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Content Article
BD - Voices of safety videos
Patient-Safety-Learning posted an article in Patient stories
This series of videos produced by pharmaceutical company BD features patients, caregivers and healthcare professionals telling their stories about patient safety. Each video highlights an experience of avoidable harm, with topics including sepsis, antimicrobial resistance, medication errors and healthcare associated infections. -
EventThe Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include national developments, including the recent recommendations on NEWS2 and Covid-19, and implementing the recommendations from the HSIB Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis and Covid-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code Follow on Twitter @HCUK_Clare #DeterioratingPatient
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Content ArticleRyan Saunders is a little boy who died in 2007 from an undiagnosed streptococcal infection, which led to Toxic Shock Syndrome. According to the Queensland Clinical Excellence Division, when Ryan’s parents were worried he was getting worse, they did not feel their concerns were acted on in time. This blog outlines Ryan's Rule, a process introduced by the Queensland Department of Health to try and prevent similar events happening in future. Ryan's Rule allows patients and their families and carers to escalate serious concerns about their own or a family member's condition.
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Content ArticlePeople with developmental disability have higher healthcare needs and lower life expectancy compared with the general population. Poor quality of care resulting from interpersonal and systemic discrimination may further entrench existing inequalities.
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News ArticleTina Hughes, 59, died from sepsis after doctors allegedly delayed treating the condition for 12 hours while they argued over which ward to treat her on. Ms Hughes was rushed to A&E after developing symptoms of the life-threatening illness on September 8 last year. Despite paramedics flagging to staff they suspected sepsis, it was not mentioned on her initial assessment at Sandwell General Hospital, in West Bromwich. A second assessment six hours later also failed to mention sepsis while medics disagreed over whether to treat her on a surgical ward or a high dependency unit. The grandmother-of-five was eventually transferred to the acute medical unit at 3am the next morning where sepsis was finally diagnosed, but she continued to deteriorate and was admitted to intensive care four hours later and put on a ventilator. She died the following morning. A serious incident investigation report by Sandwell and West Birmingham Hospitals NHS Trust has since found there was "a delay in explicit recognition of sepsis". Read full story (paywalled) Source: The Telegraph, 4 October 2022
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Content ArticleSepsis is the leading killer of infants and children worldwide and kills more than 250,000 Americans each year. On 1 April 2012, 12-year-old Rory Staunton died from sepsis after grazing his arm while playing basketball at school. This account by Rory's parents Orlaith and Ciaran Staunton describes the multiple errors by the school and different healthcare professionals that led to their son's death - from the wound not being cleaned by the school, to Rory's paediatrician missing key sepsis warning signs and the ER's failure to read Rory's blood test results that showed he was seriously ill. The article also includes a link to a short video where Orlaith and Ciaran describe what happened to Rory.
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News Article
NHS staff shortages are ‘biggest’ sepsis risk this winter, charity warns
Patient Safety Learning posted a news article in News
The looming NHS staffing crisis could lead to more patients dying from sepsis, a major UK charity has warned. Doctors have told the UK Sepsis Trust that staff shortages and high numbers of patients to treat are two of the most common factors preventing them from following national sepsis guidance. The chief executive of the UK Sepsis Trust, Dr Ron Daniels, warned that the NHS was in a “fragile” state and said workforce shortages were some of the “biggest potential causes of harm” in the context of diagnosing the condition. In a report by the trust, shared with The Independent, 65 out of 100 doctors in the UK warned that they had missed cases of sepsis. The most common reason for this was staff shortages alongside “high patient caseloads”, they said. Dr Daniels warned that staff might find it increasingly difficult to spot sepsis in the coming months as the staffing crisis intensifies. He told The Independent: “The NHS is in a fragile state after the pandemic... and staff absence is a fact of life within the NHS at the moment. That’s partly because staff have left, it is partly because we have high caseloads, but it is also because staff are still off sick". “It is my view that staff shortages are one of the biggest potential causes of harm that our public face in the context of developing sepsis, and we need to urgently address it.” Read full story Source: The Independent, 26 September 2022 -
News Article
Reasons for hospital admissions in people with type 2 diabetes are changing
Patient Safety Learning posted a news article in News
The most common reasons why people with type 2 diabetes (T2DM) are admitted to hospital with greater frequency than the general population are changing, with hospitalisation for traditional diabetes complications now being accompanied by admissions for a diverse range of lesser-known complications including infections (i.e., pneumonia, sepsis), mental health disorders, and gastrointestinal conditions, according to an analysis of national data from Australia spanning seven years. The findings, being presented at this year's European Association for the Study of Diabetes (EASD) Annual Meeting in Stockholm, Sweden (19-23 Sept), reveal that just four traditional diabetes complications (cellulitis, heart failure, urinary tract infections, and skin abscesses) were ranked in the top ten leading causes of hospitalisation in men and women with T2DM. "Although traditional complications such as heart failure and cellulitis remain a substantial burden for people with T2DM, infections less commonly linked with diabetes and mental health disorders are emerging as leading causes of hospital admissions, and have substantial burdens that sometimes exceed the top-ranked well-known complications," says lead author Dr. Dee Tomic from the Baker Heart and Diabetes Institute, Melbourne, Australia. She adds, "The emergence of non-traditional diabetes complications reflects improvements in diabetes management and people with diabetes living longer, making them susceptible to a broader range of complications. Increasing hospitalizations for mental health disorders as well as infections like sepsis and pneumonia will place extra burden on healthcare systems and may need to be reflected in changes to diabetes management to better prevent and treat these conditions." Read full story Source: MedicalXpress, 1 September 2022 -
Content ArticleThis video series by the Australian Commission on Safety and Quality in Healthcare aims to promote sepsis awareness among healthcare professionals and the wider community. The three videos were created as part of the Australian National Sepsis Awareness Campaign. The videos provide key information about: sepsis signs and symptoms. potential health problems after sepsis. simple ways to reduce the risk of sepsis. timely recognition and management of sepsis across healthcare settings.
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News ArticleAt least 12,000 people were treated for sepsis in hospitals in Ireland last year, with one in five of those dying from the life-threatening condition. However, the HSE said the total number of cases is likely to be much higher. Marking World Sepsis Day, it said the condition kills more people each year than heart attacks, stroke or almost any cancer. The illness usually starts as a simple infection which leads to an “abnormal immune response” that can “overwhelm the patient and impair or destroy the function of any of the organs in the body”. Dr Michael O’Dwyer, the HSE’s sepsis clinical lead, said: “The most effective way to reduce deaths from sepsis is by prevention. “A healthy lifestyle with moderate exercise, good personal hygiene, good sanitation, breastfeeding when possible, avoiding unnecessary antibiotics and being vaccinated for preventable infections all play a role in preventing sepsis. “Early recognition and then seeking prompt treatment is key to survival. Recognising sepsis is notoriously difficult and the condition can progress rapidly over hours or sometimes evolve slowly over days.” Read full story Source: Independent Ireland, 13 September 2022 hub resources on sepsis RCNi: Sepsis resource collection NSW Clinical Excellence Commission - Sepsis toolkit Dr Ron Daniels video: Recognising sepsis Introducing the Suspicion of Sepsis Insights Dashboard
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Content ArticleThis toolkit from the New South Wales Clinical Excellence Commission (CEC) provides information, resources and quality improvement (QI) tools for managers and clinicians to improve sepsis care. The resources can be adapted to suit local needs and cover: Getting started Making improvements Data for improvement Communicating changes Providing education Sustain and spread
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Content ArticleOn 3 September 2021 assistant coroner Jonathan Stevens commenced an investigation into the death of Martha Mills, aged 13 years. Martha sustained a handlebar injury whilst cycling on a family holiday in Wales. She was transferred to King’s College Hospital London and died approximately one month later. Her medical cause of death was: 1a refractory shock 1b sepsis 1c pancreatic transection (operated) 1d abdominal trauma.
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Content ArticleSharing her story in the Guardian, Merope gives a heart breaking account of how her daughter, Martha Mills, was allowed to die, but also what happens when you have blind faith in doctors – and learn too late what you should have known to save your child’s life.
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News Article
Trust boards instructed to ‘scrutinise’ sepsis data by NHSE
Patient Safety Learning posted a news article in News
Trust boards should start scrutinising performance against new indicators set out by NHS England this month as part of a national push to iron out unwarranted variation in performance on key sepsis blood tests, according to an NHSE report. Blood cultures are the primary test for detecting blood stream infections, determining what causes them, and directing the best antimicrobial treatment to deal with them. However, it is too often seen as part of a box-ticking exercise, according to a report published by NHSE yesterday. Improving performance on this important pathway should be integrated into existing trust governance structures for sepsis, antimicrobial stewardship, and infection control “to help secure a ‘board to ward’ focus on improvement,” the report says. It says there is too much variation in how blood cultures are taken prior to analysis and sets out two targets for trusts to use to standardise their collection. The first is ensuring clinicians collect two bottles of blood, each containing at least 20ml for culturing. The more blood collected, the higher the rate of detecting bloodstream infections. Blood culture bottles “are frequently underfilled”. The second is ensuring blood cultures are loaded into an analyser as fast as possible, within a maximum of four hours, because delaying analysis reduces the volume of viable microorganisms that can be detected. Read full story (paywalled) Source: HSJ, 1 July 2022 -
Content ArticleNHS England’s report into blood culture practices outlines key improvement steps in the pre-analytical phase of the blood culture pathway. Through targeted recommendations to trust chief executives, clinical and pathology staff, we have an opportunity to improve the blood culture pathway, antimicrobial stewardship and patient outcomes from sepsis. This document sets out proposals to improve and standardise the pre-analytical phase of the blood culture pathway. It details the outputs of the antimicrobial resistance (AMR) diagnostics improvement workstream at NHS England and NHS Improvement, and examines the required changes to improve existing processes within the blood culture pathway. It concludes with a set of recommendations for best practice.
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News Article
New drugs to fight superbugs will save 1,700 lives a year
Patient Safety Learning posted a news article in News
Two drugs that combat superbugs are being introduced on the NHS, offering a lifeline to thousands of patients with deadly infections such as sepsis which fail to respond to antibiotics. About 65,000 people a year in the UK develop drug-resistant infections and 12,000 die, many after routine operations or from infections such as pneumonia or urinary tract infections. These superbugs such as MRSA have mutated to develop resistance to many different types of antibiotics as a result of overuse of the drugs. It means patients end up dying from common infections that would previously have been easily treatable with antibiotics. In a attempt to “turn the tide” on antibiotic resistance, the NHS has announced a deal for two drugs, cefiderocol and ceftazidime–avibactam, which can kill bacteria that is resistant to many other types of drugs. The drugs, manufactured by Shionogi and Pfizer respectively, will save the lives of about 1,700 patients a year. They will be offered to patients with conditions such as drug-resistant pneumonia, sepsis or tuberculosis who have run out of other treatment options. Amanda Pritchard, NHS chief executive, said this would make the UK a world leader in tackling “the global challenge of antimicrobial resistance”. Read full story (paywalled) Source: The Times, 15 June 2022 -
Content ArticleWhen something goes wrong in health and social care, the people affected and staff often say, "I don’t want this to happen to anyone else." These 'Learning from safety incidents' resources are designed to do just that. Each one briefly describes a critical issue - what happened, what the Care Quality Commission (CQC) and the provider have done about it, and the steps you can take to avoid it happening in your service.
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News Article
Multiple deaths due to care delays highlighted in damning CQC report
Patient Safety Learning posted a news article in News
Dozens of patients died or suffered ‘severe harm’ after long waits for ambulances during a three-month period in a health system facing ‘extreme pressure’ on its emergency services. The 29 serious incidents in Cornwall included patients waiting many hours for assistance despite being in “extreme pain”, patients having suspected sepsis, patients in cardiac arrest, and patients experiencing a stroke. The incidents were reported to the Care Quality Commission by staff at South Western Ambulance Service Foundation Trust during an inspection of the Cornwall integrated care system’s urgent and emergency care services. According to the CQC, the pressures on the ambulance service were “unrelenting”, while “significant work” was needed to “alleviate extreme pressure”. This meant there was a “high level of risk to people’s health when trying to access urgent and emergency care in the county”, the report said. Read full story (paywalled) Source: HSJ, 27 May 2022 -
News Article
Blackpool death: Abortion sepsis risk training inadequate
Patient Safety Learning posted a news article in News
Doctors are receiving "inadequate" training about the risk of sepsis after a mother-of-five died following an abortion, a coroner has warned. Sarah Dunn, 31, died of "natural causes contributed to by neglect" in hospital on 11 April 2020, an inquest found. Assistant coroner for Blackpool and Fylde, Louise Rae, said Ms Dunn had been treated as a Covid patient even though the "signs of sepsis were apparent". Her cause of death was recorded as "streptococcus sepsis following medical termination of pregnancy". In her record of inquest, the coroner noted Ms Dunn was admitted to Blackpool Victoria Hospital in Lancashire on 10 April 2020. She was suffering from a streptococcus infection caused by an early medical abortion on 23 March, which had produced sepsis and toxic shock by the time she was admitted to hospital. The coroner said "signs of sepsis were apparent" before and at the time of Ms Dunn's hospital admission but she was instead treated as a Covid-19 patient. "Sepsis was not recognised or treated by the GP surgery, emergency department or acute medical unit and upon Sarah's arrival at hospital, the sepsis pathway was not followed," she added. Read full story Source: BBC News, 19 May 2022 -
Content ArticleSarah Louise Dunn was admitted to the Blackpool Victoria Hospital on 10 April 2020. She was suffering from a Group A Streptococus infection following an early medical abortion on 23 March 2020 which by the time of her admission at hospital had produced sepsis and had progressed to toxic shock. Signs of sepsis were apparent before and on her admission given Sarah’s history and symptoms but Sarah was treated upon admission to hospital as a Covid-19 patient. Prior to admission, Sarah had not been seen by a doctor on either 9 or 10 April despite contacting both her GP surgery and the Out of Hours Service. The surgery pharmacist had not read Sarah’s notes properly and was not aware on 9 April that she had recently had undergone an early medical abortion. Her GP on 1 April had not recorded his face to face consultation with her nor noted the possibility of infection. Sepsis was not recognised or treated by the GP surgery, emergency department or Acute Medical Unit and upon Sarah’s arrival at hospital, the sepsis pathway was not followed. Antibiotics were not given to Sarah until 7.5 hours after her arrival at hospital. Sarah suffered a seizure at 6.30pm on the Acute Medical Unit and was transferred to the Intensive Care Unit. These matters in aggregate impacted on her care and Sarah would not have died had she been admitted to hospital sooner. Sarah died on 11 April 2020 on the Intensive Care Unit at Blackpool Victoria Hospital at 2.15am.
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EventThe Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include National Developments including the recent recommendations on NEWS2 and Covid-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis & Covid-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for the discount code Follow the conference on Twitter @HCUK_Clare #DeterioratingPatient
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News Article
Hospital admits negligence over failings leading to baby’s sepsis death
Patient Safety Learning posted a news article in News
A hospital has admitted clinical negligence over maternity care failings that led to the potentially avoidable death of a 10-day-old baby, The Independent has learned. Kingsley Olasupo and his twin sister Princess were born on 8 April 2019 at Royal Bolton Hospital. Kingsley died 10 days later following a catalogue of mistakes, which included failing to screen him for sepsis. Kingsley and his sister were born premature at 35 weeks. Three days later he was admitted to the special care unit due to a low temperature and “poor” feeding. Despite being reviewed by two doctors he was not screened for an infection and not given antibiotics. His condition deteriorated and on 12 April he was diagnosed with bacterial meningitis and sepsis. Days later scans revealed he had severe brain damage and would not survive. Kingsley’s family said they had been “torn apart” by their son’s death and had pursued the trust to ensure a full independent investigation was carried out and lessons learnt. BFT launched an investigation into Kingsley’s care after Mr Olasupo and Ms Daley raised concerns over their son’s death. According to the trust’s investigation report, seen by The Independent, failings in care included that Kingsley was not screened for sepsis despite several “red flags”. Had this been done he would have been given antibiotics. When midwives first escalated concerns to the neonatal team no physical medical review of Kingsley took place. The investigation also found neonatal staff did not carry out daily reviews, and reviews that were done were incomplete and contained “inaccurate” and “misleading” information. Other failings included: “Ineffective” assessment of Kingsley’s wellbeing on the postnatal ward Poor communication between staff and poor handover processes No consideration was given to the fact Kingsley was not feeding well Inadequate recording of observations. Read full story Source: The Independent, 20 April 2022 -
Content ArticleThis article by the US Centers for Disease Control and Prevention (CDC) provides advice for patients about steps they can take to help avoid catching healthcare-associated infections, which can ultimately lead to sepsis and even death. It outlines ten things patients and their families can do to protect themselves or their loved ones while receiving medical care. Speak up Keep hands clean Ask each day if your central line catheter or urinary catheter is necessary Prepare for surgery Ask your healthcare provider, “Will there be a new needle, new syringe, and a new vial for this procedure or injection?” Be antibiotics aware Watch out for deadly diarrhoea (aka Clostridium difficile) Know the signs and symptoms of infection Get vaccinated Cover your mouth and nose
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News Article
Girl, 13, likely to have survived if moved to intensive care, coroner rules
Patient Safety Learning posted a news article in News
A 13-year-old girl who died after contracting sepsis in an NHS hospital probably would have survived if doctors had identified the warning signs and transferred her to intensive care earlier, a coroner has ruled. Martha Mills was the first ever child to die at King’s College hospital (KCH) with a pancreatic injury of the type she sustained in a fall from her bike on an off-road family trail in Wales while on holiday last year. She was transferred to the south London hospital because it is one of three national centres for the care of children with pancreatic trauma. An inquest at St Pancras coroner’s court, north London, heard that several opportunities were missed to refer Martha to intensive care, which probably would have saved her life. In an emotional witness statement, Martha’s mother, Merope, said that after their daughter contracted an infection on 21 August last year, she and her husband, Paul Laity, raised concerns about Martha’s deteriorating health a number of times but doctors sought to reassure them rather than escalate her care. Mills said in her statement that she explicitly raised her fears about Martha going into septic shock over the bank holiday weekend. On 29 August, Martha had high fever, low blood pressure, a racing heart and a rash, which was misdiagnosed by a junior doctor despite Mills voicing her concern that it was caused by sepsis. It was only the next day that Martha was admitted to paediatric intensive care. “I felt that my anxieties about all of Martha’s symptoms, and especially what they might mean when put together and considered in the round, weren’t given proper acknowledgement,” Mills told the court. Prof William Bernal, who produced a serious incident report on Martha’s death for KCH, said there were at least five occasions when she should have had a critical care review. He wrote that Martha’s chances of survival “would have been greatly increased” if she had been admitted to critical care earlier. The inquest heard that KCH was making changes in the wake of Martha’s death, including improving diagnostics and taking account of parents’ views. Read full story Source: The Guardian, 3 March 2022 -
News Article
Failure to act on sepsis led to man’s death
Patient Safety Learning posted a news article in News
A man died after an NHS trust failed to diagnose and treat sepsis quickly enough, a Parliamentary and Health Service Ombudsman investigation has found. Stephen Durkin died after suffering organ failure from sepsis. Stephen’s wife Michelle made a complaint to the Ombudsman after she was left floored by his sudden death which she believed was avoidable. Stephen was an otherwise healthy 56-year-old when he attended Wye Valley Trust A&E in July 2017 with chest pain. Hospital staff suspected he had a major blood vessel blockage and admitted him to a ward overnight. The next morning his overall condition had worsened but staff did not monitor him more closely, as national guidance advises, and he continued to deteriorate throughout the day. The next day Stephen was admitted to intensive care and treated for sepsis but tragically died later that evening. In the space of 48-hours his condition deteriorated rapidly but staff did not act quickly enough and the critical care team attended Stephen ten hours too late. His wife Michelle arrived at the hospital to visit Stephen, only to find that he was critically ill and unresponsive. She was left devastated by his death and turned to the Ombudsman to look into what had happened with his care. Ombudsman Rob Behrens said: "Stephen’s tragic death could so easily have been avoided. His case shows why early detection of sepsis, as set out in national guidelines, is crucial." "Sadly, this is not the first time we have had to highlight this issue. There is clearly more the NHS needs to do. It is vital that NHS trusts ensure their staff are sepsis-aware to reduce the number of avoidable deaths from this life-threatening condition." Read full story Source: PHSO, 3 March 2022
