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Found 479 results
  1. News Article
    A hospital A&E department has been rated "inadequate" after inspectors found patients at "high risk of avoidable harm". The Care Quality Commission (CQC) reported a "range of regulation breaches" and a shortage of nurses at Stepping Hill hospital's A&E unit. It also criticised maternity and children's services. Stockport NHS Foundation Trust's chief executive said the trust had taken "immediate steps" to improve. The CQC inspected Stepping Hill Hospital in January and February and found A&E performance "had deteriorated significantly" since its last inspection in 2018. Inspectors found shortcomings "relating to patient-centred care, dignity and respect, safe care and treatment, environment and equipment, good governance, and staffing". Their report said the service "could not assure itself that staff were competent for their roles" and patient outcomes "were not always positive or met expectations in line with national standards". Read full story Source: BBC News, 19 May 2020
  2. News Article
    A joint letter from the Health Foundation, The King’s Fund and Nuffield Trust has been delivered to the Health and Social Care Select Committee identifying five key aspects which need addressed ahead of their evidence session on delivering core NHS and care services during and beyond the coronavirus pandemic. Health and Social Care Secretary Matt Hancock told the House of Commons on 22 April 2020 that the pandemic had reached its peak and talked of his intention to ‘gradually reopen’ the NHS as soon as it was safe to do so. For the joint authors of the letter, before any services look to begin being restarted key areas need addressed including a reliable supply of PPE to protect staff and a clear understanding within the system of the full extent of unmet need – particularly important as at present, from a big picture view, it is not clear how many services have been suspended. The joint letter puts five key questions to the Select Committee to address: How and when will appropriate infection prevention and control measures be available for all settings delivering care, and what impact will these have on capacity to reopen? How will the system understand the full extent of unmet need? How will the public’s fear of using NHS and social care services be reduced? What is the strategy for looking after and growing the workforce? Can the system improve as it recovers? Read full story Source: National Health Executive, 14 May 2020
  3. News Article
    “Recurrent safety risks” around clinical care at an embattled NHS trust’s maternity service have been identified in a report published on Tuesday. The Healthcare Safety Investigation Branch (HSIB) has been investigating East Kent hospitals university NHS foundation trust since July 2018 after a series of baby deaths. Among those treated at the trust was Harry Richford, whose death was “wholly avoidable”, seven days after his emergency delivery in November 2017, an inquest found. Speaking on Tuesday, Harry’s grandfather Derek Richford said it is clear that sufficient lessons were not learned from his death. The independent report, published on Tuesday by the Department of Health and Social Care, 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.” Read full story Source: The Guardian, 8 April 2020
  4. News Article
    The Independent Inquiry into the issues raised by Paterson is yet another missed opportunity to tackle the systemic patient safety risks which lie at the heart of the private hospital business model, says David Rowland from the Centre for Health and the Public Interest in a recent BMJ Opinion article. Although the Inquiry provided an important opportunity for the hundreds of patients affected to bear witness to the pain and harm inflicted upon them it fundamentally failed as an exercise in root cause analysis. None of the “learning points” in the final report touch on the financial incentives which may have led Paterson to deliberately over treat patients. Nor do they cover the business reasons which might encourage a private hospital’s management not to look too closely. He suggests that the Inquiry report threw the responsibility for managing patient safety risks back to the patients themselves in two of its main recommendations but that it should be for the healthcare provider first and foremost to ensure that the professions that they employ are safe, competent and properly supervised, and for this form of assurance to be underpinned by a well-functioning system of licensing and revalidation by national regulatory bodies. Read full story Source: BMJ Opinion, 20 February 2020
  5. News Article
    An NHS trust has been criticised for advising pregnant women to stay at home for as long as possible during labour to increase the chances of a “normal birth”. University Hospitals Bristol NHS Trust also suggested mothers should avoid having epidurals or inductions and should try to have a home birth. The advice has been described as “shocking” by experts, who said the guidance was contrary to evidence and could be “dangerous” for mothers and babies. Others criticised the language used by the trust which suggested women who needed medical help were somehow “abnormal”. Earlier this month, the Bristol trust paid out £5.8m in compensation to the family of a six-year-old boy after he was left brain damaged at birth following complications during labour. After being contacted by The Independent, the trust deleted the childbirth advice from its website and accepted it was “outdated”. Read full story Source: The Independent, 13 February 2020
  6. News Article
    The toxicity of a commonly prescribed beta blocker needs better recognition across the NHS to prevent deaths from overdose, a new report warns today. The Healthcare and Safety Investigation Branch (HSIB) report focuses on propranolol, a cardiac drug that is now predominately used to treat migraine and anxiety symptoms. It is highly toxic when taken in large quantities and patients deteriorate quickly, making it difficult to treat. The investigation highlighted that these risks aren’t known widely enough by medical staff across the health service, whether issuing prescriptions to at risk patients, responding to overdose calls or carrying out emergency treatment. Dr Stephen Drage, ICU consultant and HSIB’s Director of Investigations, said: “Propranolol is a powerful and safe drug, benefitting patients across the country. However, what our investigation has highlighted is just how potent it can be in overdose. This safety risk spans every area of healthcare – from the GPs that initially prescribe the drug, to ambulance staff who respond to those urgent calls and the clinicians that administer emergency treatment." The report also emphasises that there is a link between anxiety, depression and migraine, and that more research is needed to understand the interactions between antidepressants and propranolol in overdose. Read full story Source: HSIB, 6 February 2020
  7. News Article
    The new executive must act urgently if it is to "divert the current mental health epidemic among young people", Northern Ireland's children's commissioner has said. Koulla Yiasouma said progress in implementing recommendations in a report on children and young people's mental health services, produced 12 months ago, had been "too slow". The stark read captured the scale of youth mental health problems in Northern Ireland. The report found that young people are waiting too long to ask for help and even longer to access the right support. Health Minister Robin Swann said his aim was that young people do not wait longer than nine weeks to see a CAMHS (child and adolescent mental health services) professional."I take the mental health and wellbeing of our children and young people very seriously and I am committed to working with my colleagues in a new executive working group on mental well-being, resilience and suicide prevention," he said. Read full story Source: 6 February 2020
  8. News Article
    Shipman, Mid Staffordshire, Morecambe Bay, and now Ian Paterson, the breast surgeon that performed botched and unnecessary operations on hundreds of women. The list of NHS-related scandals has got longer. It's tempting to say the health service has not learned lessons even after a string of revelations and reviews. But is that fair? asks BBC Health Editor Hugh Pym. The inquiry, chaired by Bishop Graham James, makes clear there were failings at every level of a dysfunctional health system when it came to patient safety. The public and private health systems did not compare notes about suspicious behaviour by a consultant. Staff working with Paterson thought that his surgical methods were unusual but, perhaps cowed by being ignored after raising concerns, kept their heads down. Add to that the power and status of a surgeon in the medical world and, in the words of the report, Paterson was "hiding in plain sight". So could it happen again? James says it's clearly impossible to eliminate the activities of determined criminals in any profession. He acknowledges that some improvements have been made on policing. But he says that a decade on from the Paterson scandal, he is not convinced that medical regulators, with a combined budget of half a billion pounds a year, are doing enough collectively or collaboratively to make the system safe for patients. The review chair notes tellingly that while regulators spoke of major improvements which should identify another Paterson, some doctors and nurses had told the inquiry that it was "entirely possible that something similar could happen now". Read full story Source: BBC News, 4 February 2020
  9. News Article
    A culture of "avoidance and denial" allowed a breast surgeon to perform botched and unnecessary operations on hundreds of women, an independent inquiry has found. The independent inquiry into Ian Paterson's malpractice has recommended the recall of his 11,000 patients for their surgery to be assessed. Paterson is serving a 20-year jail term for 17 counts of wounding with intent. One of Paterson's colleagues has been referred to police and five more to health watchdogs by the inquiry. The disgraced breast surgeon worked with cancer patients at NHS and private hospitals in the West Midlands over 14 years. His unregulated "cleavage-sparing" mastectomies, in which breast tissue was left behind, meant the disease returned in many of his patients. Others had surgery they did not need - some even finding out years later they did not have cancer. Patients were let down by the healthcare system "at every level" said the inquiry chair, Bishop of Norwich the Rt Revd Graham James, who identified "multiple individual and organisational failures". One of the key recommendations from the report is that the Government should make patient safety a the top priority, given the ineffectiveness of the system identified in this Inquiry. Read full story Source: BBC News, 4 February 2020
  10. News Article
    The failure to pass a damning report about a scandal-hit hospital trust to the care watchdog has been criticised by the man who led the inquiry into baby deaths at Morecambe Bay. On Friday, a coroner ruled that the death of baby Harry Richford in 2017 resulted from neglect in the maternity unit of East Kent Hospitals NHS Trust. A report by the Royal College of Obstetrics and Gynaecologists (RCOG) completed a year earlier had warned of issues that contributed to Harry’s death, including senior doctors not showing up for their shifts. However, the report was never passed on to the Care Quality Commission (CQC), despite the recommendation of the Morecambe Bay inquiry in 2015 that relevant external reviews should be passed on to the watchdog. Bill Kirkup, who chaired the inquiry into deaths of mothers and babies at Furness General Hospital in Barrow-in-Furness, told The Independent: “When there is sufficient concern about a service to prompt an external review, the report must be available immediately to those responsible for assuring the quality of the service. That was the reason for the recommendation of the Morecambe Bay investigation, and it is disappointing that the Care Quality Commission apparently had no sight of this report until now.” Read full story Source: 26 January 2020
  11. News Article
    The Care Quality Commission (CQC) missed multiple opportunities to identify abuse of patients at a privately run hospital and did not act on the concerns of its own members, an independent review has found. Bosses at the CQC have been criticised in an independent report by David Noble into why the regulator buried a critical report into Whorlton Hall hospital, in County Durham, in 2015. His report published today said the CQC was wrong not to make public concerns from one of its inspection teams in 2015. “The decision not to publish was wrong,” his report said, adding: “This was a missed opportunity to record a poorly performing independent mental health institution which CQC as the regulator, with the information available to it, should have identified at that time.” Read full story Source: The Independent, 22 January 2020
  12. News Article
    Up to half of all patients who suffer an acute aortic dissection may die before reaching crucial specialist care, according to a new Healthcare Safety Investigation Branch (HSIB) report. The report highlights the difficulty which can face hospital staff in recognising acute aortic dissection. The investigation was triggered by the case of Richard, a fit and healthy 54-year old man, who arrived at his local emergency department by ambulance after experiencing chest pain and nausea during exercise. It took four hours before the diagnosis of an acute aortic dissection was made, and he spent a further hour waiting for the results of a CT scan. Although Richard was then transferred urgently by ambulance to the nearest specialist care centre, he sadly died during the journey. The report has identified a number of risks in the diagnostic process which might result in the condition being missed. These include aortic dissection not being suspected because patients can initially appear quite well or because symptoms might be attributed to a heart or lung condition. It also highlighted that, once the diagnosis is suspected, an urgent CT scan is required to confirm that an acute aortic dissection is present. Gareth Owens, Chair of the national patient association Aortic Dissection Awareness UK & Ireland, welcomed the publication of HSIB’s report, saying: “HSIB’s investigation and report have highlighted that timely, accurate recognition of acute Aortic Dissection is a national patient safety issue. This is exactly what patients and bereaved relatives having been telling the NHS, Government and the Royal College of Emergency Medicine for several years." Read full story Source: HSIB, 23 January 2020
  13. News Article
    One of the country’s smallest trusts recorded 277 serious incidents over a two-year period, HSJ can reveal. Delays in treatment, missed diagnoses, adverse media coverage and “suboptimal” care were among the hundreds of serious incidents reported at the struggling Isle of Wight Trust from the start of 2018 and up to November 2019. There were also two never events in 2019 — a “wrong site” surgery and an incident in which a patient was mistakenly connected to an air flow meter, rather than an oxygen supply. The trust said the level of incidents did not neccessarily reflect poor care, and did not mean patients had come to harm. The trust was placed in special measures in April 2017 after it was rated “inadequate” by the Care Quality Commission due to “significant” concerns over patient safety. It was upgraded to “requires improvement” in September 2019, but remains in special measures. Read full story (paywalled) Source: HSJ, 22 January 2020
  14. News Article
    Ten years on from the Mid Staffordshire NHS trust scandal, the man who led the inquiry into one of the worst care disasters in the service’s history has said he remains worried about the safety of patients and a culture that leaves staff too frightened to speak up. Sir Robert Francis QC said some safety risks highlighted a decade ago remain unresolved and he threw his weight behind calls for senior managers in the NHS to be regulated. The barrister said he believed the NHS was safer now than a decade ago but added he worried whether actions taken since the disaster had made a real difference. “What keeps me awake at night is not so much has anyone implemented recommendation 189 or not, but more whether the collectivity of what has happened since has actually resulted in things being better for patients and staff,” he told The Independent. Read full story Source: The Independent, 15 January 202
  15. News Article
    A backlog of thousands of deaths of people with learning disabilities awaiting official review has grown further, despite NHS England committing in spring last year to “address” the buildup. Information obtained by HSJ shows the number of incomplete reviews increased slightly between May and November last year – from 3,699 to 3,802. The “national learning disabilities mortality review” programme – known as LeDeR – was launched in 2016 and is meant to review all deaths of people aged four and over. Mencap head of policy and public affairs, Dan Scorer, said: “It is unacceptable that thousands of deaths have still not been reviewed despite NHS England announcing further funding to make sure all reviews were carried out quickly and thoroughly. These latest figures show that little progress has been made; the programme is still failing to address outstanding reviews as well as keep pace with incoming referrals." “Behind these figures are families whose loved ones’ deaths may have been potentially avoidable and they have a right to know that health and care services are learning and acting on LeDeR reviews’ recommendations.” Read full story (paywalled) Source: HSJ, 8 January 2020
  16. News Article
    A hospital A&E department has been rated "inadequate" after warnings over urgent and emergency care. The Care Quality Commission (CQC) reported a lack of support for staff and safety concerns in Weston General hospital's A&E department. Dr Nigel Acheson, deputy chief inspector of hospitals for the South NHS , said it was "disappointing". Weston Area Health NHS Trust "fully recognises that while improvements have been made... further work is required." Read full story Source: BBC News, 17 December 2019
  17. News Article
    European clinical guidelines on how to treat a major form of heart disease are under review following a BBC Newsnight investigation. Europe's professional body for heart surgeons has withdrawn support for the guidelines, saying it was "a matter of serious concern" that some patients may have had the wrong advice. Guidelines recommended both stents and heart surgery for low-risk patients, but trial data leaked to Newsnight raises doubts about this conclusion. Thousands of people in the UK and hundreds of thousands worldwide will be treated for left main coronary artery disease each year. This is a narrowing of one of the main arteries in the heart. The guidelines on how to treat it were largely based on a three-year trial to compare whether heart surgery or stents – a tiny tube inserted into a blocked blood vessel to keep it open – was more effective. The trial called Excel started in 2010 and was sponsored by big US stent maker, Abbott. Led by US doctor Gregg Stone, the study and aimed to recruit 2,000 patients. Half were given stents and the other half open heart surgery. Success of the treatments was measured by adding together the number of patients that had heart attacks, strokes, or had died. The research team used an unusual definition of a heart attack, but had said that they would also publish data for the more common "Universal" definition of a heart attack alongside it. There is debate around which is a better measure and the investigators stand by their choice. In 2016, the results of the trial for patients three years after their treatments were published in the New England Journal of Medicine. The article concluded stents and heart surgery were equally effective for people with left main coronary artery disease. But researchers had failed to publish data for the common, "Universal" definition of a heart attack. Newsnight has seen that unpublished data and it shows that under the universal definition, patients in the trial that had received stents had 80% more heart attacks than those who had open heart surgery. The lead researchers on the trial have told Newsnight that this is "fake information". But Newsnight has spoken to experts who say they believe the data is credible. Read full story Source: BBC News, 9 December 2019
  18. Content Article
    Yakob Seman Ahmed, former Director General for Medical services in Ethiopia and the chair of national patient safety task force, and a recent Humphrey fellow, Public Health Policy, at the Virginia Commonwealth University, reflects on Patient Safety Learning's recent report 'Mind the implementation gap: The persistence of avoidable harm in the NHS' and the similar challenges Ethiopia faces in implementing its own standards and policies.
  19. Content Article
    Patient safety alerts are issued to providers of NHS care to support them to take specific actions to keep patients safe. Although some content of past alerts is outdated, some of the actions from previously issued alerts continue to be relevant and remain valid beyond the timescales of the original alert. Over 140 alerts issued up to November 2019 (including ‘notices’ or ‘rapid response reports’) were recently clinically reviewed to identify which actions within those alerts remain valid and should be considered as ‘enduring standards’. The review covered alerts issued by the NHS England and NHS Improvement National Patient Safety Team and its predecessor organisation, the National Patient Safety Agency (NPSA). The review also summarised other content from the alerts identified as general principles that can be applied more widely to inform wider ongoing safety improvement. The key elements from the review are highlighted. The pages do not set out any new actions for organisations to implement, but act as an aid to support providers to confirm that ‘enduring standards’ from previously completed alerts have been embedded locally, and that the general principles are considered within ongoing patient safety improvement.
  20. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation explores the care of patients who present to child and adolescent mental health services (CAMHS) with questions about their gender identity and are referred to specialised gender dysphoria services. Gender dysphoria is a sense of unease, distress or discomfort that a person may have because of a mismatch between their biological sex and their gender identity. For example, a child who is registered as male at birth might feel or say that they are a girl, or feel that neither ‘boy’ nor ‘girl’ are the right word to describe how they feel about themselves. Gender dysphoria is not identified as a mental illness by the NHS, but some people may develop mental health problems because of gender dysphoria.
  21. Content Article
    In this report, Patient Safety Learning highlights a patient safety implementation gap in the UK that results in the continuation of avoidable harm. It focuses on six specific policy areas where the implementation gap acts as barrier to patient safety improvement and calls for system-wide action in healthcare to transform our approach to learning and safety improvement. It also details six specific recommendations relating to policy areas identified in the report. This article contains a summary of the report, which can be read in full here.
  22. Content Article
    Government must take a cautious and evidence-based approach to exiting the pandemic, factoring in six key elements for a fail-safe exit strategy.
  23. Content Article
    This World Health Organization (WHO) guideline aims to improve the quality of essential, routine postnatal care for women and newborns with the ultimate goal of improving maternal and newborn health and well-being. It recognises a “positive postnatal experience” as a significant end point for all women giving birth and their newborns, laying the platform for improved short- and long-term health and well-being. A positive postnatal experience is defined as one in which women, newborns, partners, parents, caregivers and families receive information, reassurance and support in a consistent manner from motivated health workers; where a resourced and flexible health system recognises the needs of women and babies, and respects their cultural context. This is a consolidated guideline of new and existing recommendations on routine postnatal care for women and newborns receiving facility- or community-based postnatal care in any resource setting.
  24. Content Article
    This is the transcript of a statement given in the House of Commons by the Secretary of State for Health and Social Care, Sajid Javid MP, in response to the publication of the final report of the Ockenden Review. In the statement he makes a commitment that the local trust, NHS England and the Department of Health and Social Care will accept all 84 recommendations made by the Review. This is followed by questions from MPs in the Chamber and Mr Javid's responses.
  25. Content Article
    In this blog Patient Safety Learning sets out its initial response to the report of the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust (also known as the Ockenden Maternity Review).
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