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Content ArticleThe UK government and devolved administrations, along with the emergency services and other local responders, have clear responsibilities for identifying, assessing, preparing for and responding to emergencies, as well as supporting affected communities to recover. The government has risk management processes in place that aim to identify risks, to ensure that plans are drawn up to mitigate risks and prepare for shocks, and to prevent risks from being overlooked despite short-term pressures. Cabinet Office guidance states that preparedness is the preparation of plans that are flexible enough both to address known risks and to provide a starting point for handling unforeseen events. This report sets out the facts on: the government’s approach to risk management and emergency planning the actions the government took to identify the risk of a pandemic like COVID-19 the actions the government took to prepare for a pandemic like COVID-19 recent developments. The report sets out central government’s risk analysis, planning, and mitigation strategies prior to the arrival of the COVID-19 pandemic, with the aim of drawing out wider learning for the government’s overall risk management approach.
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Event
Priorities for NICE in health & social care
Patient Safety Learning posted an event in Community Calendar
untilThis Westminister Forum conference will discuss the priorities for NICE within health and social care following the publication of the NICE Strategy 2021 to 2026: Dynamic, Collaborative, Excellent earlier this year, which sets out NICE’s vision and priorities for transformation over the next five years, including: rapid and responsive evaluation of technology, and increasing uptake and access to new treatments flexible and up-to-date guideline recommendations which integrate the latest evidence and innovative practices improving the effective uptake of guidance through collaboration and monitoring providing scientific leadership through driving research and data use to address gaps in the evidence base. It will be an opportunity to discuss the role of NICE in a changing health and social care landscape following the pandemic, as well as the opportunities presented for guidance to keep pace with the development of integrated care, innovative treatments, and data-driven research and technology. Sessions in the agenda include: key priorities for delivering the future vision and transformation of NICE going forward developing evidence-based guidelines in a changing health and social care landscape: flexibility, patient engagement, collaboration, and effective implementation lessons learned from the use of rapid guidelines in response to COVID-19 the opportunities presented for improving the utilisation of data and the future for data-driven evidence and guidelines taking forward new approaches to evaluating health technology - speed, cost-effectiveness, and engagement priorities for industry engagement and improving value and access to innovative health technology supporting the development and adoption of innovative medicines the role of managed access and funding in delivering improved patient access to innovation opportunities for using research and data analytics to meet gaps in the evidence base. Register -
Content ArticleThe purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) is to help improve patient safety in relation to the management of patients with COVID-19 being treated with non-invasive respiratory support, for example continuous positive airway pressure (CPAP), in non-critical care settings. The HSIB investigation reviewed the experience of Terry, who was admitted to hospital with symptoms of COVID-19 and required support with is breathing using CPAP. On the second day after his admission to hospital, Terry was found on the floor next to his bed, having called for assistance. Terry’s CPAP tubing had become disconnected from his mask, meaning that Terry’s breathing was not supported. Staff attempted to resuscitate Terry, however they were unsuccessful, and he died.
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Content ArticleLast week the Professional Standards Authority for Health and Social Care published a new report, Reshaping regulation for public protection, outlining their view on the implications of the Health and Care Bill for professional regulation.[1] In this blog, Patient Safety Learning looks at this report in more detail and explores the key patient safety aspects of this.
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Content Article
House of Commons Debate - NHS Allergy Services (29 October 2021)
Mark Hughes posted an article in Allergies
This is the transcript of an Adjournment Debate from the House of Commons on the 29 October 2021 on NHS Allergy Services, tabled by Jon Cruddas MP. -
Content ArticleNICE has published its updated guideline on the diagnosis and management of myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome (ME/CFS). It is estimated that there are over 250,000 people in England and Wales with ME/CFS, with about 2.4 times as many women affected as men. The guideline covers every aspect of ME/CFS in children, young people and adults from its identification and assessment before and after diagnosis to its management, monitoring and review.
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Content ArticleThe purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) is to help improve patient safety in relation to the care of patients who have NHS-funded surgery in an independent hospital. This was initiated in the context of the COVID-19 pandemic, where because of increased pressure on the NHS, independent hospitals have been providing more care for NHS patients, including urgent elective surgical care and delivery of cancer pathways. The HSIB investigation reviewed the experience of a patient with a diagnosis of bowel cancer, who was booked to undergo laparoscopic (keyhole) surgery to remove part of his bowel in in an independent hospital. Following surgery, the patient made slow progress and on day eight following surgery he started to deteriorate rapidly. He was transferred to the local NHS hospital for investigation and further surgery. He died later the same day as a result of sepsis following a complication of his recent surgery.
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Content ArticleThe All Party Parliamentary Group for Allergy, in conjunction with the National Allergy Strategy Group (NASG), has launched a new report which calls for the appointment of an influential lead for allergy who can implement a new national strategy to help the millions of people across the UK affected by allergic disease. This report brings to Ministers’ attention the growing allergy epidemic and the lack of NHS services for people with allergic disease. 20 million people in the UK, a third of the population, are living with allergic disease with five million of these severe enough to require specialist care yet our allergy services remain inadequate, often hard to access and are failing those who need them the most. Change is required and is now long overdue. For the growing number of people living with allergic disease in the UK, their condition can have a significant and negative impact on their lives. It is frightening and restrictive to live with a condition which could cause a severe or life threatening reaction at any time.
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Content ArticleThis is an Early Day Motion tabled in the House of Commons on the 21st October 2021, which notes disappointment with the UK Government’s response to the Independent Medicines and Medical Devices Safety Review. The motion calls on the Government to reconsider its response and to implement all nine recommendations in their entirety, and to ensure patient safety remains paramount in any changes to regulatory approval frameworks.
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Content ArticleThis document provides guidance for maternity services and Local Maternity Systems on how to develop a local plan for achieving Midwifery Continuity of Carer as the default model of care offered to all women. The guidance sets out recommended practice, how delivery against these plans will be assured nationally, and how provision will be measured at provider and Local Maternity System level. Midwifery Workforce Tools designed to help midwifery leaders safely plan, simulate and design maternity services can be used alongside this guidance.
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Content Article
HSIB Maternity newsletter (May 2021)
Patient Safety Learning posted an article in HSSIB investigations
HSIB is pleased to present the first quarterly newsletter sharing learning from trusts across the whole of England. The purpose of this newsletter is to allow clinical teams and trusts to share the changes that have been made as a result of the findings and recommendations from maternity investigations undertaken by the Healthcare Safety Investigation Branch (HSIB). These initiatives were developed by the trusts and their maternity teams, we would like to thank them for sharing their work with others. This approach to collaborative learning supports trusts to share resources and improvement ideas that relate to similar concerns each trust experiences, as they strive to continually improve the care and safety of mothers and their babies. These examples of learning reflect what is being implemented in trusts with varying requirements to support their maternity services. This allows what is learnt in Newcastle to be known about in Penzance. -
News ArticleA third of stillbirths at two south Wales hospitals could have been prevented with better care or treatment, an investigation has concluded. It emerged two years ago that more than 60 women suffered the heartbreak of a stillbirth at at the Royal Glamorgan, Llantrisant, and Prince Charles Hospital, Merthyr Tydfil, and that many of these were never reported or investigated. An independent panel set up by the Welsh Government to oversee improvements in these maternity units has now concluded that many of these babies could have been saved. It looked at whether the care provided to women and their babies between January 2016 and September 2018 fell below the standards expected. The failures were split into different levels of severity, known in the report as "modifiable factors". Their investigation looked at 63 stillbirths between January 1, 2016, and September 30, 2018, and discovered that 21 (33%) of them had at least one "major modifiable factor", meaning the stillbirth could potentially have been avoided. More than half (59%) of the 63 had at least one "minor modifiable factor" while in three-quarters (76%) of them "wider learning" was required. In only four of the 63 stillbirths the panel found no modifiable factors. The panel also discovered that "areas for learning" were identified in 59 of the 63 episodes of care reviewed. Read full story Source: Wales Online, 5 October 2021 Read report
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Content Article
This is the second in a series of thematic reports to be published by the Independent Maternity Services Oversight Panel about their ongoing programme of independent clinical reviews of the maternity and neonatal care provided by the former Cwm Taf University Health Board. This report focuses on the care of mothers and their babies who were stillborn. It summarises the key themes and issues which emerged from the clinical review of 63 individual episodes of care which were provided by the Health Board between 01 January 2016 and 30 September 2018. -
Content ArticleThis Clinical Audit Guide has been written to help community and hospital pharmacists prepare for and conduct clinical audits. To view this guidance you need to be a Royal Pharmaceutical Society member.
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Content ArticleThis is the Government’s formal response to the recommendations made by the Health and Social Care Committee in its report, ‘The Safety of Maternity Services in England’. The Committee’s inquiry examined evidence relating to the safety of maternity services. It builds upon current investigations following incidents at East Kent Hospitals University Trust and Shrewsbury and Telford Hospitals NHS Trust, as well as the inquiry into the University Hospitals of Morecambe Bay NHS Trust. The inquiry also considered whether the clinical negligence and litigation processes need to be changed to improve the safety of maternity services and explored the impact of blame culture on learning from incidents.
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Content ArticleThe Health Information and Quality Authority (HIQA) has published its annual overview report of lessons learned from receipt of statutory notifications of accidental and unintended exposures to ionising radiation in 2020. This report provides an overview of the findings from these notifications and shares learnings from the investigations of these incidents.
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News Article
Pandemic changes affected maternity care for women who had stillbirths
Patient Safety Learning posted a news article in News
Changes to maternity services during the pandemic, including the mandatory redeployment of midwives and doctors to care for infected patients, may have affected the care given to women who had stillborn babies, a Healthcare Safety Investigation Branch (HSIB) investigation has found. The safety watchdog launched an investigation after the number of stillbirths after the onset of labour increased between April and June 2020. During the three months there were 45 stillbirths compared to 24 in the same period in 2019. The HSIB launched a probe examining the care of 37 cases. Among its findings the watchdog said staffing levels were affected because of the NHS response to the pandemic. In its report it said this “influenced normal work patterns and the consistency and availability of clinicians.” As an example, in one maternity unit the staffing numbers were short by three midwives due to sickness and redeployment. In another consultant presence was reduced overnight. During the pandemic both the Royal College of Midwives and the Royal College of Obstetricians criticised NHS trusts for redeploying maternity staff when mothers continued to need services regardless of the pandemic. HSIB said none of the women in its report were recorded as having the virus, but it found the pressures and changes as a result of the pandemic may have affected the care they received. The study stressed that the proportion of consultations undertaken remotely was not known and "the impact of remote consultations is not clear from this review". Read full story Source: The Independent, 16 September 2021 -
Content ArticleThe number of intrapartum stillbirths referred to the Healthcare Safety Investigation Branch (HSIB) between April and the end of June 2020 increased compared to the same time in the previous year. The data initiated a HSIB national learning report, which explores the findings from their maternity investigations during this time. They investigated intrapartum (labour) stillbirths after 37 weeks, where a baby was thought to be alive at the start of labour and was born with no signs of life.
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News Article‘Very heavy-handed, laborious and expensive’ inspections ‘have not been the right way’ of regulating hospitals, according to the Care Quality Commission’s (CQC) former chair. Speaking at a Royal Society of Medicine event on Wednesday, Lord David Prior, who is now the chair of NHS England, said “very few” physicians will have improved their work after reading a report from the regulator. He added that there is a role for the CQC to move in when “things are going wrong” although he is “sceptical” the regulator can actually drive improvement in hospitals. Lord Prior said: “I am highly sceptical as to whether or not CQC or any regulator can really drive improvement and drive the top hospitals to make them better. “And certainly I think there’ll be very few physicians who will say that their clinical work has improved as a result of reading a CQC report. “I think the sadness I have about CQC is that we have not been able, or it has not been able, to develop a series of predictive metrics that could replace these very heavy handed, very laborious and very expensive visits that we used to do.” Read full story (paywalled) Source: HSJ, 9 September 2021
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Content ArticleThis document sets out guidelines for recommended nurse/midwife to patient ratios in the Kingdom of Saudi Arabia. It describes the rationale for introducing national regulations for safe staffing ratios, considers concerns and challenges in this respect, and then outlines specific ratios in different areas of care. This has been produced by the Saudi Patient Safety Center, in collaboration with the Saudi Commission for Health Specialties and the Saudi Nurses Association.
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Content Article
NHS England Clinical Audit webpage
Patient-Safety-Learning posted an article in Clinical governance and audits
This webpage contains information about local and national clinical audits including: The National Clinical Audit and Patient Outcomes Programme (NCAPOP) National Quality Improvement and Clinical Audit Network (NQICAN). -
Content Article
HSIB maternity programme year in review 2020/21 (August 2021)
Mark Hughes posted an article in HSSIB investigations
This report provides a review of the Healthcare Safety Investigation Branch (HSIB) maternity investigation programme during 2020/21, including an overview of activity during this period, themes arising from investigations and plans for the future. It is intended for healthcare organisations, policymakers and the public to understand the work HSIB have undertaken. -
Content ArticleThe Royal College of Obstetricians and Gynaecologists reviewed maternity care at two hospitals: The Royal Glamorgan hospital Prince Charles hospital The report makes recommendation on improvements to ensure the safety of mothers and babies. "During interviews and in group sessions the assessors were repeatedly and consistently told by staff of a reluctance to report patient safety issues because of a fear of blame, suspension or disciplinary action." "The assessors found little evidence among staff at all levels and professional backgrounds, of a coherent approach towards patient safety, or an understanding of their roles and responsibilities towards patient safety beyond the care they provided for a specific woman or group of women. This perception extended to senior members of midwifery and medical staff."
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Content ArticleIn this article, published by the Harm & Evidence Research Collaborative, Sharon Hartles examines the UK Government’s response in relation to the implementation of the recommendations set out in the Independent Medicines and Medical Devices Safety Review, First Do No Harm report. She explores how the Government’s response has impacted on those harmed by the side effects of Primodos, Mesh and Sodium Valproate.
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Content Article
Thought piece on the Ockenden Report by Susan Stanford
Patient Safety Learning posted an article in Maternity
People with an interest in patient safety read the interim Ockenden report with despair. It was immediately and starkly apparent that it repeated many of the common themes which have emerged in other patient safety investigations. Many of the recommendations in the Ockenden report were already covered by national guidance, Susan Stanford asks why the guidance wasn’t followed and whether it might not be being followed elsewhere.
