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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 ArticleLiving with dementia at any time brings everyday challenges for the person and those around them. Coronavirus is making daily life much harder. You may feel anxious, scared or lonely. But you are not alone – the Alzheimer's Society have collated guidance, tips and advice.
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Content ArticleSerious incidents not only have a considerable human impact, but they are also detrimental to NHS reputations and finances. The current Serious Incident Framework (SIF) is a reactive, bureaucratic process, where opportunities to reduce the recurrence of a harmful incidence is often missed. With a ‘Get It Right First Time’ mentality, the new PSIRF framework was road-tested by a number of nationally appointed ‘early adopter’ Trusts and commissioners working to implement it during the course of 2021. Now a wider implementation across the NHS is planned, starting spring 2022, with guidance informed by the early adopter pilots. This blog was written by Sian Williams, NHS Team Lead & Managing Consultant, and Paul Binyon, who in a recent assignment has worked with an NHS Trust contributing to an early adopter PSIRF pilot rollout.
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Content ArticleBipolar UK's 'Bipolar Minds Matter' report calls for an immediate restructure of the healthcare system that is failing millions affected by bipolar, and puts forward the case for developing a dedicated care pathway so that people with bipolar can have access to specialist treatment and continuity of support over a lifetime.
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Content Article
The dangerous practice of sending people with a mental illness hundreds of miles away from home for weeks at a time continues in England, according to new analysis published by the Royal College of Psychiatrists. Despite Government pledges to end the shameful practice, known as inappropriate out of area placements, by March 2021, almost 206,000 days have been spent by patients out of area in the 12 months since the deadline passed. Being far away from home, with friends and family not being able to visit, can leave patients feeling extremely isolated and emotionally distressed with devastating, long-lasting consequences for their mental health. Not only that, but it comes at a huge cost to the NHS. The health service spent £102 million on inappropriate out of area placements last year – the equivalent to the cost of the annual salary of over 900 consultant psychiatrists. The Royal College of Psychiatrists is calling on the NHS to adopt a ‘zero tolerance’ approach to inappropriate out of area placements and to take urgent action to ensure all patients get the care they need from properly staffed, specialist services in their local area. -
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 ArticleBased on extensive interviews with the leaders of seven trusts in the NHS providing good or outstanding care to people with a learning disability and people with autism, and broader ongoing engagement with trusts providing these services, this report from NHS Providers sets out in detail the common themes behind high-quality care, offering detailed case studies of how these services have succeeded.
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Content ArticleThe creation of a national network of medical examiners (MEs) was recommended in the Shipman inquiry and was alluded to in the Mid-Staffordshire and Morecambe Bay public inquiries. The Parliamentary Under-Secretary of State for Health, Lord O’Shaughnessy, confirmed in October 2017 that a national system of medical examiners will be introduced from April 2019. The ME reforms set out in the 2009 Coroners Act will be implemented nationally in two phases. By April 2019, NHS trusts should set up non-statutory schemes, based upon the national pilots (particularly in Leicester, Sheffield and Gloucester), funded in part from cremation form fees, in preparation for the commencement of a statutory scheme in 2020/21. A National Medical Examiner will be appointed, reporting directly to the National Director of Patient Safety.
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Content ArticleThe Academic Health Science Network’s (AHSN) plan 'Patient safety in partnership' has been developed to support the NHS Patient Safety Strategy and sets out how England’s 15 AHSNs, and the Patient Safety Collaboratives (PSCs) they host, will work more closely with their local health and care organisations to improve safety both in hospitals and community-based services such as care homes.
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Content ArticleThis toolkit supports the implementation of the Structured Judgement Review (SJR) process to effectively review the care received by patients who have died. This will allow learning and support the development of quality improvement initiatives when problems in care are identified. This toolkit also provides information and links to resources on change management and quality improvement methodologies.
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Content ArticleSince the Government initially consulted on the package of Death Certification Reforms, new information about how Medical Examiner (ME) system could be introduced has been generated by the Department of Health and Social Care (DHSC), ME pilot sites, early adopters of the ME system, as well as from the Learning from Deaths initiative. This case study outlines the approach of South Tees Hospitals NHS Foundation Trust as one of the early adopter sites.
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Content Article
Healthcare Safety Investigation Branch Annual Review 2019/20
Sam posted an article in HSSIB investigations
The Healthcare Safety Investigation Branch (HSIB) has published their third annual review. During 2019/20: 109 patient safety referrals received. 515 maternity investigation reports completed. 15 national investigation reports published. 58 national safety recommendations made. 88% of families engaging with the maternity investigations and 87% with the national investigations. Family information available in over 20 languages to ensure greater inclusivity. Keith Conradi, Chief Investigator, said: “There has been a huge amount of hard work from everyone within the HSIB during this period and I want to thank them and acknowledge the support of our stakeholders in the wider healthcare sector, and in particular to all the organisations who responded promptly to our safety recommendations.” -
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) report looks at the transfer of critically ill adults. It has previously been referred to as 'Cardiac and vascular pathways', but the original investigation was split. This is part one of the investigation and part two, with a focus on the clinical diagnosis of aortic dissection, is due to be published in Spring 2019.
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Content ArticleThe government needs to set out a contingent exit plan, involving carefully specified levels of lockdown, and the thresholds at which they would be triggered. This will allow businesses and people to plan, and begin to look to the future. This report from the Institute of Global Changes puts forward suggestions for a lockdown exit plan.
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Content ArticleSurgery is lifesaving or life-enhancing for millions of patients every year. However, the operation is not in itself an isolated ‘event’: it is part of a process which includes preparation and recovery. Ensuring the quality of the entire perioperative pathway is important to achieving the best possible outcome for every patient. This guidance is intended to be used by primary care, surgeons, anaesthetists, perioperative teams and preoperative assessment (POA) services. It applies to all patients who are being considered for surgery, or are on a waiting list for surgery in the non-emergency setting, irrespective of the magnitude of procedure or the type of anaesthesia contemplated. Its recommendations will support the care of individual patients, the recovery of elective services, and achieving key goals of the NHS Long Term Plan including reducing health inequalities and preventing serious health deterioration.
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Content ArticleThe aorta is the largest artery in the body. Acute dissection occurs when a spontaneous tear allows blood to flow between the layers of the wall of the aorta, which may then rupture with catastrophic consequences. There are about 2,500 cases per year in England, with around 50% of patients dying before they reach a specialist centre for care and 20-30% of patients dying before they reach any hospital. This Healthcare Safety Investigation Branch (HSIB) report highlights the difficulty which can face hospital staff in recognising acute aortic dissection. Although sudden severe chest or back pain is the most common symptom, the picture can vary or mimic other conditions, which may lead to an incorrect diagnosis or delays in recognising a life-threatening condition which needs urgent treatment.
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Content ArticleHow are trauma-informed approaches being implemented by public services – and what are the barriers to embedding the approach more widely? Produced jointly by the Centre for Mental Health and the Agenda, the alliance for women and girls at risk, this reports explores how trauma-informed approaches are being implemented by public services including women’s centres, prisons and mental health services. Evidence has shown that there are strong links between traumatic experiences and poor mental health. The need for public services to be trauma-informed has been repeatedly demonstrated. A sense of safety summarises the findings of interviews and site visits to a range of public services for women, including substance misuse, homelessness, mental health, the criminal justice system, and domestic and sexual abuse and exploitation. It found that services taking a holistic approach to supporting women’s needs were best able to make the change to becoming trauma-informed. However, many organisations faced barriers including short-term and fragile funding.
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Content ArticleTHIS Institute at the University of Cambridge has undertaken a rapid response project to develop an ethical framework for COVID-19 testing for NHS workers. It sought to identify and characterise the ethical considerations likely to be important to the testing programme, while recognising the tension between different values and goals. The project was guided by an expert group and by an online consultation exercise held between 27 May and 8 June 2020 to characterise the range and diversity of views on this topic. The 93 participants in the consultation included NHS workers in clinical and non-clinical roles, NHS senior leaders, policy-makers, and relevant experts. The project report emphasises that getting the COVID-19 swab testing programme for NHS workers right is crucial to support staff and patient safety and broader public health. It also recognises that COVID-19 does not affect all population groups equally. People who are socio-economically disadvantaged or members of Black, Asian and Minority Ethnic (BAME) groups may face distinctive issues in relation to testing.
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Content ArticleThis Healthcare and Safety Investigation Branch (HSIB) report explores the under recognised toxicity of propranolol in overdose. Propranolol is used to treat a number of medical conditions, including migraine, cardiovascular problems and the physical effects of anxiety. The case that prompted the investigation was Emma, a 24-year old woman, took an overdose of both propranolol and citalopram (an antidepressant). She called an ambulance, but her condition quickly worsened. Despite resuscitation efforts from both paramedics and medical staff in the hospital she was transferred to, Emma sadly died. There has been a steady rise in the number of propranolol prescriptions issued to NHS patients. Between 2012 and 2017 there was a 33% increase in the number of deaths reported as being linked to propranolol overdose, with 52 deaths recorded as having been linked to propranolol overdose in 2017.
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Content ArticleThis short guide, by the General Medical Council, provides patients with an overview of what they should be able to expect from the doctors providing their care. It is important that patients have clear expectations about the responsibilities and duties of doctors, particularly with regard to patient safety. This web-based resource offers a short, simply written and easily accessible overview that patients can be provided with, outlining the role of doctors in ensuring patient safety. This includes highlighting the importance of patients speaking up if they they safety is being compromised, the responsibility of doctors to report safety incidents, and the role of annual appraisals and peer review in monitoring safety.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) carried out a themed review of their maternal death investigations during the coronavirus (COVID-19) pandemic. The national learning reports can be used by healthcare leaders, policymakers, and the public to: Aid their knowledge of systemic patient safety risks. Understand the underlying contributing factors. Inform decision making to improve patient safety. Explore wider patient safety processes.
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Content ArticleIn healthcare, telling stories brings benefits to both storytellers and audience members, but also presents risks of harm. A reflective storytelling practice aims to honour stories and storytellers by ensuring there is time to prepare, reflect, learn, ask questions, and engage in dialogue with the storyteller to explore what went well and where there are learning and improvement opportunities. Healthcare Excellence Canada (HEC) is a pan-Canadian health organisation focused on improving the quality and safety of care in Canada. The HEC Patient Engagement and Partnerships team have co-developed these recommendations on how best to meaningfully share stories from those leading, providing and receiving care at Board meetings. This Case Study outlines the process HEC used to co-develop storytelling recommendations, focusing on a trauma-informed approach to create safe spaces for preparing, learning from and reflecting on stories, to clearly articulate their purpose, and to ensure the locus of control for storytelling rests with the storytellers.
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Content ArticleUK experts have issued an update on the timing of elective surgery and risk assessment after COVID-19 infection. Your operation may be delayed if you test positive for Covid-19. Studies of people who had COVID-19 just before or after their surgery show that they had more complications and an increased risk of dying. The risks of chest problems, blood clots or death are about 3 or 4 times greater for a full 7 weeks following COVID-19. These risks are increased even if the patient had no symptoms from COVID-19 (i.e. just a positive test).
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Content ArticleThe latest Healthcare Safety Investigation Branch (HSIB) report focuses on the life-threatening risk posed by the accidental misplacement of tubes that deliver food or medication to critically ill patients.
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Content ArticleThe Regulation and Quality Improvement Authority (RQIA) is the independent body responsible for regulating and inspecting the quality and availability of Health and Social Care services in Northern Ireland. The (RQIA) was commissioned to examine the application and effectiveness of the Procedure for the Reporting and Follow-up of Serious Adverse Incidents in Northern Ireland. The review was conducted by an Expert Review Team established by the RQIA and made five recommendations for implementation.
