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Content Article
How can Parliament make health and care safer for all? (4 November 2022)
Mark Hughes posted an article in Others
In this blog for the cross-party think tank Policy Connect, the Professional Standards Authority for Health and Social Care sets out its view on the biggest challenges affecting the quality and safety of health and social care outlined in its report Safer care for all - solutions from professional regulation and beyond. It describes gaps in the wider framework to protect the public highlighted in this report and considers where Parliament and the Government have an opportunity to act to support safer care for all. Related reading Patient Safety Learning: Joining up a fragmented landscape: Reflections on the PSA report ‘Safer care for all’ (12 September 2022) Working together to achieve safer care for all: a blog by Alan Clamp (12 September 2022) -
Content ArticleIn 2021-22 the House of Commons Health and Social Care Select Committee held an inquiry into Cancer services, asking for evidence of why cancer outcomes in England continue to lag behind comparable countries internationally and examine evidence relating to the underlying causes of these differences. This document was submitted by Pancreatic Cancer UK as part of the call for written evidence in this inquiry.
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Content ArticleIf you want to find out what the new Patient Safety Incident Response Framework is all about, and how it will support the NHS to learn and improve, this video provides a helpful introduction.
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Content ArticleThe Hyponatraemia Inquiry is the longest-running public inquiry in recent history: its report was delivered in January 2018, without fanfare. Yet its very existence has gone unnoticed. Marcus Shepheard argues that there are important lessons to be learned for other public inquiries – and for government.
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Content Article
In this short blog, Patient Safety Learning sets out its initial response to the publication of the report of the independent investigation into maternity and neonatal services at the East Kent Hospitals NHS Foundation Trust.- Posted
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Content ArticleIn February 2020 the UK Government commissioned Dr Bill Kirkup to undertake a review into maternity and neonatal care services between 2009 and 2020 in two hospitals, the Queen Elizabeth The Queen Mother Hospital (QEQM) at Margate and the William Harvey Hospital (WHH) in Ashford. Both these services fall under the East Kent Hospitals NHS Foundation Trust. The report found that over this period those responsible for these services too often provided clinical care that was suboptimal and led to significant harm, failed to listen to the families involved, and acted in ways which made the experience of families unacceptably and distressingly poor. It identifies four key areas for action which must be addressed to improve patient safety in maternity and neonatal care services.
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Content ArticleA thematic review can identify patterns in data to help answer questions, show links or identify issues. Thematic reviews typically use qualitative (e.g, open text survey responses, field sketches, incident reports and information sourced through conversations and interviews) rather than quantitative data to identify safety themes and issues. Thematic reviews can sometimes use a combination of qualitative data with quantitative data. Quantitative data may come from closed survey responses or audit, for example. These top tips support health and social care staff to carry out thematic reviews, but organisations may take different approaches, depending on the purpose and scope of their review.
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Content ArticleThe All Party Parliamentary Group on Menopause (the APPG), chaired by leading parliamentary campaigner Carolyn Harris MP, has published its final report following a year-long inquiry into the subject. The MPs findings demonstrate that widespread action is needed across all spheres to improve the situation for those going through the menopause, and the families, friends and colleagues affected by it. Menopause symptoms can have a debilitating impact on the day-to-day lives of women. Whether from the inability to get the right diagnosis at the right time, difficulties in accessing HRT, a lack of support from their employer while struggling at work, or simply not being able to recognise what is happening to them and their bodies and seek help. Despite the fact that 51% of the population will experience the menopause, the entrenched taboo around women’s health issues has meant that the support for the 13 million women currently going through peri-menopause or menopause is completely inadequate. The APPG is particularly concerned about the socio-economic divide emerging between women who are able to access the right treatment, and those who lose out in the postcode lottery and do not have the financial means to seek treatment elsewhere.
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Content ArticleThis report from Skills for Care provides a comprehensive analysis of the adult social care workforce in England and the characteristics of the 1.50 million people working in it. Topics covered include recent trends in workforce supply and demand, employment information, recruitment and retention, demographics, pay, qualification rates and future workforce forecasts.
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Content ArticleOn 23 April 2020 Jaqueline Lake commenced an investigation into the death of Eliot Harris aged 48. Eliot had schizophrenia and diabetes. Eliot had not been taking medication for several days and his condition deteriorated. He was admitted to Northgate under the Mental Health Act after assessment on 5 April. He was initially in seclusion then on the ward from 6 April, he spent a lot of time in his room and only ate cheese sandwiches. He only accepted medication in intramuscular form and on 9 April by depot injection. His physical observations were recorded as being normal, and a blood test on 7 April showed he did not have diabetes. His intake of food and fluid remained minimal but he was not put on a chart to monitor this. Staff last entered his room at 17:46 on 9 April. He was last seen conscious at 18:10 on 9 April. He was found unresponsive at 01:33 and declared dead at 02:00. The investigation concluded at the end of the inquest on 8 August 2022. Medical cause of death: 1a) Unascertained Conclusion: Open – the evidence does not reveal the means by which Eliot Harris came by his death.
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Content ArticleThis article in The Milbank Quarterly summarises an extensive literature review addressing the question, "How can we spread and sustain innovations in health service delivery and organisation?" The authors identify three key outputs of the systematic review: A parsimonious and evidence-based model for considering the diffusion of innovations in health service organisations Clear knowledge gaps on which further research on the diffusion of innovations in service organisations should be focused A robust and transferable methodology for systematically reviewing complex research evidence
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Content ArticleHealthcare Inspectorate Wales (HIW) is the independent inspectorate of the NHS and regulator of independent healthcare in Wales. This annual report highlights key findings from HIW's regulation, inspection and review of healthcare services in Wales. It demonstrates how HIW carried out its functions and outlines the number of inspections and quality checks it undertook during 2021-22.
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EventuntilBased on the participant feedback and interest in the 'Reimagining Healing after Harm: the Potential for Restorative Practices' webinar, Patients for Patient Safety Canada is pleased to offer this follow up session. Restorative practices involve inclusive democratic dialogue between all those affected by healthcare harm. They are guided by concern to address harms, meet needs, restore trust, and promote repair or healing for all involved. This webinar will further explore New Zealand's approach to healing after healthcare harm from surgical mesh: What was the impetus for a restorative approach? What inspired the choice of a relationship-centric and reconciliatory model? How did restorative practices support the co-design process between consumer advocates and Ministry of Health representatives? How do restorative approaches support New Zealand's commitment to Te Tiriti o Waitangi- The treaty that determines the partnership between the Crown and indigenous peoples? It will follow with a participant discussion about what this means for Canada. Further information and registration
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Content ArticleDr Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, interviews Robyn Begley, Chief Executive Officer, American Organization for Nursing Leadership (AONL), and Senior Vice President and Chief Nursing Officer, AHA, around her most recent discoveries in the COVID-19 pandemic. The team conducted a study with over 1,800 participants, ranging from nursing staff to hospital administrators, on the effects of COVID-19 and the challenges and fallbacks that occurred during three periods of the pandemic. After discussion of results, recommendations are proposed for supporting hospitals and healthcare workers.
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Content ArticleIn this video, Barts Health NHS Trust explain what measures frontline medical staff can take to help avoid the risk of pressure ulcers.
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Content ArticleParty leaders have written an open letter to Boris Johnson asking him to ensure recommendations made by Baroness Cumberlege are put in place. It's more than three months since her review found three treatments - mesh, primodos and sodium valproate - ruined thousands of lives.
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Content ArticleIdentifying improvements in maternity care to help reduce the risk of delays in crucial interventions during labour when a baby is suspected to be unwell is the focus of this latest Healthcare Safety Investigation Branch (HSIB) report. The report was compiled after a review of 289 of our maternity investigations into intrapartum stillbirths, neonatal deaths and potential severe brain injuries. In 14.9% of the cases the delay was a contributory factor. The review identified issues such as inadequate staffing, poor infrastructure and high workload as contributory factors to the delays. Evidence from national reports confirms that such delays are a recognised patient safety risk.
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Content ArticleThe 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.
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Content ArticleKeith Conradi, Chief Investigator at the Health Service Investigation Branch, presented at the Patient Safety Learning Conference on HSIB’s challenges and achievements in its first year.
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Content ArticleSocial care in England is at a crossroads. All three major political parties in the 2019 general election have recognised in their manifestos that the social care system is in need of change. So what needs to be done?
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Content ArticleThe objective of this investigation was to explore the care of patients who have ureteric stents inserted following a diagnosis of a kidney or ureteric stone. A ureteric stent is a narrow tube that is inserted into the ureter (the tube that connects the kidney to the bladder) to help with urine drainage. The reference event investigated was a woman who suffered an episode of kidney stones which was treated successfully but required the insertion of a ureteric stent. The stent was left in situ (in position) for a longer period than intended and became encrusted – that is, minerals filtered from the bloodstream attached to and built up on the stent. This led to the patient needing a more extensive operation to remove the stent. The findings and conclusions aim to prevent the future occurrence of unplanned delayed removal of stents and improve care for patients across the NHS.
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Content ArticleThe work presented here was undertaken by the OECD to provide a strategic background report for the Patient Safety Priority within the G20 Health Working Group (HWG) 2020. It was commissioned by the Saudi Government. ‘"Acting on patient safety requires leadership and communication, political will, and investment. Transparency across a health system is also integral to begin improving safety and reducing harm. This can only be achieved through investing in a modern information infrastructure, but also relies on sound governance, accountability and proactive leadership. The analysis is clear: unsafe care kills millions, and harms tens of millions of people each year. It also exerts a great economic cost on health systems and society, consuming valuable resources that could be put to productive uses elsewhere. Much of this can be prevented through concerted action and adequate investment. The time for action is now."
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Content ArticleA report by Fiona Ritchie OBE, Chair on behalf of Oliver’s Independent Panel for NHS England and NHS Improvement, has been published following an investigation into Bristol, North Somerset and South Gloucestershire clinical commissioning group’s Learning Disability Mortality Review (LeDeR) review into the death of Oliver McGowan.
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Content ArticleThe British Thoracic Society has published the results of their 2019 national audit of acute non-Invasive ventilation (NIV) in adult patients in NHS hospitals. Data were collected in 2019, before the pandemic, and the audit did not look at things such as pandemic preparedness or numbers of NIV hardware available, but at the quality of the service provided. The audit analysed data provided from over 150 hospitals, for a total of over 3500 patient records, and looked for adherence to our quality standards in the provision of the service.
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Content ArticleAn Inquiry by the All Party Parliamentary Group (APPG) on Endometriosis has highlighted the devastating impact endometriosis can have on all aspects of a person’s life, and urges Ministers to take bold action to ensure those with endometriosis have access to the right care at the right time. The inquiry surveyed over 10,000 people with endometriosis, interviewed healthcare practitioners and those with the condition about their experiences.
