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Content ArticleThis report, written in collaboration with the Royal College of Nursing (RCN), sets out proposals to reduce the number of preventable natural deaths in prisons. It identifies how natural deaths occurring in prison might be prevented, where possible, and end-of-life care managed with dignity and compassion.
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Content ArticleIn this blog, Patient Safety Learning considers the need for global action to improve patient safety and sets out its response to the WHO’s consultation on the draft Global Patient Safety Action Plan 2021-2030.
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Content ArticleThe 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.
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Content ArticleThe Royal College of Obstetrics and Gynaecology (RCOG) has guidance on group B Strep infection in newborn babies, which was last updated in September 2017. A national learning published earlier in 2020 by the Healthcare Safety Investigation Branch (HSIB) highlighted that the RCOG guidance was not being followed. This report from the Group B Strep Support reinforces these findings. Only a tiny number of NHS Trusts are following the key new recommendations around giving pregnant women information on group B Strep, offering testing to some pregnant women, and following Public Health England guidelines on testing for group B Strep. As a result, pregnant women face a postcode lottery, potentially receiving significantly different care from recommended practice. Group B Strep Support recommends that the NHS prioritises the prevention of group B Strep infection in newborn babies. A key step towards this would be to ensure published national guidance from recognised expert bodies is adopted and implemented in a timely manner.
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Content ArticleThe Royal College of General Practitioners has updated its guidance on online consultations. The resource gives a useful set of questions to consider when using online consultations, such as which provider is used, the standard of patient care, and ensuring equitable access.
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Content ArticleThe World Health Organization (WHO) has recently published, for consultation, the third draft of its Global Patient Safety Action Plan 2021-2030. In this blog, Patient Safety Learning reflects on areas where our initial feedback in September 2019 has been incorporated into the new draft and where we believe the Action Plan can be further strengthened
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Content Article‘Never events’ are patient safety incidents that are defined as being wholly preventable. They are considered wholly preventable because guidance or safety recommendations are in place at a national level and should have been implemented by all providers in the healthcare system. This should act as a strong systemic barrier to prevent the serious incident from happening. The latest national report from the Healthcare Safety Investigation Branch (HSIB) says that 'Never Events' should not be defined as such if they don’t have strong enough barriers in place to stop them happening.It recommends that seven Never Events on a list of 15 should be removed until better barriers are in place. They are using the Safety Engineering Initiative for Patient Safety (SEIPS) model to carry out the analysis. SEIPS provides a framework for understanding structures, processes and outcomes in healthcare, and their relationships.
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Content ArticleWorld Health Organization (WHO) presentation summarising the global guidelines and recommendation for the prevention of surgical site infections.
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Content ArticleSurgical site infections (SSIs) present a considerable challenge for healthcare systems across the world, including in the UK, and have a substantial impact on patients and healthcare professionals. Despite clear evidence and guidelines on how to reduce the risk of these infections on a global, regional and national basis – and the fact that research shows up to 60% of SSIs are preventable – infection rates remain high. Progress has been made in recent years, yet more than 5% of patients undergoing a surgical procedure still develop an SSI, and each infection has been estimated to cost the NHS between £10,0003 and £100,000 per patient. It is now time to act. Collectively we need to reduce the variation in practice across the UK, embed evidence-based examples of best practice, and work collaboratively with the NHS to help reduce the incidence of SSIs to improve patient outcomes. Embedding this guidance and changes to practice cannot take place in silos. It will require action from the whole healthcare community: from policymakers, to trusts, to hospitals, healthcare professionals and medical Royal Colleges, right the way through to the patient themselves. This report, Time to Act: A State of the Nation report on Surgical Site Infections in the UK, will review the available evidence, examples of best practice and reflections from the front line, to make recommendations to each of these groups in order to drive significant improvement in reducing SSI rates in the UK.
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Content ArticleThe Care Quality Commission (CQC) has published the second report of Professor Glynis Murphy’s independent review of its regulation of Whorlton Hall between 2015 and 2019. CQC commissioned Professor Murphy to conduct an independent review to look at whether the abuse of patients at Whorlton Hall could have been recognised earlier by the regulatory process and to make recommendations for how CQC can improve its regulation of similar services in the future. In addition, CQC asked Professor Murphy to conduct a review of international research evidence to look at how abuse is detected within services for adults with a learning disability and autistic people and how such detection can be improved. The first report of Professor Murphy’s review made a number of recommendations for CQC to strengthen its inspection and regulatory approach for mental health, learning disability and/or autism services. This second report outlines the progress that CQC has made to implement the recommendations. This includes publication of the final report of its review of restraint, seclusion and segregation; work on closed cultures and the development of a tool for rating support plans.
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Content ArticleIn the summer of 2019, following a televised Panorama programme showing abusive care of people with learning disabilities and/or autism in Whorlton Hall (an independent hospital in the north of England), the Care Quality Commission (CQC) requested an independent review of its inspections of Whorlton Hall. Professor Glynis Murphy was appointed to conduct the review.
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Content ArticleThis video supports the launch of our thematic review that presents a detailed analysis of claims made after an individual has attempted to take their life. Claims relating to completed suicide and attempted suicide are reviewed, regardless of whether the claim resulted in financial compensation. It identifies common problems with care and provides recommendations for improvement to support service delivery.
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Content ArticleJames Titcombe, Patient Safety Campaigner and co-founder of Harmed Patients Alliance, discusses the findings of the recent Bill Kirkup report 'The Life and Death of Elizabeth Dixon: A Catalyst for Change'.
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Content ArticleSerious complications and deaths resulting from maternity care have an everlasting impact on families and loved ones. The families who have contributed to the Ockenden Review want answers to understand the events surrounding their maternity experiences, and their voices to be heard, to prevent recurrence as much as possible. They are concerned by the perception that clinical teams have failed to learn lessons from serious events in the past. The learning of lessons and embedding of meaningful change at The Shrewsbury and Telford Hospital NHS Trust and in maternity care overall is essential both for families involved in this review and those who will access maternity services in the future. After reviewing 250 cases and listening to many more families, this first report identifies themes and recommendations for immediate action and change, both at The Shrewsbury and Telford Hospital NHS Trust and across every maternity service in England.
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Content ArticleThis report from Verita, an independent consultancy, provides an independent account into the disciplinary process regarding Nurse Amin Abdullah in late 2015. It was commissioned by Imperial College Healthcare NHS Trust (‘the trust’) in 2017 to review the process that it followed in dealing with Nurse Abdullah’s case and whether fair and appropriate action was taken
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) report charts the emerging patient safety risks that can come with the introduction of ‘smart’ infusion pump technology into hospitals. Smart infusion pumps are the latest generation of programmable devices that administer medication. They are seen as a way of improving safety as the smart functionality aims to prevent underdoses or overdoses – they are equipped with features such as alerts or alarms to help detect problems. The investigation was launched after one NHS Trust recorded three incidents where a smart infusion pump delivered an overdose of fentanyl, a powerful pain medication. The patients weren’t harmed as it was swiftly picked up, however it emphasised the new risks that come with introducing new technology and the potential for serious medication errors. The investigation focused on the barriers to implementing the technology effectively across the NHS, rather than on the technology itself.
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Content ArticleLaura Anne Jones MS (Member of the Senedd) tabled a formal written question concerning the implementation of the findings of the Cumberlege Review in Wales. This is the formal response from the Minister for Health and Social Services, Vaughan Gething MS.
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Content ArticleA report on the investigation into the death of Elizabeth Dixon and a series of recommendations in respect of the failures in the care she received from the NHS.
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Content ArticleThis policy paper sets out the key elements of national support available for the social care sector for winter 2020 to 2021, as well as the main actions to take for local authorities, NHS organisations, and social care providers, including in the voluntary and community sector.Working together will ensure that high-quality, safe and timely care is provided to everyone who needs it, whilst protecting people who need care, their carers and the social care workforce from COVID-19.
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Content ArticleThis report sets out the progress and learning from the first phase of the COVID-19 pandemic in informing advice and recommendations to government and the social care sector. The Social Care Sector COVID-19 Support Taskforce was commissioned in June 2020, with this report seeing the completion of its work in August 2020. The taskforce was set up to oversee the delivery of two packages of support that the government had put in place for the care sector: the Social Care Action Plan and the Care Home Support Plan. In addition, the taskforce was asked to support the government's work on community outbreaks – areas of the country that needed particular help and intervention to deal with higher rates of infection – and advising and supporting local places to consider and respond to reducing the risk of infection in care homes and the wider social care sector. Its further remit was to provide advice on the requirements for the response to COVID-19 in the next few months, ahead of and into winter.
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Content ArticleThe Institute for Healthcare Improvement (IHI)-convened National Steering Committee for Patient Safety (NSC) has released a National Action Plan intended to provide US health systems with renewed momentum and clearer direction for eliminating preventable medical harm. Safer Together: A National Action Plan to Advance Patient Safety draws from evidence-based practices, widely known and effective interventions, exemplar case examples and newer innovations. The plan is the work of 27 influential federal agencies, safety organisations and experts, and patient and family advocates. The plan provides clear direction that health care leaders, delivery organisations, and associations can use to make significant advances toward safer care and reduced harm across the continuum of care.
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Content ArticleA framework has been developed by the Royal College of Obstetricians and Gynaecologists (RCOG), Royal College of Midwives and the Society and College of Radiographers, in partnership with NHS England and NHS Improvement, to support maternity services with the local reintroduction of hospital visitors and individuals accompanying women to appointments. This framework has been designed to assist NHS trusts to reintroduce access for partners, visitors and other supporters of pregnant women in English maternity services. It applies to inpatient and outpatient settings. Reintroducing visits is challenging during a pandemic, and the priority must be the safety of all service users (including pregnant women), staff and visitors.
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Content ArticleThis was a debate from the Scottish Parliament on the 8 September 2020 concerning the recommendations in the recently published First Do No Harm report by the Independent Medicines and Medical Devices Safety Review, chaired by Baroness Cumberlege (also known as the Cumberlege Review). The debate centred on a motion put forward by Jeane Freeman MSP, Cabinet Secretary for Health and Sport, which read as follows: That the Parliament welcomes the recommendations made by Baroness Cumberlege in her report on the independent medicines and medical devices safety review; acknowledges the Scottish Government's apology to women and families affected by Primodos, sodium valproate and transvaginal mesh; welcomes the Scottish Government’s commitment to establish a Patient Safety Commissioner, and notes the actions taken by the Scottish Government to offer improved services for women who have suffered complications as a result of transvaginal mesh.
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Content ArticlePatient Safety Learning’s formal response to the Healthcare Safety Investigation Branch’s (HSIB) report looking into a safety risk concerning guidelines around the use of personal protective equipment to reduce the risk of COVID-19 transmission when delivering care in people’s homes.
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Content ArticleThe case contains useful guidance for practitioners, healthcare providers and commissioners concerning when an inquest into the death of a vulnerable person at a care home will engage Article 2 ECHR.
