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Found 149 results
  1. News Article
    An amputee's wife having to "carry him to the toilet" after her husband was sent home from hospital without a care plan was just one of many findings in a report into vascular services at Betsi Cadwaladr University Health Board in north Wales. The critical report by the Royal College of Surgeons England makes five urgent recommendations "to address patient safety risks". Part one of the report, published last summer, made nine urgent recommendations and raised issues including too many patient transfers to the centralised hub, a lack of vascular beds and frequent delays in transfers. The final part of the report, published on 3 February, focussed on the clinical records of 44 patients dating from 2014 - five years before centralisation - to July 2021, two years after the Ysbyty Glan Clwyd hub opened. Assessors were "extremely concerned" about the case of a man where a decision was made to "amputate the foot rather than proceed to a below-the-knee amputation as the primary procedure". The report adds: "The review team also noted that the patient had been discharged without a care plan and that the patient's wife was having to 'carry him to the toilet'." It also highlights an "inappropriate" decision to offer a patient an "unnecessary and futile" amputation when "palliation and conservative therapy should have been considered instead". Referring to that case, the report added that the risk from "major amputation was extremely high". Read full story Source: BBC News, 3 February 2022
  2. Content Article
    At the first Patient Safety Management Network (PSMN)* meeting of 2022, we were privileged to hear from a bereaved relative about her shocking experience, which reminded us all of why we do what we do.  Claire Cox, one of the PSMN founders, invited Susan (not her real name to protect her confidentiality) to share with us the causes of her relative’s untimely death and the poor and shameful experience when she and her GP started to ask questions. This kicked off a valuable and insightful discussion about how patients are responded to when things go wrong and about honesty and blame, patient and family engagement in decision making when patients are terminally ill, and how we need to ensure that the new Patient Safety Incident Response Framework (PSIRF) guidance embeds good practice informed by the real-life experience of patients and staff.
  3. Content Article
    Medical error is the third leading cause of death in the U.S. After a routine partial hip replacement operation leaves the mother of filmmaker and comedian Steve Burrows in a coma with permanent brain damage, what starts as a personal video diary becomes a citizen’s investigation into the state of American healthcare.
  4. Content Article
    Whether you’re just getting started with involving patients and the public in your work, or if you’re looking for some new techniques, there are some great resources out there. The NIHR have pulled together some of the best available resources to help you involve patients, service users, carers and family members in your research. 
  5. News Article
    Patients are dying in hospital without their families because of pressure on NHS services, hospices have told The Independent. A major care provider has warned that it has seen a “huge shift” in the number of patients referred too late to its services. The warning comes as NHS England begins a new £32m contract with hospices to help hospitals discharge as many patients as possible this winter. NHS chief executive Amanda Pritchard said the health service was preparing for an Omicron-driven Covid wave that could be as disruptive as, or even worse than, last winter’s crisis. Hospices are already dealing with a “huge volume of death and patients needing support”, according to the head of policy at Hospice UK, Dominic Carter. He told The Independent that hospices had seen a huge shift in the number of patients referred to their services too late, when they are in a “very serious” state of health. He added: “We don’t really know what kind of support is actually out there for those people, while hospitals have difficulties and deal with challenges around backlogs and Covid. There are lots of people that have been in the community, where hospices are trying to reach them but aren’t always able to identify who needs that care and support. “They’re really important, those five or six final days, for the individual and their families. Yet this is spent in crisis rather than being helped as much as possible in a comfortable environment by the hospice ... [instead] an ambulance is called, and they’re having to be cast into hospital.” Read full story Source: The Independent, 26 December 2021
  6. Content Article
    Many people are taking on more caring responsibilities for their relatives and friends who are disabled, ill or older and who need support. For Carers Rights Day, Miriam Martin, Chief Executive of Caring Together, looks at the role carers play at hospital discharge, why poor quality discharge can put the patient at risk and discusses what more can be done to support carers when patients return home from hospital.
  7. News Article
    The widow of a top Scottish government official, who died after contracting Covid, believes the full details of his illness were concealed to protect the reputation of a troubled hospital. Andrew Slorance, Scottish government's head of response and communication unit, in charge of its handling of the Covid pandemic, went into Glasgow's Queen Elizabeth University Hospital for cancer treatment a year ago. His wife Louise believes he caught Covid there as well as another life-threatening infection. Andrew went in to the £850m flagship Queen Elizabeth University Hospital (QUEH) at the end of October 2020 for a stem cell transplant and chemotherapy as part of treatment for Mantle Cell Lymphoma (MCL). He died nearly six weeks into his stay, with the cause of his death listed as Covid pneumonia. But after requesting a copy of his medical notes, Mrs Slorance discovered her husband had also been treated for an infection caused by a fungus called aspergillus, which had not been discussed with either of them during his hospital stay. The infection is common in the environment but can be extremely dangerous for people with weak immune systems. Mrs Slorance questions whether it may have played a part in her husband's death, and if so, why she was not told? She told the BBC: "I think somebody and probably a number of people have made an active decision not to inform his family of that infection, either during his admission or post-death." Mrs Slorance believes that officials wanted to protect the hospital, which is already the subject of a public inquiry, and its reputation, "no matter what the cost". Mrs Slorance says a full investigation should take place into incidences of aspergillus at the hospital campus. In response, NHS Greater Glasgow and Clyde said: "We are sorry that the family are unhappy with aspects of Mr Slorance's treatment, details of which were discussed with the family at the time. "While we cannot comment on individual patients, we do not recognise the claims being made. We are confident that the appropriate care was provided. There has been a clinical review of this case and we would like to reassure the family that we have been open and honest and there has been no attempt to conceal any information from them." Read full story Source: BBC News, 18 November 2021
  8. News Article
    The mother of a man who took his own life said bereaved families would be left "in limbo" by a mental health trust's serious incident report delays. Local health officials have raised concerns over the "timeliness" of Cambridgeshire and Peterborough NHS Foundation Trust's (CPFT) reports. Maria Nowshadi, whose son James died in 2020, said they should be done quickly "so there's answers for families". Ms Nowshadi said: "These investigations should happen in a timely, quick manner so there's answers for families, but also in case there's any learning to be had... to make sure there's no further deaths that happen in the same way, because of any errors within the system." She said when the original date the report was due to be completed passed, she "reached the stage where I was looking at the mailbox every day". She said she told a patient liaison officer: "This is actually starting to affect my mental health. The chief nurse at Cambridgeshire and Peterborough's Clinical Commissioning Group (CCG), Carol Anderson, said there were "concerns... [around] serious incident processes and reporting" at CPFT. A CCG spokeswoman added they had agreed an extension with CPFT "for the completion of serious incident reports due to additional pressures due to the pandemic and staff redeployment". "Our overall concern is the timeliness of serious incident reporting, so that we can ensure that learning is put in place as soon as possible," she added. Read full story Source: BBC News, 17 November 2021
  9. Content Article
    Parkinson’s is the fastest growing neurological condition in the world. It affects young or old, and in the UK around 145,000 people are living with the condition. With population growth and ageing, this figure is estimated to increase by 20%, within the next ten years. Currently there is no cure for Parkinson’s, but medication plays a vital role in managing symptoms and preventing deterioration. In this blog, Laura Cockram, Head of Policy and Campaigning at Parkinson's UK, talks about: How people with Parkinson’s can prepare their medication to go into hospital. Resources that can support you.
  10. Event
    Panelists will provide a robust overview of the challenges that accompany medical care and propose actionable recommendations for patients, family members, and carers to balance life demands for patients with complex medical needs. Register
  11. Content Article
    In this blog Dr Chris Tiplady, consultant haematologist at Northumbria Healthcare NHS Foundation Trust, talks about the importance of building relationships with patients, carers and relatives. When a patient's family member dies, it leaves an empty chair in the consultation room and brings a sense of unexpected loss. Dr Tiplady reflects that throughout the pandemic, empty chairs have become a very common sight and he encourages readers to see these empty chairs as a reminder: "They should remind you to talk, to enquire over who should be in that chair, to have the conversations that need to be had, to recognise the relationships we all have that support us and that make our days better."
  12. News Article
    The co-founder of a coronavirus bereaved families group has said he hopes Boris Johnson will "at long last... take us seriously" when he meets them at Number 10 today. Matt Fowler said it is vital the prime minister understand the need to start a public inquiry as soon as possible. Mr Johnson will meet members of the Covid-19 Bereaved Families for Justice group today - more than a year after promising to meet people whose loved ones had died. They will share how their family members caught the disease and died, and repeat calls for a public inquiry to get priority. The group plans to raise issues with the PM such as the disproportionate effect of COVID on some ethnic groups, transmission of the disease on public transport and in the workplace, the impact of late lockdowns, and failures to learn from the first wave. Boris Johnson previously said the inquiry would start in spring 2022. Read full story Source: Sky News, 28 September 2021
  13. News Article
    A coroner has raised concerns about how a family was allowed to bring a restricted item that contributed to a man's death into a mental health unit. Joshua Sahota, 25, died as a result of asphyxia and psychosis in Bury St Edmunds, Suffolk, on 9 September 2019. Suffolk coroner Nigel Parsley said Mr Sahota's relatives were not told the item they brought in when visiting was on a restricted list. The NHS trust which runs the unit said it had improved its internal processes. Mr Sahota, from Kennett in Cambridgeshire, was taken to the Wedgewood Unit on the West Suffolk Hospital site three weeks before his death as his mental health had declined. Insufficient staffing levels contributed to his death, an inquest jury at Suffolk Coroner's Court concluded. Other factors included insufficient observations and one-to-one processes, no clear and concise risk assessments, being slow to develop a care plan and the absence of a documented crisis plan. Read full story Source: BBC News, 21 September 2021
  14. Content Article
    Joshua Sahota died as a result of asphyxia and psychosis while a patient in Northgate Ward at Wedgewood House, operated and staffed by Norfolk and Suffolk NHS Foundation Trust. In his report, the Coroner raised patient safety concerns regarding how the trust communicates to relatives which items are restricted and not allowed to be brought into the ward. He raised concerns that family and friends of current inpatients may still inadvertently take a restricted item onto the ward unless changes are put in place.
  15. Content Article
    This episode of HSJ’s Health Check podcast considers concerns raised in Coroners Prevention of Future Deaths reports about the impact of pandemic hospital visiting restrictions on patient care and patient safety.
  16. Content Article
    The findings of this study, published in the Patient Experience Journal, indicate that the policy to allow for visitors, or subjective advocates, individuals with a vested interest in the well-being of the patient, is beneficial not only for the patient, but also in sustaining high quality of care. Recommendations are given for how hospitals might achieve improved quality and safety outcomes even in instances when organisations believe visitation needs to be disallowed or restricted. The results of this study suggest those decisions should be made with great care and in only the most extreme circumstances.
  17. Event
    Join the Patient Safety Movement for a unique opportunity to view the award-winning HBO hit film Bleed Out and talk with the filmmaker, Steve Burrows afterwards. Bleed Out is the harrowing HBO feature documentary film that explores how an American family deals with the effects of medical malpractice. After Judie Burrows goes in for a routine partial hip replacement and comes out in a coma with permanent brain damage, her son, Steve Burrows, sets out to investigate the truth about what really happened. The documentary film takes place in real time over a span of ten years. Tickets
  18. News Article
    An NHS trust has become the first in the country to individually contact every family of patients who caught coronavirus while they were in hospital in a large-scale bid to be transparent over the scale of infections. Bosses at the Queen Elizabeth Hospital Kings Lynn NHS Trust have set up a team to work through hundreds of cases where patients caught coronavirus in hospital. At least 99 patients are known to have died after becoming infected with more cases still to review. In a unique approach to transparency the trust is sending a letter by recorded delivery to every affected patient or family where it is thought the patient picked up the virus within the hospital. The letter offers an apology for what happened and is followed by a phone call with a nurse and a meeting with officials if families have more concerns. Some families have asked to meet the nurses who cared for their loved ones. Read full story Source: The Independent, 6 June 2021
  19. Content Article
    Back in February, the team at Patient Safety Learning highlighted how the number of antipsychotic medication prescriptions for people living with dementia had increased in care settings.  What’s worrying, is these prescriptions can be administered inappropriately and cause tremendous harm. This is one family's pandemic story. 
  20. News Article
    More than 60 care homes have been investigated by the care regulator for preventing families from visiting their vulnerable elderly relatives. The Care Quality Commission (CQC) said it had conducted 1,282 inspections since 8 March and had taken action against 5% of care providers about which it had “outstanding concerns” relating to visiting, and had taken further steps against 37 cases of blanket bans on visiting. The CQC was responding to criticism from the Relatives and Residents Association (R&RA) which said the regulator had failed to act to ensure that families can check whether their parents, grandparents or spouses are receiving appropriate care. The R&RA has campaigned throughout the pandemic to allow families to see their relatives, amid concerns that depriving older people of contact with loved ones led to cognitive and physical decline. Families have also been concerned that their older relatives are more likely to suffer abuse or neglect without oversight, and even in high-quality care settings relatives can be more likely to spot signs of distress or ill-health. Read full story Source: The Guardian, 16 May 2021
  21. News Article
    Extremely unwell eating disorder patients are having to be tube fed at home by their families owing to a lack of hospital beds, as the Royal College of Psychiatrists reports a rise in people being treated in units without specialist support. Leading psychiatrists are urging the government for an emergency cash investment as the pandemic has prompted a rise in demand for treatment for conditions such as anorexia, amid “desperate pressure in the system”. In interviews with the Guardian, a number of parents told of the struggles of helping a severely unwell person from home. A number of families said they had no choice but to tube feed their children at home daily. Other parents said their children had been admitted to general children’s wards, where they were being treated by staff who had no experience of eating disorders. It is unclear how many patients are being treated at home, but Agnes Ayton, the chair of the Eating Disorder Faculty at the Royal College of Psychiatrists, said she had heard of people being unable to find beds and being creative in the community: “There is desperate pressure in the system.” Read full story Source: The Guardian, 22 April 2021
  22. News Article
    An elderly woman died alone in a care home while her daughter was left waiting in a nearby room, an ombudsman says. When the daughter went into her mother's room at the Puttenham Hill House Care Home in Guildford, Surrey, she found she had died. The Local Government and Social Care Ombudsman said the care home had not protected the woman's dignity. Surrey County Council has apologised to the family for the distress caused. The council had arranged and funded the woman's care at the Bupa-run home. A Bupa spokesman said it had apologised to the family and introduced "comprehensive measures" to prevent such a situation happening again. The woman's daughter had complained she had been called too late to the care home when her condition deteriorated in August 2019. When she arrived she was left in a waiting area and not told her mother was seriously ill, the ombudsman said. When she went into her mother's room 15 minutes later it was apparent her mother had died, and she found dried blood on the floor and oxygen pipes in her mother's nose. The agency nurse looking after the woman never spoke to the daughter, the ombudsman said. An inquest found the woman died from a brain haemorrhage, which would have been difficult to spot. Michael King, Local Government and Social Care Ombudsman, said: "The daughter was not able to be with her mother as she died and her mother should not have been alone in the final moments of her life." Read full story Source: BBC News, 23 March 2021
  23. News Article
    The unlawful or inappropriate use of “do not attempt cardiopulmonary resuscitation” (DNACPR) orders by some clinicians risks undermining the care of terminally ill patients, almost 40 leading doctors, nurses and charities have warned. During the coronavirus pandemic repeated examples of unlawful decisions have emerged including widespread blanket orders on care home residents and patients with learning disabilities. Now the charity Compassion in Dying along with Marie Curie, Hospice UK and Sue Ryder, as well as more than 30 GPs, nurses and doctors, are warning more must be done to listen to patients and their families. In a joint statement, signed by more than 30 clinicians, they warn: “There have been examples of poor practice in relation to DNACPR decision-making during the pandemic, and the distressing impact this has had on patients and families cannot be underestimated. It is essential to thoroughly understand and learn from these cases to ensure that they do not happen again." “We are aware that the benefits of DNACPR decisions can be easily undone if they are not accompanied by honest, open and sensitive communication with a person’s healthcare team. To ensure that everybody who encounters a DNACPR discussion has a positive experience, we need to do more to listen to individuals and their families; their wishes must be sought and documented, their questions answered and their feelings acknowledged. “A DNACPR decision must always involve the person, or those close to them, and should be part of a wider conversation about what matters to that individual.” Read full story Source: The Independent, 8 March 2021
  24. Content Article

    John's Campaign

    Sam

    Sam posted an article in Dementia

    Dr John Gerrard was a doctor and a business man, and diagnosed with Alzheimers in his mid seventies. It was a slow decline, that sped up when he was ill or upset, for ten years. Then, at the start of February 2014, he went into hospital. He had infected leg ulcers which weren’t responding to antibiotics. The hospital had a norovirus outbreak which meant visitors weren’t allowed at all. He was there for five weeks. John went in strong, mobile, smiling, able to tell stories about his past, to work in his garden and help with things round the house. He was able to feed himself, to keep clean, to have a good kind of daily life. He came out skeletal, immobile, incoherent, requiring 24-hour care and barely knowing those around him. His family are sure that if he had not spent that time alone, without them, he would not have descended into such a state of deep delirium. Having someone with you - someone who you love, who you know, whose face you know (be they your carer, your family, your friend, your lover) - helps keep you tied to reality, to life, to sanity. John died in November 2014. His story, however, is still repeated. Far too many people die cut off from the people who care for them. Far too many places have dangerously over-restrictive policies (both predating and during the present pandemic) preventing people from being with people who need them. In the wake of his death, John’s daughter, Nicci Gerrard, cofounded John’s Campaign with Julia Jones, whose mother, June, also lived well with dementia (both Alzheimer’s and vascular) for many years before her death in 2018. John’s Campaign is June’s Campaign, is Everyone’s Campaign, for none of us should be blocked from our best, most special friends, family or carers.
  25. Content Article
    If you have a relative with a learning disability who is at risk of behaviour that challenges, you may want to find out more about Positive Behavioural Support (PBS). PBS provides support for a person, their family and friends to help people lead a meaningful life and learn new skills without unnecessary and harmful restrictions. It is not simply about getting rid of challenging behaviour, but with the right support at the right time the likelihood of behaviour that challenges is reduced. The Positive Behavioural Support Resource for Family Carers has been developed with The Challenging Behaviour Foundation.
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