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Found 685 results
  1. News Article
    An NHS trust at the centre of an inquiry into preventable baby deaths will repay money it received for providing good maternity care. In 2018, Shrewsbury and Telford NHS Trust received almost £1m, weeks before its services were rated inadequate. The BBC revealed in December the trust had qualified for the payment under the NHS's Maternity Incentive Scheme. The trust said an "incorrect submission" had been made and it had ordered an independent review. Shrewsbury and Telford NHS Trust (SaTH) is at the centre of England's largest inquiry into poor maternity care, with more than 900 families contacting a review looking into concerns over preventable deaths and long-term harm. Former health secretary Jeremy Hunt wrote to ministers questioning if improvements to the Maternity Incentive Scheme were needed in light of payments made to both Shrewsbury and Telford and East Kent Hospitals, despite both facing serious questions over the safety of maternity services. The trust in Shropshire was paid £963,391 after certifying it had met the 10 safety standards demanded by the scheme, which is run by NHS Resolution. In the letter, seen by the BBC, Mr Hunt suggested one improvement would be to link payments to CQC maternity and safety ratings. "The whole approach is likely to be discredited if trusts can meet all 10 actions and yet still be delivering poor standards of care," the letter said. Read full story Source: BBC News, 6 March 2020
  2. Content Article
    The human element can give us kindness and compassion; it can also give us what we don't want— mistakes and failure. Leilani Schweitzer's son died after a series of medical mistakes. In her talk she discusses the importance and possibilities of transparency in medicine, especially after preventable errors. And how truth and compassion are essential for healing.
  3. Content Article
    This is part 5 of a series of blogs about human factors and investigations in healthcare. The theme is ‘when’ and that covers ‘when’ to investigate and ‘when’ to try any remedies or interventions your investigation data suggests might prevent the incident occurring again. As this blog can be explained by a photo and a graph, we have some time to recap the story so far and, perhaps, predict a bit of the future. 
  4. Content Article

    Marking your own homework

    Anonymous

    Anonymous posted an article in Florence in the Machine

    Having read the recent blog on the hub, ‘Silent witness’, this nurse too was compelled to share with us her frustrations on the current hospital reporting system. 
  5. News Article
    There is a “strong association” between staff experience of senior management and whether an organisation acts on error reporting, exclusive analysis for HSJ of the staff survey data suggests. Analysis by health and social care charity Picker Institute examined statistical relationships between responses to staff survey questions regarding staff communication with managers and those relating to error reporting. The analysis, which included all trust types, looked at the relationships between statements such as “communication between senior managers and staff is effective” and “I know who the senior managers are here” to “When errors, near misses or incidents are reported, my organisation takes action to ensure they do not happen again” and other similar indicators. A high correlation to the questions does not categorically prove a direct causal relationship but the data suggested “strong associations”, Picker Institute chief statistician Steve Sizmur told HSJ. He said: “There are a number of strong associations in the latest staff survey data, to the extent that there is likely to be a link between staff experiences of senior management and their views about error reporting and whether the organisation addresses their concerns.” Read full story (paywalled) Source: HSJ, 27 February 2020
  6. Content Article
    Patient Safety Learning's Chief Executive Helen Hughes, alongside Professor Alison Leary and Professor Sara Ryan, talk on BBC Radio 4 about coroner reports that are specifically designed to help prevent future deaths and question whether it's working in practice. Health researchers warn that lives are at risk because warnings from Coroners are not being acted upon. Analysis of more than 1000 Prevention of Future Death reports has identified five themes that come up time and time again. Patient Safety Learning has written to the Chief Coroner because of their concerns about this. Sara Ryan is a mother who believes lessons from her son's death have not been learned.
  7. Content Article
    Incident reporting systems are commonly deployed in healthcare but resulting datasets are largely warehoused. This study, published in the International Journal of Health Care Quality Assurance, explores if intelligence from such datasets could be used to improve quality, efficiency, and safety. Results indicate that healthcare incident reporting data is underused and, with a small amount of analysis, can provide real insight and application to patient safety.
  8. Content Article
    Root cause analysis (RCA) is a widely used method deployed following adverse events in health care. Using a range of information-gathering and analytical tools (such as interviews, the "five whys" technique, fishbone diagrams, change analysis, and others), RCA seeks to understand what happened and why and to identify how to prevent future incidents. In this PSNet Case and Commentary, Mohammad Farhad Peerally and Mary Dixon-Woods discuss a case where a hospital planned to perform a root cause analysis (RCA) to investigate an adverse event which resulted in an individual blamed and no interventions to prevent similar errors or address systems issues were ever implemented.
  9. Content Article
    The No Fault Compensation Review Group were asked by the Cabinet Secretary for Health and Wellbeing to consider the potential benefits for patients in Scotland of a no fault compensation scheme for injuries resulting from medical treatment, and whether such a scheme should be introduced alongside the existing clinical negligence arrangements. This report sets out the approach they adopted together with their findings, conclusions and recommendations which help and inform consideration of what is required to ensure that the compensation scheme in operation in Scotland meets the needs of those involved.  
  10. Content Article
    In this BMJ Opinion article, David Rowland from the Centre for Health and the Public Interest discusses why he thinks the Independent Inquiry into the issues raised by Paterson is yet another missed opportunity to tackle the systemic patient safety risks which lie at the heart of the private hospital business model. David believes that although the Inquiry provided an important opportunity for the hundreds of patients affected to bear witness to the pain and harm inflicted upon them it fundamentally failed as an exercise in root cause analysis.   None of the “learning points” in the final report touch on the financial incentives which may have led Paterson to deliberately over treat patients. Nor do they cover the business reasons which might encourage a private hospital’s management not to look too closely. Yet these concerns about how the private hospital system works and the associated patient risks it produces had been established in a number of previous inquiries.   He suggests that the Inquiry report threw the responsibility for managing patient safety risks back to the patients themselves in two of its main recommendations but that it should be for the healthcare provider first and foremost to ensure that the professions that they employ are safe, competent and properly supervised, and for this form of assurance to be underpinned by a well-functioning system of licensing and revalidation by national regulatory bodies.
  11. Content Article
    The Central Alerting System (CAS) is a web-based cascading system for issuing patient safety alerts, important public health messages and other safety critical information and guidance to the NHS and others, including independent providers of health and social care. Alerts available on the CAS website include National Patient Safety Alerts (from MHRA, NHS England and NHS Improvement and the UK Health Security Agency (UKHSA)), NHS England and NHS Improvement Estates Alerts, Chief Medical Officer (CMO) Alerts, and Department of Health & Social Care Supply Disruption alerts.
  12. News Article
    The government has announced an independent review into maternity services at an NHS trust where a number of babies have died. “Immediate actions” have also been promised and an independent clinical team has been placed “at the heart” of East Kent Hospitals University NHS Foundation Trust. It comes amid reports that at least seven preventable baby deaths may have occurred at the trust since 2016, including that of Harry Richford. Harry died seven days after his emergency delivery in a “wholly avoidable” tragedy, contributed to by neglect, in November 2017, an inquest found. Speaking in the House of Commons, the health minister Nadine Dorries confirmed the independent review would be carried out by Dr Bill Kirkup, who led the investigation into serious maternity failings at Morecambe Bay. It will look at preventable and avoidable deaths of newborns to ensure the trust learns lessons from each case and will put in place appropriate processes to safeguard families. The review is expected to begin shortly and work in partnership with affected families. Read full story Source: 13 February 2020
  13. Content Article
    A newly qualified nurse describes what happened when she reported her first Datix for a serious incident.
  14. Content Article
    Responding to the Paterson Inquiry, Ian Kennedy, Emeritus Professor of Health Law and Policy at University College London, discusses the systemic weaknesses in the NHS.
  15. Content Article
    Presentation from Joanna Lloyd, Bevan Brittan, on incident investigations.
  16. News Article
    A GP has been given three life sentences for 90 sex assaults on female patients. Manish Shah assaulted 23 women and a 15-year-old girl while working in London - carrying out invasive examinations for his own gratification. The Old Bailey heard he used Angelina Jolie and Jade Goody as examples to frighten patients about their health. Judge Anne Molyneux described him as a "master of deception who abused his position of power". "You made up stories which got into heads and caused panic," she said. Shah, from Romford, convinced his victims to have unnecessary checks between May 2009 and June 2013. Read full story Source: BBC News, 7 February 2020
  17. Content Article
    The Parliamentary Under-Secretary of State for Health and Social Care, Ms Nadine Dorries, responds to the Paterson Inquiry in the House of Commons. It is followed by questions from MPs in the chamber and Ms Dorries' responses.
  18. Content Article
    In 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.
  19. News Article
    A number of doctors have claimed a service under which adolescents with gender dysphoria can be given puberty-suppressing hormone blockers is "unsafe" and must be immediately stopped, but their concerns were suppressed. The service is provided in Ireland by flying in two clinicians from an NHS trust in London to run clinics at Crumlin Children's Hospital. But the Irish Independent has learned at least three doctors working in the gender area expressed grave concerns over the service provided by the Tavistock and Portman NHS Foundation Trust at Crumlin. The concerns over standards of clinical care and governance were raised at a meeting of doctors and hospital officials in Crumlin last March. These included that children had been started on hormone treatment when they did not appear to be suitable. However, the issues raised and calls by the doctors for the service to be "terminated with immediate effect" were omitted from draft minutes of the meeting. News of their concerns comes days after it emerged a lawsuit was being taken by a former nurse, a parent, and a former patient against the trust in the London High Court. The action is challenging the clinic's practice of prescribing hormone blockers and cross-sex hormones to children under the age of 18. The trust has also been hit by a series of resignations by psychologists amid disquiet about the alleged "over-diagnosis" of gender dysphoria. Read full story Source: Irish Independent, 3 February 2020
  20. News Article
    More than half of all incidents resulting in death reported by health boards in Wales came from troubled Betsi Cadwaladr. The 53% figure from a Welsh Government safety report came to light during First Minister Questions in the Senedd yesterday. Plaid Cymru Leader Adam Price said there had been “an alarming rate” of patient safety incidents in the Betsi Cadwaladr University Health Board area and that between December 2018 and November 2019 there were 40 incidents resulting in death registered within Betsi. Between November 2017 and November 2019 there were 520 incidents within Betsi that resulted in death or serious harm - higher than all the other health boards in Wales combined. Mr Price questioned whether there is an issue with Betsi itself, or whether there is an issue of "under-reporting of serious incidents" in the rest of Wales. Defending the figures, the First Minister said that reporting incidents and learning from them has become part of the culture of a health board that they “want to see everywhere in Wales”. Read full story Source: North Wales Live, 29 January 2020
  21. News Article
    Calls for immediate compensation for thousands of victims contaminated by infected NHS blood have been rejected by ministers at a meeting with campaigners and survivors – but more health support may be made available. Despite one person dying every four days on average from HIV, hepatitis C or other conditions, the government on Tuesday turned down a request for a national compensation scheme. There are estimated to be between 5,000 and 7,000 victims still alive who acquired viral infections through transfusions from the health service. Many are haemophiliacs who need regular transfusions to help their blood clot. Products supplied by the NHS in the 1970s and 1980s came from the US using blood obtained from prisoners and drug addicts who were paid for their donations. Imported products were inadequately screened. Read full story Source: The Guardian, 28 January 2020
  22. News Article
    The government has ordered an urgent inquiry into the local hospital of the health secretary, Matt Hancock, after the Guardian revealed its unprecedented “witch-hunt” for a whistleblower. The Department of Health and Social Care (DHSC) has told NHS England to commission a “rapid review” of the actions of bosses at West Suffolk hospital. They are under fire for demanding that staff give fingerprints and samples of their handwriting to help identify who wrote to a family alerting them to failings in care that contributed to a patient’s death. Unusually, the investigation has been instigated by Edward Argar, a junior minister at the DHSC, because Hancock and another health minister, Jo Churchill, are both local MPs who have close ties to the hospital. Argar has made clear to NHS England that the inquiry must be undertaken by independent experts, given those existing relationships. Announcing the review, Argar made clear that he wanted hospital personnel to speak openly. “I want all staff to feel that they can speak up and have the confidence that anything they raise will be taken seriously,” he said. Read full story Source: The Guardian, 28 January 2020
  23. News Article
    The failure to pass a damning report about a scandal-hit hospital trust to the care watchdog has been criticised by the man who led the inquiry into baby deaths at Morecambe Bay. On Friday, a coroner ruled that the death of baby Harry Richford in 2017 resulted from neglect in the maternity unit of East Kent Hospitals NHS Trust. A report by the Royal College of Obstetrics and Gynaecologists (RCOG) completed a year earlier had warned of issues that contributed to Harry’s death, including senior doctors not showing up for their shifts. However, the report was never passed on to the Care Quality Commission (CQC), despite the recommendation of the Morecambe Bay inquiry in 2015 that relevant external reviews should be passed on to the watchdog. Bill Kirkup, who chaired the inquiry into deaths of mothers and babies at Furness General Hospital in Barrow-in-Furness, told The Independent: “When there is sufficient concern about a service to prompt an external review, the report must be available immediately to those responsible for assuring the quality of the service. That was the reason for the recommendation of the Morecambe Bay investigation, and it is disappointing that the Care Quality Commission apparently had no sight of this report until now.” Read full story Source: 26 January 2020
  24. Content Article
    Six monthly summaries of how the NHS reviewed and responded to the patient safety issues you reported.
  25. Content Article
    The objective of this study, published in Health Services Research, was to determine whether a communication and resolution approach to patient harm is associated with changes in medical liability processes and outcomes.
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