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Found 290 results
  1. Content Article
    Please help the Campaign Against Painful Hysteroscopy uncover the circumstances, quantify the contributing factors, and evidence the consequences of painful and distressing hysteroscopies. The survey is anonymous. The results will be put in the public domain to be used to help improve hysteroscopy services for future patients.
  2. Content Article
    When Joe Fassler's wife was struck by mysterious, debilitating symptoms, their trip to the ER revealed the sexism inherent in emergency treatment.
  3. Content Article
    In this blog, The Patients Association's Chief Executive Rachel Power argues that the findings of the independent investigation into maternity and neonatal services at East Kent Hospitals NHS Foundation Trust demonstrate the repeated failure of maternity services in England to offer safe and compassionate care to families. She outlines the key findings of the report, including catastrophic failures in the organisation's culture, team working and professionalism, and failure to listen to patients. She highlights that the lack of honesty shown by the Trust to individuals and families harmed by the hospitals' failures is shocking, and compounded the suffering felt by each family.
  4. Content Article
    World Menopause Day is held every year on 18 October to raise awareness of the menopause and the support options available for improving health and wellbeing. In this blog, I want to raise awareness of surgical menopause, which affects over 4000 young women a year, specifically around the lack of information and support received before and after surgery.  
  5. Content Article
    Specialist centres for those affected by mesh implants, as recommended by the Independent Medicines and Medical Devices Safety Review, became operational formally in April 2021. HSJ analyses how they performed in their first year.
  6. Content Article
    Mr B was 71 years' old and was undergoing treatment for cancer of the oesophagus. During surgery, a nasogastric tube that had been inserted became dislodged and was put back into place by medical staff, despite guidelines against this. The family realised that something had gone wrong in the operation and Mr B became very seriously ill, dying five months later. When the family asked the hospital for an investigation, they revealed that a hole had been made in Mr B’s stomach when the nasogastric tube was replaced. There was no assurance given that steps would be taken to prevent similar errors in the future, and no apology from the hospital. The family sought legal advice and came to an out of court settlement with the hospital.
  7. Content Article
    The gap in healthy life expectancy is being driven by the increasing numbers of people managing a long-term condition (LTC) and, increasingly more than one – known as multi-morbidity. This situation affects a higher proportion of the population facing systemic discrimination and marginalisation, and those experiencing higher levels of deprivation. This report from the Chartered Society of Physiotherapy raises awareness of health inequities in rehabilitation and recovery services across the UK
  8. 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.
  9. Content Article
    Hysteroscopy is a diagnostic gynaecological procedure traditionally requiring administration of general anaesthesia, but more frequently completed using local anaesthesia within a day-case (ambulatory) setting. Advantages associated with this transition include decreased completion times, fewer risks, and lower clinical costs. Numerous services advertise the procedure as being either pain free or low pain; however, it is estimated that 25% of patients report experiencing intense or intolerable pain. For severe pain, local anaesthetic can be administered, but this does not guarantee effective pain management. This research, published in the British Journal of Anaesthesia, found that very few patients feel no pain and a significant number felt pain of greater than 7/10. It also found a disconnect between the patient's experience of pain and the clinician's perception of it. This research paper is paywalled, but can be purchased via the link below.
  10. Content Article
    Authors of this commentary published in the Canadian Medical Association journal argue that many patients suffer from a specific adverse event on a daily basis: pain. It is never reported as an adverse event and corrective action is often not taken.
  11. Content Article
    This blog, published in the BMJ, sets the context for an Evidence Based Nursing (EBN) Twitter Chat that took place on 18 March 2015. The chat focused on whether mismanaged (undertreated) pain should be considered an adverse event. The Twitter Chat was hosted by Dr Alison Twycross who is editor of EBN and has also done lots of work in the area of paediatric pain management. This blog provides some context for the chat. The examples given relate to paediatric pain but the principles apply to pain in patients of all ages.
  12. Content Article
    In this blog, Stephanie O'Donohue, Content and Engagement Manger for Patient Safety Learning, discusses some of the patient safety issues that specifically impact on women. Drawing on recent inquiries, patient testimonials and research, Stephanie focuses on three main issues; consent, patient engagement and bias. She highlights the need for people to work in partnership to understand the barriers to safe care for women and to prevent future harm. 
  13. Content Article
    Dr Richard Harrison is a pain researcher employed at the University of Reading and affiliated with the School of Psychology and Clinical Language Sciences (SPCLS) and Centre for Integrative Neuroscience and Neurodynamics (CINN). His research focuses predominately on pain, examining psychological processes underlying how pain is processed, as well as individual differences in the ability to modulate (or control) the experience of pain. In this blog, Richard reflects on his recent research on pain experience and assessment during hysteroscopy procedures, published recently in the British Journal of Anaesthesia. "The dangers of advertising hysteroscopy as a mildly painful procedure are many. Firstly, this stands to put women off engaging with a very useful diagnostic test for the identification of serious medical conditions, such as ovarian cancer or endometriosis. But secondly, it is highly plausible that the resulting prediction error stands to make the experience even more painful than if patients were appropriately warned."
  14. Content Article
    Hysteroscopy is a procedure used as a diagnostic tool, to identify the cause of common problems such as abnormal bleeding, unexplained pain or unusually heavy periods in women. It involves a long, thin tube being passed into the womb, often with little or no anaesthesia. In recent years, there has been an increased focus on these procedures being performed within outpatient services. The availability of pain relief is much reduced in these settings. There are financial incentives in place to support this move to day surgery.[1] Reflecting on activity to date, Patient Safety Learning discusses the important role that consent, patient engagement and collaborative action is playing in highlighting a serious patient safety concern and in driving the change needed for safe hysteroscopy.
  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. Content Article
    The Campaign Against Painful Hysteroscopy is a campaign group raising awareness of the safety flaws that exist within the processes surrounding hysteroscopy procedures for women.  On 20 October 2020, they wrote to Matt Hancock MP, Secretary of State for Health and Social Care and Nadine Dorries MP, Minister for Patient Safety, Suicide Prevention and Mental Health. In their letter they used both empirical data and the personal stories of women to illustrate the prevalence and seriousness of the issue. 
  17. 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.
  18. Content Article
    Having stepped down as Chief Executive of the Point of Care Foundation last year, Jocelyn Cornwell reflects on the journey that she and the organisation have made and what she has learnt. This is her personal take on their history, the principles behind the work and achievements plus some reflections on changes that have and have not happened over the last fifteen years. 
  19. 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.
  20. Content Article
    Sarah Seddon's son (Thomas) was stillborn in May 2017. The lack of candour following Thomas’ death and the conduct of the serious incident investigation impacted significantly on Sarah and her family. The local investigation was followed by a Fitness to Practise (FtP) investigation where Sarah experienced how damaging, dehumanising and traumatic FtP processes can be for patients who are required to be witnesses. Here she reflects on the impact of being a witness in a Fitness to Practise (FtP) hearing had on her.
  21. Content Article
    Authors of this article, previous argued that inadequately managed pain in children should be considered an adverse event, a harmful patient outcome. They argued that inadequately managed pain meets the definition of an adverse event and further hypothesised that treating pain as an adverse event may improve care by raising health care administrators and quality improvement experts’ awareness of this issue.  In this article, published in the Journal of Child Care Health five years on, they reflect on the progress made in both moving this proposition forward and testing out the concept. They then move on to look at what still needs to be done to ensure that children’s pain is managed effectively.
  22. Content Article
    Chaired by Baroness Julia Cumberlege, the Independent Medicines and Medical Devices Safety Review report, First Do No Harm, examines how the healthcare system in England responds to reports about the harmful side effects from medicines and medical devices. In this blog, Patient Safety Learning reflects on one of the key patient safety themes featured in the Review – informed consent. 
  23. Content Article
    In this interview, Dr Jake Suett talks about his experience of persisting and debilitating symptoms after he was suspected to have contracted COVID-19. Additional reading: Patient safety concerns for Long COVID patients (6 July 2020) Press release: Patient Safety Learning calls for urgent action to ensure Long COVID patients are heard and supported (6 July 2020) My experience of suspected 'Long COVID' (6 July 2020) Dismissed, unsupported and misdiagnosed: Interview with a COVID-19 ‘long-hauler’
  24. Content Article
    An increasing number of people with confirmed or suspected COVID-19 are continuing to struggle with prolonged, debilitating and sometimes severe symptoms months later.[1] Many were never admitted to hospital and have instead been trying to manage their symptoms and recovery at home. These patients are sometimes referred to as the ‘long-haulers’ or described as having ‘post-acute’, ‘chronic’ or ‘long-term’ COVID-19. Here, we will use the term ‘Long COVID’. With social distancing restrictions still in place, patients in the UK and across the world have been turning to social media support networks[2] to connect with others who are experiencing similar challenges. These patients have raised very credible concerns about the care they are receiving[3] and the uncertainties they face. Their concerns are revealing many implications for patient safety. We have recently shared on the hub the story of Dr Jake Suett[4], one of the many people experiencing symptoms of Long COVID. When we conclude this article, we will return to his story and highlight the changes that he is calling for. However, first, we will focus on the patient safety aspects of Long COVID, highlighting key areas of concern and action needed (a full list of actions can be found summarised here).
  25. Content Article
    In this blog, intensive care doctor Jake Suett draws on his personal journey and that of others to highlight the prolonged and frightening symptoms many patients with confirmed or suspected COVID-19 are experiencing. Jake outlines his concerns and sets out recommendations for future action to address the needs of these 'Long COVID' patients. Included is an example letter that can be adapted by others to call on MPs to raise awareness of those suffering persisting symptoms of COVID-19. 
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