. Sometimes there are other ways of helping people so they need less medicine or none at all.
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Content ArticleSTOMP stands for stopping over medication of people with a learning disability, autism or both with psychotropic medicines. It is a national project involving many different organisations which are helping to stop the over use of these medicines. STOMP is about helping people to stay well and have a good quality of life.
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Content Article
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 Article
UK Covid-19 Inquiry website
Patient Safety Learning posted an article in Covid-19 Inquiry
The UK Covid-19 Inquiry has been set up to examine the UK’s response to and impact of the Covid-19 pandemic, and learn lessons for the future. The Inquiry’s work is guided by its Terms of Reference. -
Content ArticleLack of timely follow-up for glaucoma patients is a recognised national issue across the NHS. Research suggests that around 22 patients a month will suffer severe or permanent sight loss as a result of the delays. In this Healthcare Safety Investigation Branch (HSIB) report, the reference case patient saw seven different ophthalmologists and the time between her initial referral to hospital eye services (HES) and laser eye surgery was 11 months. By this time her sight had deteriorated so badly, she was registered as severely sight impaired. The HSIB investigation identified that there is inadequate HES capacity to meet demand for glaucoma services, and that better, smarter ways of working should be implemented to maximise the current capacity. The report highlights that there are innovative measures implemented by some trusts that have reduced the risk, but this good practice is yet to be implemented more widely.
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Content ArticleThe purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) is to help improve patient safety in relation to the prescribing of medicines for children based on their weight. This HSIB investigation reviewed the case of a four-year-old child who was diagnosed with a blood clot in her leg following a surgical procedure in hospital. She was prescribed an anticoagulant medicine using an electronic prescribing and medicines administration (ePMA) system. Errors in the prescription, dispensing and administration processes meant that the child received ten times the intended dose on five separate occasions over three days. A scan of the child’s brain showed evidence of a bleed and she was admitted to the paediatric intensive care unit. Following three months in hospital, the child was discharged home with an ongoing care plan.
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Content ArticleIn March 2020, the Healthcare Safety Investigation Branch (HSIB) published a national learning report to highlight the themes emerging from the initial investigations carried out as part of their maternity investigation programme. These initial investigations were carried out between April 2018 and December 2019. One of these themes was babies significantly larger than average who were at increased risk of a birth injury, brain damage or very rarely death because their shoulders get stuck during birth (known as shoulder dystocia). This was identified as an area where further analysis could benefit system-wide learning.
