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Content Article
In praise of NHS domestics: a blog by Adam's mum
Claire Cox posted an article in By patients and public
This blog written by Adams mum gives praise to the domestic staff that work with in our hospitals. She explains how the domestic staff were a source of support and company for Adam and the family when he was admitted. Adams mum is a mother an academic, lawyer and lay advisor. -
News Article
Hospital wrong to ban woman visiting partner on his deathbed
Patient Safety Learning posted a news article in News
The partner of a dying man was denied the chance to be at his bedside during his final moments after a hospital wrongly banned her from daily visits, an ombudsman report has found. Brian Boulton, 70, was admitted to Royal Gwent Hospital in Newport, South Wales, after suffering from a chest infection, which was later diagnosed as aspiration pneumonia caused by oesophageal cancer. Celia Jones, his “long term life partner” of twenty years, was accused by hospital staff of giving the retired tailor a larger dose of the prescribed furosemide medication than was allowed. Ms Jones, 65, was restricted to one-hour visits twice a week, meaning she was unable to be with him when he died a day after her last authorised visit on Wednesday 27 September 2017. The Public Services Ombudsman for Wales has upheld her complaints about her “appalling” treatment, ruling that the visiting restrictions were imposed “without warning” and resulted in a “significant injustice”. It found no record of Ms Jones, a retired nurse, admitting to a senior ward manager that she gave the large dose of medicine to her partner. Read full story Source: The Telegraph, 6 January 2020 -
Content Article
BMJ Editorial: Abandon the term "second victim"
Patient Safety Learning posted an article in Second victim
Families of patients who died after medical errors argue that it’s time to abandon the term “second victim” to describe doctors who are involved in a medical error. In an editorial published by The BMJ, Melissa Clarkson at the University of Kentucky and colleagues say that by referring to themselves as victims, “healthcare providers subtly promote the belief that patient harm is random, caused by bad luck, and simply not preventable.” This mindset “is incompatible with the safety of patients and the accountability that patients and families expect from healthcare providers,” they argue. -
News Article
Father-to-be died in hospital 'screaming in pain'
Patient Safety Learning posted a news article in News
The family of a father-to-be have criticised hospital staff who left him "screaming out in pain" in the final hours of his life. Adam Hurst, 31, died from a rare type of hernia a few hours after arriving at Hinchingbrooke Hospital in Cambridgeshire, last December. The hospital found Mr Hurst's pain management and the communication with him and his relatives was "inadequate". The Medical Director of North West Anglia NHS Foundation Trust, Dr Kanchan Rege, said: "Our staff strive to provide high quality care at all times and this was not the case in this instance." At the inquest into his death, the coroner concluded it was "not possible to say whether on the balance of probabilities earlier surgery would have resulted in a different outcome due to the rare and complex nature of the surgery". But the hospital's serious incident report, seen by the BBC, found Mr Hurst's pain "should have been more aggressively managed, from the outset". It also found the frequency of his observations was "inadequate" and stated the documentation in the emergency department "was generally very poor from the nursing staff that cared for the patient". The report also said "clear explanations to the patient and relatives are essential to allay fears and reduce anxiety". Read full story Source: BBC News, 5 December 2019 -
News ArticleNHS bosses have been accused of using a 2013 report to “maintain a false narrative” about maternity services in Shropshire, which meant poor practices and conditions went unchallenged for years. The Independent has obtained a 2013 report, commissioned by NHS managers in Shropshire, which concluded maternity services at the Shrewsbury and Telford Hospital Trust were “safe”, of “good quality”, and “delivered in a learning organisation”. The report, written by rheumatologist Dr Josh Dixey (now high sheriff of Shropshire), delivered a glowing assessment of the care given to women and babies and appeared to gloss over hints of deeper problems within the service. Sources within the Shropshire and Telford clinical commissioning groups (CCGs), which paid £60,000 for the report, said since it was written it had been “proven to be wrong, inaccurate and to have come to the wrong conclusions and recommendations”, but also stressed it was based on the information received from the trust at the time. A leaked report last month revealed dozens of mothers and babies had died at the Shrewsbury and Telford Hospital Trust, with incidents of poor care stretching over four decades, due to repeated failures to learn from mistakes. Read full story Source: The Independent, 4 December 2019
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News Article
Let’s do our duty: Top nurse leads NHS staff flu jab drive
Patient Safety Learning posted a news article in News
England’s most senior nurse has called on the NHS’ million-plus frontline workers to protect themselves and their patients this year by taking up their free flu jab. Ruth May, the Chief Nursing Officer for England, is spearheading this year’s drive to ensure that as many NHS staff as possible get vaccinated against seasonal flu – meaning they are both less likely to need time off over the busy winter period, and less likely to pass on the virus to vulnerable patients. Since September, hospitals and other healthcare settings across the country have been laying on special activities designed to highlight the importance of the flu vaccine, and celebrate those staff who choose to protect themselves and their patients. A record 70% of doctors, nurses, midwives and other NHS staff who have direct contact with patients took up the vaccine through their employer last year, with most local NHS employers achieving 75% or higher. Ruth has been joined in writing an open letter to NHS staff by other heads of professions like the NHS National Medical Director, Professor Stephen Powis, Chief Allied Health Professions Officer, Suzanne Rastrick, Chief Midwifery Officer, Professor Jacqueline Dunkley-Bent, and Chief Pharmaceutical Officer, Dr Keith Ridge. In it they urge every member of the NHS’ growing frontline workforce to work together to achieve even higher level of coverage this year. Read full story Source: NHS England, 25 November 2019 -
Content ArticleChristine Reddall talks about the diagnosis and subsequent care of her daughter who had young onset dementia.
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News ArticleIn March 2015, the Morecambe Bay investigation, chaired by Dr Bill Kirkup, published its report into serious failures in care that led to the avoidable deaths of 11 babies and a mother at Furness General Hospital (FGH) between 2004 and 2012. One of the babies that died was James Titcombe's son, Joshua. The report described a seriously dysfunctional maternity unit where certain midwives pursued an “over-zealous” approach to promoting “normal” childbirth, relationships between doctors and midwives was poor, midwifery practice fell well below acceptable standards and, unforgivably, instances of avoidable harm and death were covered up – meaning lessons were not learned and similar failures were repeated year after year. The report detailed how opportunities to intervene at Morecambe Bay were missed at all levels and how the families who raised concerns were treated as problems to be managed, rather than voices that needed to be heard. More than four years later, it is both tragic and distressing to read about the litany of failures identified in the leaked interim report into care at Shrewsbury and Telford Hospital Trust (SaTH). Far from events at Morecambe Bay being a “one-off”, it is now painfully clear that not only have similar failures in care occurred elsewhere, but that they have happened on an even larger scale. James, speaking to The Independent, says "Worryingly, the reason why we are reading about these issues now isn’t because the regulatory system identified a problem and called for further scrutiny, but rather because of the extraordinary efforts of bereaved families." Read full story Source: The Independent, 21 November 2019
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Content ArticleA powerful account from a daughter on the care her mum and dad received in hospital.
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Content ArticleWhen someone you love is hospitalised, it can be scary-even terrifying-for the patient and for family and friends. A hospital may seem like a foreign land. Sounds, smells, and the culture are unfamiliar; even the medical terminology sounds like a different language. Understanding the hospital environment and knowing how to navigate its complicated pathways can make you a strong champion for your loved one. You are as critical to your loved one's recovery as the doctors and nurses. Your role is different, but vital. In some cases, you can make the difference between life and death. Hospital Warrior de-mystifies the process and provides the tools, understanding and insight you need to get the best care for your loved one.
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Content ArticlePatients who are actively involved in their health and health care tend to have better outcomes and care experiences and, in some cases, lower costs. Implementing patient and family engagement strategies has led to fewer hospital-acquired infections, reduced medical errors, reduced serious safety events, and increased patient satisfaction scores. After reviewing best practices and evidence-based strategies for increasing patient and family engagement in direct care settings, hospitals, health systems, the community, and through policy, the Task Force on Patient and Family Engagement developed and refined a set of 16 recommendations that will catalyse patient and family engagement and improve health and health care systems in North Carolina.
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Content ArticleThe human element can give us kindness and compassion; it can also give us what we don't want — mistakes and failure. Leilani Schweitzer's son died after a series of medical mistakes. In her talk she discusses the importance and possibilities of transparency in medicine, especially after preventable errors. And how truth and compassion are essential for healing.
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Content ArticlePatient diaries have often been used in the adult intensive care setting. This paper explores the use of diaries with the paediatric population and how this can enhance care and rehabilitation post critical care stay.
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Content Article
Safer outcomes for people with psychosis
Dorit posted an article in By patients and public
Dorit describes the assessment and subsequent death of her much loved daughter-in-law who died during a psychotic episode having been discharged the previous evening. Her story raises a number of questions: How should families be included in making judgements and assessments about the patient and their well-being? What support do they need to care for a very distressed loved one? Why aren't written care and contingency plans provided to the patient and their family? What more needs to be done to ensure standard practices are in place to protect patients with psychosis? -
Content ArticleReporters in the US from the Houston Chronicle and NBC News spent nine months examining more than 40 cases and spoke with more than 100 attorneys, doctors and current and former state employees. Their reporting reveals that some doctors have diagnosed child abuse with a degree of certainty that critics say is not supported by science. This article, the first in a series, was published in partnership with NBC News.
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Community PostWhat training have you had to have that crucial end of life conversation with a patient and their relatives? What has helped you have those conversations?
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Content Article
What it feels like working with unsafe staffing
Anonymous posted an article in Florence in the Machine
This blog has been written by a healthcare worker and demonstrates the reality of what it is like caring for patients and families while being chronically low on staff. They describe the impact this has on staff morale and the impact it has on patients, patients family members and the relationship between staff and patients.- Posted
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Content Article
The real second victims
Patient Safety Learning posted an article in Second victim
In many professions, specific terms – both old and new – are often established and accepted unquestioningly, from the inside. In some cases, such terms may create and perpetuate inequity and injustice, even when introduced with good intentions. One example is the term ‘second victim’. The term ‘second victim’ was coined by Albert W Wu in his paper ‘Medical error: the second victim’. Wu wrote the following: “although patients are the first and obvious victims of medical mistakes, doctors are wounded by the same errors: they are the second victims”. In his blog, Stephen Shorrick discusses the term second victim, what patients and families think of this term, and proposes that healthcare professionals are perhaps the 'third victims'. -
Content Article
Why investigate? The patient's perspective
Joanne Hughes posted an article in Investigations and complaints
A brief, heartfelt piece presented purely from the harmed patient's perspective and urging those involved in making decisions about whether or not to investigate to consider the impact of a good investigation on the ability of the harmed patient and their family to heal... Well received on twitter and described by a number of patients as 'you've said what I feel'. A reminder that a crucial purpose of the investigation is to give a harmed patient and their family a full explanation to help them understand, process and share for learning their experience. All necessary to their recovery. All necessary to their own 'safety' following an incident (we know poor responses cause additional suffering to those already harmed). The author also highlighted (via twitter) how much of this blog relates to the needs of staff involved in incidents too...- Posted
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Content Article
Why we need courage to keep our patients safe
Patient Safety Learning posted an article in Florence in the Machine
An insightful blog from a nurse on the frontline. The author of this blog has requested to stay anonymous.- Posted
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Content ArticlePatient Safety Learning speaks to sepsis survivor, Dave Carson, and his wife, Margaret Carson, who tell us how things have improved and what more still needs to be done for sepsis.
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Community PostHello everyone, We know there is much learning to be gained from listening to patient and families. This is particularly true when it comes to patient safety. Have you had an experience that you'd like to share with us? Maybe you identified a risk or shared a concern and were listened to and unsafe care was avoided? Maybe you weren't listenied to or you didn't realise what was going on and you or your family member were harmed? How did you find out about the patient safety incident? Was information shared with you that you needed to know? Were you supported? Was there an invetsigation into the incident and were you invited to contributed to it? Were lessona learned and acted upon? Have others learned from this experience, do you know?
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Content Article
NHS at 70: The Story Of Our Lives
Claire Cox posted an article in Stories from the front line
NHS at 70: The Story Of Our Lives is a national programme of work supported by The National Lottery Heritage Fund and led by The University of Manchester recording stories from people who worked and were cared for by the NHS since its creation in 1948. These stories will be available on the public Digital Archive and will provide a lasting resource for audiences to discover NHS history through the voices of the people who have worked and were cared for by the NHS since 1948. -
Content Article
Patient Stories: Paul's Story (10 March 2013)
Claire Cox posted an article in Patient stories
In 2007, when Paul Richards was diagnosed with non-Hodgkin lymphoma, his family were stunned by the news. This powerful film from Patient Stories is based on the testimony of Lisa, Paul’s wife, who gives a moving account of the events that led to Paul’s death and explores the effects on their family. -
Content Article
Patient Stories: Beth's story (27 December 2013)
Claire Cox posted an article in Patient stories
A moving and challenging short film about the Bowen family following the tragic death of five year old Bethany during ‘routine’ surgery and subsequent sudden death of father Richard aged 31, following the trauma of his daughter’s death and the ‘torture’ of the inquest.
