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Showing results for tags 'Patient harmed'.
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News Article
Mouth-cancer deaths fear over NHS dentist shortage
Patient Safety Learning posted a news article in News
Lack of access to dentists is costing lives because mouth cancers are not being spotted or treated early enough, a health charity has told BBC News. The disease killed more than 3,000 people in 2021 - up 46%, from 2,075 a decade ago, latest figures obtained by the Oral Health Foundation show. And last year, a BBC News investigation revealed 90% of UK NHS dental practices were not accepting new adult patients. The government has announced plans to increase dental-training places by 40%. It also said the NHS was treating more people for cancer at an earlier stage than ever before. Oral Health Foundation chief executive Nigel Carter says dental check-ups "are a key place for identifying the early stage of mouth cancer". "With access to NHS dentistry in tatters, we fear that many people with mouth cancer will not receive a timely diagnosis," he adds. Read full story Source: BBC News, 8 November 2023 -
Content Article
In this blog, Pandora Pound, Research Director at Safer Medicines Trust, highlights the patient safety issues that come when we rely on animal testing to determine the safety of new drugs for use in humans. She looks at cases where animal testing has led to the belief that medications were safe to test in human clinical trials—with sometimes tragic results. Highlighting innovative technologies that offer a more accurate picture of the safety of medications in humans, she calls on policy makers to lead a move towards human biology-based approaches. -
Content ArticleWould you know what to do if something went wrong with your medical treatment in private/independent healthcare? This guide from PHIN tells what you should understand before choosing where to have your treatment and what to do if everything doesn’t go to plan.
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News Article
Poor maternity care at Hull Royal Infirmary risked babies' lives, say mums
Patient Safety Learning posted a news article in News
Maternity services at Hull Royal Infirmary have recently been described in a damning report by the health watchdog as chaotic, unsafe and not fit for purpose. Three mothers, who claim staff missed signs of life-threatening conditions that could have killed them or their babies, have spoken to the BBC about their harrowing experiences at the hospital. One woman, a BBC journalist who does not want to be named, said she knew her newborn son was seriously ill within minutes of giving birth at the infirmary in 2021. "As soon as they handed him to me, I noticed something was wrong. He was panting and his breathing wasn't right," she said. Over the course of an hour, she said her concerns were dismissed by the newly-qualified midwife who said his breathing was "completely normal". "She kept reassuring me over and over that's how babies breathe. I felt like I was drowning surrounded by lifeguards," she said. But after being examined by a more experienced midwife, the baby was rushed to intensive care and diagnosed with potentially fatal sepsis. "It was like time stood still. The midwife ripped him off me and she slammed an oxygen mask on his face, called the crash team and he was taken away to the neonatal intensive care unit. "The anger I felt was overwhelming because I'd been saying for nearly an hour he was seriously ill. I was right and he had sepsis." A few months after her son's birth, she read about an inquest into the death of a four-day-old baby who had sepsis and was born at Hull Royal Infirmary. A coroner found that midwives had failed to respond to his infection quickly enough. "My blood ran cold because it was exactly the same circumstances that happened to me and that baby died. I thought they clearly haven't learned anything," she said. Read full story Source: BBC News, 6 November 2023 -
Content Article
UKCVFamily was set up in November 2021 to support patients in the UK who have had an adverse reaction to a Covid-19 vaccination. The group provides help and advocacy as well as raising awareness amongst healthcare professionals, the media and the Government. In this video, founder of UKCVFamily Charlet Crichton talks to us about why she established the group and describes the support it offers to patients. She outlines some of the issues people face when trying to access diagnosis and treatment, and discusses the limitations of the MHRA's Yellow Card scheme in collecting data about adverse reactions. She also describes how healthcare professionals can support people with adverse reactions by taking their concerns seriously and investigating symptoms thoroughly. -
News Article
Patient safety at risk as pharmacists replace GPs, doctors warn
Patient Safety Learning posted a news article in News
Doctors are warning that patient safety is being put at risk as podiatrists and pharmacists replace GPs “on the cheap”. Dozens of family doctors have contacted The Telegraph claiming that talk of a GP shortage is “a big lie” and that they are being replaced by less qualified, cheaper staff, in a “crisis”. Documents seen by The Telegraph show staff including podiatrists, pharmacists and physician associates being used in lieu of GPs to diagnose and treat patients with conditions they are not trained in. In the most extreme cases, poorly children with viral infections, asthma-related issues and concerns about menstruation have been seen and diagnosed by a podiatrist – a healthcare professional trained exclusively to care for feet. It is not clear what happened to any of the patients afterwards, or if their parents were aware they had seen a podiatrist rather than a doctor. One GP said it was “a matter of patient safety” and the notion of “everything being supervised” did not work at a GP practice like it does in hospitals. Read full story (paywalled) Source: The Telegraph, 4 November 2023 -
News Article
Private health firm Sciensus fails to fix defects that led to UK patient’s death
Patient Safety Learning posted a news article in News
A private health company paid millions by the NHS has failed to fix safety defects that led to the death of a cancer patient, the Guardian can reveal. Three patients were hospitalised and a fourth died when they were given the wrong doses of a powerful chemotherapy drug after a catastrophic IT failure at the medicine manufacturing unit of Sciensus in April this year. The incident, first revealed by the Guardian in July, prompted an investigation by the Medicines and Healthcare products Regulatory Agency (MHRA). Its inspectors found “significant deficiencies” at the Sciensus manufacturing facilities and ordered the partial suspension of its manufacturing licence. However, six months after the IT blunder, Sciensus has not fixed the problems identified by the regulator, according to people familiar with the matter. As a result, the suspension of its licence – originally due to be lifted last month – has been extended until July next year. Sciensus is the UK’s biggest provider of medicines services to NHS and private patients at home. It is contracted by the NHS and other organisations to deliver and administer medicines to more than 200,000 people with conditions such as heart disease, diabetes, dementia, HIV and cancer. Read full story Source: The Guardian, 5 November 2023 -
News Article
Patient left permanently blind after hospital failure
Patient Safety Learning posted a news article in News
A patient was left with permanent sight loss after a hospital failed to spot the signs of a blood vessel blockage for several months. The person referred to only as Mr L, visited the emergency department at one of Wales' hospitals in January, 2018, but medics failed to consider the possibility he had suffered a watershed stroke. Details of how it took nine months before Mr L was offered a scan to consider this diagnosis have been described in a report from the Public Service Ombudsman detailing the care under Betsi Cadwaldr University Health Board. The Ombudsman, Michelle Morris, also slammed the health board for its failure to act promptly with the complaints process. She said she "cannot fail to be shocked by the fact that, although Mr L first complained to the health board in June, 2019, it took until February, 2023 for it to recognise any failings." The report details how between January and September, 2018, the health board failed to promptly and appropriately identify, investigate and treat a blockage of blood vessels in his neck (a condition called carotid artery stenosis, where the blockage restricts the blood flow to the middle of the brain, face and head). Mr L also complained that when the issue was eventually identified in September, there was a delay in getting the treatment (surgery) until November. Read full story Source: Wales Online, 2 November 2023 -
Content Article
Roger Kline's writings
Patient Safety Learning posted an article in Suggest a useful website
Roger Kline is a research fellow at Middlesex University Business School prior to which he held senior positions in eight UK trade unions. Roger has an extensive knowledge and experience of workplace culture, primarily in the public sector. On his web page you can find a selection of his published papers, books and blogs. -
News ArticleThe safety of people with learning disabilities in England is being compromised when they are admitted to hospital, a watchdog says. The Health Services Safety Investigations Body (HSSIB) reviewed the care people receive and said there were "persistent and widespread" risks. It warned staff are not equipped with the skills or support to meet the needs of patients with learning disabilities. The watchdog launched its review after receiving a report about a 79-year-old who died following a cardiac arrest two weeks after being admitted to hospital. As part of its investigation, HSSIB also looked at the care provided in other places to people with learning disabilities. It warned systems in place to share information about them were unreliable, and that there was an inconsistency in the availability of specialist teams - known as learning disability liaison services - that were in place in hospitals to support general staff. It also said general staff had insufficient training - although it did note a national mandatory training programme is currently being rolled out. Senior investigator Clare Crowley said: "If needs are not met, it can cause distress and confusion for the patient and their families and carers, and raises the risk of poor health outcomes and, in the worst cases, harm." Read full story Source: BBC News, 2 November 2023
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News Article
The ‘wrecked’ lives of forgotten Long Covid sufferers
Patient Safety Learning posted a news article in News
Nearly four years since the start of the coronavirus outbreak, you could be forgiven for believing the pandemic is behind us. But for many, it feels far from over. Close to two million people face a daily battle with debilitating symptoms of Long Covid – the lasting symptoms of the virus that remain after the infection is gone – with some now housebound, unable to walk and even partially blind. Alan Chambers, 49, is among those who have been grappling with the illness for years, having caught coronavirus in March 2020. Mr Chambers went from being “a fit, healthy, working member of the community who would do anything to help anyone” to being “ill and isolated in our bedroom”, blind in one eye and no longer able to walk unaided, his wife Vicki said. As of March, an estimated 1.9 million people in the UK have experienced coronavirus symptoms for more than four weeks, according to the latest figures from the Office for National Statistics. Of those, 1.5 million reported the condition had adversely affected their day-to-day activities. It comes as coronavirus case rates have shown an overall increase since July, with fears the approaching winter will bring a further surge in infections. Yet in May, the World Health Organisation (WHO) declared that coronavirus no longer represents a global health emergency, which was seen as a symbolic step towards the end of the pandemic. Dr Jo House, founding member and health advocacy lead at Long Covid Support, said the advocacy group now has 62,000 members, with about 250 more people joining every month. “In their words, they feel ‘forgotten, unheard, disbelieved, isolated, unemployed, disabled, immobile’. NHS England admitted to The Independent that access to necessary support, treatment and care for Long Covid patients is still lacking. It said there was “still more to do to ensure support is there for everyone who needs it”, so that patients requiring specialist assessment and treatment for Long Covid can access care in a timely way. Read full story Source: The Independent, 29 November 2023 -
News Article
Warning as patients hospitalised after taking fake Ozempic weight-loss drug
Patient Safety Learning posted a news article in News
People have been hospitalised after taking a fake version of the weight-loss control jab Ozempic, with 369 drugs seized by the UK’s medicines safety regulator. The fake jabs, obtained without prescription through black market suppliers, were seized by the Medicines and Healthcare Products Regulatory Agency. Ozempic, the brand name for semaglutide, and demand for the medicine has contributed to shortages in the product, which is also used for people with type 2 diabetes. The watchdog said a low number of patients had been hospitalised and reported serious side effects, including hypoglycaemic shock. Others ended up in a coma, which indicates the pens may have contained insulin rather than semaglutide. It has urged the public not to buy drugs without a prescription and warned buying prescription-only medicines online “poses a direct danger to health”. Read full story Source: The Independent, 29 October 2023 -
News Article
Parents of babies who died or were harmed in NHS care demand inquiry
Patient Safety Learning posted a news article in News
Parents of babies who have died or been harmed as a result of poor care are demanding that ministers order a public inquiry into repeated failings in NHS maternity units. They want Steve Barclay, the health secretary, to set up a judge-led statutory inquiry to investigate recurring problems in maternity services, which cost the NHS in England £2.6bn a year in damages. Babies are still being damaged and dying, despite previous inquiries into maternity scandals at the Morecambe Bay, Shrewsbury and Telford, and East Kent NHS trusts recommending changes. The NHS’s failure to improve maternity safety is so alarming that a public inquiry is needed to finally ensure that women and babies no longer come to harm, the families say. The Maternity Safety Alliance, a group of relatives of newborns who have died due to lapses in NHS childbirth, warned that scandals will continue unless such an inquiry is held. “Our babies are too precious to keep on ignoring the reality that despite a raft of national initiatives and policies implemented in the wake of investigations and reports, systemic issues continue to adversely impact on the care of women and babies. “Far too much avoidable harm continues to devastate lives in circumstances that could and should be avoided. Fundamental reform is needed,” they said in a letter urging Barclay to intervene. Read full story Source: The Guardian, 31 October 2023 -
Content ArticleIn this article Sir Bernard Jenkin, Member of Parliament for Harwich and North Essex, considers the role of new statutory body to investigate patient safety concerns across England to improve NHS care at a national level, the Health Services Safety Investigations Body (HSSIB). He talks about the new “safe space” powers of the organisation and its intended role in the healthcare system.
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Content ArticleTrevor Stevens daughter, Tobi, took her own life in December 2020 whilst in the care of the Norfolk and Suffolk NHS Foundation Trust. Trevor recently attended the HSJ Patient Safety Congress. In this blog, he reflects on his experience at the Congress. Related reading on the hub: Time for a reset on safety? Highlights from day one of the HSJ Patient Safety Congress
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News Article
Sepsis killing too many as lessons not learned, warns NHS watchdog
Patient Safety Learning posted a news article in News
Sepsis is still killing too many patients due to the same hospital failings that occurred a decade ago, a damning report by the NHS ombudsman has warned. Avoidable mistakes include delays in spotting and treating the condition, poor communication between health staff, sub-standard record keeping and missed opportunities for follow-up care, according to Rob Behrens, the parliamentary and health service ombudsman (PHSO). Despite some progress since a previous report on sepsis by the ombudsman in 2013, lessons are not being learned and repeated mistakes are putting people at risk, Behrens said. Major improvements are urgently needed to avoid more fatalities, he added. “I’ve heard some harrowing stories about sepsis through our investigations, and it frustrates and saddens me that the same mistakes we highlighted 10 years ago are still occurring,” said Behrens. “It is clear that lessons are not being learned. Losing a life through sepsis should not be an inevitability.” Melissa Mead, whose one-year-old son, William, died from sepsis in 2014 after concerns were dismissed by doctors, said: “I think this report, nine years on from William’s death, really lays bare the incidences of sepsis cases.” Mead, who peer-reviewed the study, added: “Too many lives are being lost in preventable circumstances.” Read full story Source: The Guardian, 25 October 2023 Further reading on the hub: Top picks: Six resources about sepsis -
Content ArticleSepsis is a life-threatening reaction to an infection. It can affect anyone of any age. It happens when your immune system overreacts to an infection and starts to damage your body’s own tissues and organs. Sepsis is sometimes called septicaemia or blood poisoning. According to the UK Sepsis Trust, 48,000 people in the UK die of sepsis every year. This number can and should be reduced. It is often treatable if caught quickly. This report from the Parliamentary and Health Service Ombudsman(PHSO) looks at some of the sepsis complaints people have brought to PHSO, to shine a light on their experiences and encourage others to let their voices be heard. It shares case summaries and guidance to help people complain and help NHS organisations understand and learn from the issues raised Further reading on the hub: Top picks: Six resources about sepsis
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Content ArticleNHS England wants to find out how people would choose to tell the NHS about things that go wrong in healthcare, to help the NHS do things better. NHS England wants to hear from people of all ages and backgrounds, who use all kinds of NHS services. They want to know how people would choose to give feedback if something went wrong in their care, or in the care of someone they look after, so the NHS can learn. NHS England will use what you tell them to help design a new online service to make care better. Click on the link below to find out more and take the survey. Closing date: 31 December 2023
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Content Article
Medication errors are a leading cause of patient harm globally. WHO launched the Global Patient Safety Challenge: Medication Without Harm, with the objective of preventing severe medication related patient harm globally. This publication is one of the documents in the WHO Technical Series on “Medication Safety Solutions” that the WHO is publishing, to address important aspects pertaining to medication safety. -
News Article
Plan to pump 10,000 fake doctors into the NHS is insane and dangerous
Patient Safety Learning posted a news article in News
You might not have heard of a ‘physician associate’ - and that’s not your fault. They probably won’t tell you. A physician associate walks and talks like a doctor, but they are no replacement for one. To become a physician associate you need to complete a two-year postgraduate course or three-year apprenticeship. But despite much less learning than the five years a junior doctor must undergo to be qualified, they are often paid more than them. Which is why the government’s plan to flood the NHS with 10,000 more of them over the next 15 years doesn’t make any sense. There’s certainly no money-saving aspect. This is simply another corner-cutting exercise to quickly plug gaps in a struggling NHS that will put patients at risk. Far from saving doctors work (their original purpose), they often create more. Physician associates are unregulated so cannot be held accountable for their mistakes, meaning doctors must recheck any critical decisions they make. Critical decisions are made quite frequently in hospitals. But they’re not just overstretching doctors and creating more work; they’re harming patients. A recent Daily Mail investigation has found brain bleeds misdiagnosed as inconsequential headaches and lung disease mistaken for a chest infection. Doctors say they are “increasingly concerned” by this. Read full story Source: LBC, 16 October 2023 -
News Article
East Kent NHS Trust: Lessons not learned at maternity trust, mum says
Patient Safety Learning posted a news article in News
Lessons still have not been learned at a Kent hospital trust which was criticised in a damning report, a mother has said. Dr Bill Kirkup's review found at least 45 babies might have survived with better care at East Kent NHS hospitals. Victoria, whose six-year-old daughter needs 24-hour support, said: "I've had no contact from anyone from the trust." Her case was one of 202 that were examined by Dr Kirkup in his report, which was published exactly a year ago. Victoria, whose daughter is living with the consequences of failings in her care during her birth, said: "Our children have become unwell because of what has happened to them. "I don't feel lessons have been learned whatsoever. "Treatment hadn't been made available as easily as it should have done for children that are still living this experience every day." Read full story Source: BBC News, 19 October 2023 -
Content ArticleThe Thirlwall Inquiry has been set up to examine events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital. This document sets out the terms of reference for this inquiry, following an engagement process led by the inquiry’s independent chair, Lady Justice Thirlwall, with the affected families and other stakeholders.
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News Article
Two-thirds of England’s maternity units dangerously substandard, says CQC
Patient Safety Learning posted a news article in News
Almost two-thirds of maternity units provide dangerously substandard care that puts women and babies at risk, the NHS watchdog has said in a damning report. The Care Quality Commission (CQC) has rated 65% of maternity services in England as either “inadequate” or “requires improvement” for the safety of care – up from 54% last year. Services are beset by a host of problems, including serious staff shortages and internal tensions, which mean that too many mothers and their babies receive care that is not good enough, it said. Women too often face delays in accessing care, do not receive the one-to-one care from a midwife to which they are entitled or experience communication problems with staff looking after them, including being shouted at by midwives. The CQC judged overall quality of care to be inadequate or require improvement at 85 maternity units, almost as many at which it rated it to be either good or outstanding – 87. The number of units offering substandard care has soared by 30 in the last year, from 55 to 85. It said that, having inspected 73% of all maternity units, “the overarching picture is one of a service and staff under huge pressure. People have described staff going above and beyond for women and other people using maternity services and their families in the face of this pressure. “However, many are still not receiving the safe, high-quality care that they deserve.” Read full story Source: The Guardian, 20 October 2023 -
Content ArticleOn 29 September 2023, a group of NHS staff and Experts by Experience joined a Teams meeting to help the National Patient Safety team in NHS England (NHSE) to answer two important questions. 1. Is it a good idea to keep asking NHS staff to record the level of psychological harm experienced by patients and service users, after a patient safety incident? 2. If so, how we can help make sure this is done as well and accurately as possible? Here is the write up of the workshop.
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News Article
Woman's 'complete shock' at skin cancer misdiagnosis
Patient Safety Learning posted a news article in News
A woman has spoken of her "complete shock" at being misdiagnosed with cancer and undergoing surgery when she never had the condition at all. Megan Royle, 33, from East Yorkshire, was diagnosed with skin cancer in 2019. As part of her treatment, she underwent immunotherapy and her eggs were frozen due to the risk to her fertility. But after she was given the all-clear in 2021, a review showed she never had cancer and she has now won compensation from the two NHS trusts involved. Ms Royle, from Beverley, said: "You just can't really believe something like this can happen, and still to this day I've not had an explanation as to how and why it happened. "I spent two years believing I had cancer, went through all the treatment, and then was told there had been no cancer at all." "You'd think the immediate emotion would be relief and, in some sense, it was - but I'd say the greater emotions were frustration and anger." Read full story Source: BBC News, 18 October 2023
