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Content Article
On 18 August 2023, Lucy Letby was found guilty of murdering seven babies and convicted of trying to kill six other infants at the Countess of Chester Hospital. Looking ahead to the forthcoming independent inquiry into this case, Patient Safety Learning, reflecting on the inquiries of the past, sets out some key patient safety themes and issues that should be considered as part of this.- Posted
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News Article
Trust heavily criticised by coroner for delays to death investigations
Patient Safety Learning posted a news article in News
A coroner has strongly criticised a mental health trust for failing to investigate serious incidents promptly. Tees Esk and Wear Valleys Foundation Trust has been told that delays in probing serious incidents may “compromise the quality” of these investigations and hence “their value in preventing deaths”. The warnings, from Jeremy Chipperfield, senior coroner for County Durham and Darlington, come amid an ongoing inquest into the death of TEWV patient Ian Darwin. Mr Darwin died aged 42 in March, and the serious incident review into his death is still ongoing. A recently published prevention of future deaths report relating to Mr Darwin’s death said TEWV’s serious incident death investigations, “at all levels of seriousness, are routinely (if not invariably) significantly delayed and I understand there is no expectation of immediate, or any timetable for eventual rectification”. “In permitting delay of ‘serious incident’ investigations, TEWV may permit lethal hazard to persist for longer than necessary, and compromise the quality of such investigations and hence their value in preventing avoidable deaths.” -
Content ArticleOn 7 March 2023 the coroner commenced an investigation into the death of Ian Darwin, aged 42. The investigation has not yet concluded and the inquest has not yet been heard. However, during the course of the investigation the inquiries revealed matters giving rise to concern. The coroner concluded that in his opinion there is a risk that future deaths could occur unless action is taken.
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Content Article
Near misses or great catches? A blog by Emma Walker
Patient Safety Learning posted an article in In health care
After attending a recent Patient Safety Management Network session, Emma Walker reflects on reporting on near misses. -
EventuntilWorld Patient Safety Day, observed annually on 17 September, aims to raise global awareness about patient safety and calls for solidarity and united action by all countries and international partners to reduce harm to patients. Patient and family engagement is one of the main strategies to eliminate avoidable harm in healthcare and ‘Engaging Patients for Patient Safety’ is the defining theme for World Patient Safety Day 2023. Access to safe, quality, and affordable medicines and their correct administration and use is critical for patient treatment and satisfaction. However, harm from medication treatment, including that resulting from a medicine shortage, in hospitals is common. 80 million people in Europe report experiencing a serious medication error during hospitalisation. With the outcomes of enhanced pharmacovigilance practices on medication safety practices in hospitals unclear and widespread deployment and adoption of digitalisation that can contribute to medication safety lagging, error reporting remains one of the most effective strategies to improve patient safety from medication harm. The 72nd World Health Assembly affirms that informed patients and carers could support the elimination of avoidable harm during care delivery. However, in many cases, patients nor their families are unaware of what systems are available to report the error. Therefore, awareness, access and use of patient-centred, user-friendly, reporting systems, will strengthen the evidence base that medication errors are not an unfortunate occupational hazard in healthcare delivery. This webinar will raise awareness of the importance of all stakeholders engaging with patients to improve medication safety in hospitals. It will discuss the importance of ensuring that patients are informed about medication safety and know how to report an unintended medication error when it occurs. Register
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Content ArticleThe horrifying case of neonatal nurse Lucy Letby, convicted of murdering seven babies and attempting to murder six others at the Countess of Chester Hospital, has raised hard questions for NHS leaders about how organisations respond to concerns about staff, but could digital systems help detect NHS staff who harm patients at an earlier point? If the pattern connecting Letby to the babies’ deaths had been detected by a digital system, would the response from the trust have been different? Would a machine have been believed? Alison Leary, chair of healthcare and workforce modelling at London South Bank University and a leading expert on nursing and data, suggests there is potentially a much bigger role for digital in patient safety.
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News Article
Families dismay at interim report plans despite review ‘chaos’
Patient Safety Learning posted a news article in News
Families involved in a major review into maternity failings at Nottingham University Hospitals Trust (NUH) have criticised the decision of the review team to press ahead with the publication of an interim report, despite serious concerns about its terms of reference and methodology. A “thematic review” into NUH was first announced last year after reports that dozens of babies died or were brain damaged after errors were made at the trust over the last decade. More than 460 families have since contacted the review team. The review has been overseen by NHS England and local commissioners, but, in April, the families called for an independent inquiry and asked for it to be carried out by Donna Ockenden, the senior midwife who chaired the high-profile review of Shropshire maternity services, which reported in March. Last month, NHSE chief operating officer Sir David Sloman wrote to families and said former strategic health authority chair Julie Dent would be brought in to chair the review. However, Ms Dent stepped down from the role weeks later, citing “personal reasons”. A new chair is yet to be appointed. Despite these uncertainties, families have been told by the review team that an interim report will be issued shortly. Gary Andrews, whose daughter Wynter died after being delivered by caesarean section at NUH’s Queens Medical Centre in 2019, said to issue an interim report “seems at odds with the current situation” and risked causing “significant distress” to families. He added: “We need government to get to grips with this review. Put the brakes on, ensure its structure and design and objectives are fully supported by families, before any interim report can be issued.” Read full story (paywalled) Source: HSJ, 19 May 2022 -
News Article
Global COVID-19 data gap grows as countries stop reporting to WHO
Patient Safety Learning posted a news article in News
Fewer than 20 countries worldwide still report COVID-19 hospitalisation and ICU data to the World Health Organization (WHO), leaving the UN health body blind to the impact and evolution of the virus in most of the world, agency leaders have said. The decline in data reporting is a major setback for the WHO’s efforts to track the pandemic. Without reliable data, the WHO cannot accurately assess the burden of disease, identify new variants, or target its resources where they are most needed. “We don’t have good visibility of the impact of COVID-19 around the world,” said Dr. Maria Van Kerkhove, who leads the WHO’s COVID-19 task force. “It is really important that surveillance continues, and this is on the shoulders of governments right now.” “While we are certainly not in the same situation that we were in a year ago or two years ago, SARS-Cov-2 circulates in all countries right now,” said Van Kerkhove. “It is still causing a large number of infections, hospitalisations, admissions to the ICU and deaths.” The current set of dominant COVID-19 variants can still cause the “full spectrum” of disease, from asymptomatic infections to severe disease and death, Kerkhove said. Read full story Source: Health Policy Watch, 25 August 2023 -
News Article
Norfolk and Suffolk NHS trust deaths report 'watered down to spare bosses'
Patient Safety Learning posted a news article in News
A critical report into how a mental health trust mismanaged its mortality figures was edited to remove criticism of its leadership, the BBC has found. In June, auditors Grant Thornton revealed how the Norfolk and Suffolk NHS Foundation Trust (NSFT) had lost track of patient deaths. But earlier drafts included language around governance failures that were missing in the final version. NSFT and Grant Thornton said the changes were due to fact-checking. A number of drafts of the report were produced, with the first dated 23 February this year. The first version described "poor governance" in the way deaths data was managed, with governance also being called "weak" and "inadequate". But many of these critical words were missing from the report released to the public, with "governance" also being replaced with "controls", according to leaked documents. After losing her son Tim in 2014, Caroline Aldridge has been highlighting what she and others claimed had been the trust's undercounting of deaths. "I think people need to know what was removed and what was changed, because I suspect that the first report is a lot nearer to the truth," she said. Ms Aldridge added: "It takes all responsibility from governance, removing the words 'inadequate', 'poor', 'weak' governance, removing significant pieces of information that's not factual accuracy. "We cannot have people watering it [the report] down when it's about deaths." Read full story Source: BBC News, 29 August 2023 -
News Article
NHSE and government reprimanded for ‘selective reporting’ of cancer performance
Patient Safety Learning posted a news article in News
NHS England and the government have been criticised for “selective reporting” of statistics by an influential Westminster committee. The chair of the Public Accounts Committee Meg Hillier wrote to NHS England CEO Amanda Pritchard requesting “greater realism about the scale of the challenge” on cancer services. It follows the government and NHSE claiming in a government response to the committee that they had “implemented” one of its earlier recommendations, to “bring cancer treatment back to an acceptable standard”. In their February report on backlogs and waiting times, MPs said cancer delays were “unacceptable” and services should be recovered “as a matter of urgency”. The report also criticised NHSE for “over-optimism” when drawing up cancer and elective recovery plans. Read full story (paywalled) Source: HSJ, 4 July 2023 -
News Article
Hundreds died on same day as being discharged, trust review finds
Patient Safety Learning posted a news article in News
An independent review has raised concerns about a mental health trust’s reporting systems and has highlighted a significant number of patient deaths shortly after leaving the trust’s care, including almost 300 who died on the same day they were discharged. However, the review into how Norfolk and Suffolk Foundation Trust collects, processes and reports mortality data made no conclusions on the number of avoidable deaths – the issue which had originally prompted the probe. Local NHS leaders argued the review’s purpose was focused on auditing the trust’s processes, and this had been delivered. But a local MP, Clive Lewis, accused it of “explicitly dodg[ing] the big questions”. The report, which looked at data from between April 2019 and October 2022, has however raised concerns about the number of patients dying soon after being discharged. Read full story (paywalled) Source: HSJ, 28 June 2023 -
News Article
Multiple reporting systems undermine patient safety, says watchdog
Patient Safety Learning posted a news article in News
A single system to report patient safety concerns would “keep people safer”, a newly appointed NHS watchdog has told HSJ. Henrietta Hughes – who will take up the post of patient safety commissioner in September – said both clinicians and patients faced a bewildering choice when looking to raise a safety concern, and that there was a need for a “report once” system. She said that when ”exhausted” clinicians “come to the end of a 12-hour shift, they don’t want to have to do a Datix report and a yellow card report, and if they’ve got a safeguarding concern or a concern about an individual condition, [to have to] send that somewhere else”. Dr Hughes added: ”Wouldn’t it be better if we had one report that you do, and all the information that comes from that report just gets sent to the appropriate authority? That’s the type of change that I think we’d like to see. I know, as a GP myself, that’s what I would rather do as a professional. But also, I think, for all the organisations, we could get so much more richness of information, we would get more reporting, and we’d keep people safer as a result of it.” She added that if a patient “wanted to report an individual clinician” they often ended getting bounced around the system, like a pinball. They get sent from pillar to post.” Read full story (paywalled) Source: HSJ, 8 August 2022 -
News ArticleFresh concerns have been raised about the launch of the national incident reporting system, despite Steve Barclay taking a ‘personal interest’ in hitting the tight timetable, HSJ has learned. NHS England already delayed the launch of the “learning from patient safety events” database by six months, to September this year. It is due to replace the existing national reporting and learning system (NRLS) which is considered to be outdated and at risk of failing. But serious concerns are now being raised again by trust safety managers about whether the revised launch date can be met, HSJ has been told, with calls for it to be extended again until next year. HSJ has heard concerns from several managers that an upgrade due in July to the RLDatix risk management system – which is used by the majority of trusts – will cause knock-on problems implementing LFPSE in September. They said the timeframe was too short for testing and delivering the upgrade in time to make the transition and decommission the old NRLS. The creation of LFPSE is a key part of NHSE’s safety strategy, along with replacing the serious incident reporting system, with an aim of making it easier for staff to record safety events across all services, including primary care, which is excluded from NRLS. Read full story (paywalled) Source: HSJ, 3 May 2023
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Content ArticleIncomplete or inaccurate recording of ethnicity will undermine attempts to address health inequalities and improve access, experience and outcomes for Black, Asian and minority ethnic communities. This report by the Race Equality Foundation and the Office for National Statistics (ONS) looks at different aspects of the recording of ethnicity in healthcare. The authors interviewed people from a range of communities across England, as well as healthcare workers from different areas and settings to understand both sides of the process of collecting ethnicity data.
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Content ArticleIn this podcast to support providers with the transition to the Learn from Patient Safety Events (LFPSE) service, the NHS's new national system for the recording and analysis of patient safety events, NHS England talks to Zahra and Mandy, NHS England reporting leads, about the practical steps providers can take to get connected to LFPSE. It covers how to get started, what to do with your old data, the kinds of support available, what transition means for ICBs, and what the Reporting Leads have learned from the process so far.
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Content ArticleThis study, published in The New England Journal of Medicine, looks at the frequency, preventability and severity of patient harm in a random sample of admissions from 11 Massachusetts hospitals during 2018. From this sample, it identified adverse events in nearly one in four admissions, approximately a quarter of which were deemed as preventable.
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Content ArticleLaura Pickup and Suzy Broadbent present on the impact staff fatigue has on patient safety.
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Content ArticleThis article by the Betsy Lehman Center in Massachusetts draws attention to research by ECRI, a US non-profit research and risk management firm, which shows that efforts to address racial inequalities in medical care need to include an examination of the way in which patient safety events are reported. Research by ECRI shows that existing patient safety reporting systems may be undercounting events experienced by patients who are Black , Latino or from other ethnic groups. It also highlights that racial, ethnic and other demographic data about patients is missing in adverse event reports from most US healthcare organisations.
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Content ArticleIn September 2022, The Care Quality Commission published four reports into the care provided by Spectrum a provider of Autism services in Cornwall. All four inspections concluded that the services were inadequate.
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Content ArticleNHS England has recorded two podcasts sharing insight and advice from organisations that have completed the transition from the National Reporting and Learning System (NRLS) to the new Learn from Patient Safety Events (LFPSE).
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Content ArticleIncident reporting is a crucial tool for improving patient safety, alongside an open culture that supports this. In the NHS the new Learn from Patient Safety Events (LFPSE) service is now being rolled out to replace the current National Reporting and Learning System (NRLS) and Strategic Executive Information System (StEIS). This article details correspondence between Patient Safety Learning and NHS England in relation to concerns raised by staff about the development and implementation of the LFPSE service
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Content ArticleIn this podcast, the Learn from Patient Safety Events (LFPSE) team talks to the National Director for Patient Safety about the new LFPSE service, why it’s important, and the benefits he thinks it will bring for patient safety.
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Content ArticleThe Patient Safety Database (PSD), previously called the Anesthesia Safety Network, is committed in the delivery of better perioperative care. Its primary goal is to make visible the lack of reliability of healthcare and the absolute necessity to build a new system for improving patient safety. This year, PSD has also been involved in the development of the SafeTeam Academy, an e-learning training platform associated with the Patient Safety Database, which offers video immersive courses using the power of cinema to train healthcare professionals. This is the latest newsletter from PSD, featuring a wide range of content by safety experts across Europe.
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Content ArticleRadar Healthcare has published its 'Incident Reporting in Secondary Care' whitepaper – an in-depth analysis of reporting within secondary care and its effects on patient safety. It has taken a look into the current state of incident reporting: the good work being done, the concerns across the sector, and how we can all aim to improve the situation. The report was conducted using a panel provided by SERMO from its database of UK Nurses and includes the views from 100 nursing staff members working in hospital wards across the UK. Those surveyed work with hospital in-patients daily and are responsible for reporting safety and regulatory incidents involving patients to senior colleagues.
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News ArticleThe deadline for the NHS to move to a new system for safety incident reporting has been delayed after widespread concerns the rollout could be a ‘disaster’. A memo from NHS England to local teams yesterday, seen by HSJ, says the deadline to transition to the new “learning from patient safety events” database has been pushed back by six months to September 2023. The creation of LFPSE is a key strand of NHSE’s safety strategy, along with the overhaul of how serious incidents are investigated. It aims to make it easier for staff across all healthcare settings to record safety events, as the service will be expanded to include primary care. It will replace the current national reporting and learning system, a central database created in 2003 to help identify trends and maximise learning from mistakes. The new system is part of a national strategy that pledges to save 1,000 extra lives and £100m in care costs each year from 2023-24. Multiple patient safety managers at local trusts had raised concerns to HSJ about the previous March deadline, with one patient safety lead saying it would have been a “disaster” if enforced. Helen Hughes, chief executive of charity Patient Safety Learning, said NHSE also needs to change its way of working, as well as the deadline extension. She said: “We believe that NHS England needs to seriously reconsider their approach to engaging with trust leaders and staff on this issue, so that improvements can be made to the new LFPSE service to ensure it has the best possible chance of success, and to enable patient safety improvement.” Read full story (paywalled) Source: HSJ, 20 October 2022
