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Found 128 results
  1. News Article
    A six-year-old girl thought to have died from sepsis was in fact suffering from a blood condition triggered by E coli infection, an inquest has found. Coco Rose Bradford was taken to the Royal Cornwall hospital in the summer of 2017 suffering from stomach problems and later transferred to the Bristol Royal hospital for children, where she died. The following year an independent review flagged up failings in her care in Cornwall and the Royal Cornwall hospitals trust apologised for how it had treated her. Her family were left with the belief she had died of sepsis and could have been saved if she had been given antibiotics. But on Friday, coroner Andrew Cox, sitting in Truro, found that Coco died from multiple organ failure caused by haemolytic uraemic syndrome (HUS). The inquest heard there is no proven treatment for HUS. Cox said Coco’s family had been misled over the sepsis diagnosis, which he said was deeply regrettable, adding: “As a matter of fact, I find Coco had overwhelming HUS, not overwhelming sepsis.” During the inquest, the court heard Coco’s family felt staff at the Cornish hospital were “dismissive, rude and arrogant” and did not take her condition seriously. Cox found that although staff had recognised the risk of HUS from the moment Coco was admitted, this was not clearly set out in a robust management plan. The coroner also said a lack of communication had made Coco “something of a hostage to fortune”. Read full story Source: The Guardian, 14 January 2022
  2. News Article
    Advice on how new mothers with sepsis should be treated is to change after two women died of a herpes infection. The Royal College of Obstetricians and Gynaecologists says viral sources of infections should be considered and appropriate treatment offered. This comes after the BBC revealed one surgeon might have infected the mothers while performing Caesareans on them. The East Kent Hospitals Trust said it had not been possible to identify the source of either infection. Kimberley Sampson, 29, and Samantha Mulcahy, 32, died of an infection caused by the herpes virus 44 days apart in 2018, shortly after giving birth by Caesarean section. Their families were told there was no link between the deaths but BBC News revealed on Monday that both operations had been carried out by the same surgeon. Documents we uncovered showed that the trust had been told two weeks after the second death that "it does look like surgical contamination". Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, which set standards in maternity care, said routine investigation and management of maternal sepsis "should always consider viral sources of infection, and appropriate changes should be instituted to support earlier diagnosis and treatment". Medics treating Ms Sampson and Mrs Mulcahy assumed they were suffering from a bacterial infection and didn't prescribe the anti-viral medication that may had saved their lives. The Royal College said the two deaths should be "fully investigated" as "surgical infection appears to be a significant possibility". But BBC News has learned that the East Kent Hospitals Trust, which treated both women, never told the coroner's office that the same surgeon had carried out both operations or that an investigation they had ordered had suggested the virus strains the two women had died from appeared to be "epidemiologically linked". Read full story Source: BBC News, 23 November 2021
  3. News Article
    An acute trust has been fined £2.5m after pleading guilty to charges of failing to provide safe care after the deaths of two patients. The Care Quality Commission brought charges against The Dudley Group Foundation Trust earlier this year over care failings in two separate cases which the regulator said exposed two patients to “significant risk of avoidable harm”. The trust pleaded guilty to the charges in July and was fined during a sentencing hearing today. The cases, involving 33-year-old mother of six Natalie Billingham, and 14-year-old Kaysie-Jane Bland [also known as Kaysie-Jayne Robinson], were both in 2018 and related to care at the trust’s Russells Hall Hospital in Dudley. Ms Billingham was admitted to Dudley’s Russells Hall Hospital with numbness in her right foot on 28 February 2018 and died on 2 March of organ failure caused by a “time critical” infection. The court was told she was initially thought to have a deep vein thrombosis after a three-minute triage that failed to identify "disordered" observations. The hospital then had multiple reasons to reconsider the initial diagnosis, but opportunities for review were "missed or ignored". In the case of Kaysie-Jane, who had cerebral palsy, an "early warning score" was inaccurate, meaning a sepsis screening tool was not triggered. The CQC said the care both patients received at Russells Hall Hospital was undermined by the Dudley Group’s failure to address known safety failings which the regulator repeatedly raised with the trust in the months before their deaths. The CQC said the trust did not take all reasonable steps to make improvements, despite its intervention. The trust has denied it did not react to the concerns raised. Failings included errors in the hospital’s initial assessments and monitoring of both patients, which hindered the timely escalation of concerns. A lawyer acting on behalf of the Dudley Group NHS Foundation Trust had admitted the trust failed to provide treatment in a safe way, resulting in harm, in February and March 2018. Read full story (paywalled) Source: HSJ, 19 November 2021
  4. News Article
    An investigation into the outbreak of a bacterial infection that killed 15 people has found there were several “missed opportunities” in their care. Mid Essex Clinical Commissioning Group has released the outcome of a 10-month investigation into a Strep A outbreak in 2019, which killed 15 people and affected a further 24. The final report was critical of Provide, a community interest company based in Colchester, as well as the former Mid Essex Hospital Services Trust (now part of Mid and South Essex Foundation Trust). It said: “This investigation has identified that in some cases there were missed opportunities where treatment should have been more proactive, holistic and timely. These do not definitively indicate that their outcomes would have been different.” Investigators found that 13 of the 15 people that died had received poor wound care from Provide CIC. They reported that inappropriate wound dressings were used and record keeping was so poor that deterioration of wounds was not recognised. Even wounds that had not improved over 22 days were not escalated to senior team members for help or referred to the tissue viability service for specialist advice, with investigators told this was often due to concerns over team capacity. The report, commissioned by the CCG and conducted by consultancy firm Facere Melius, said: “[Some] individuals became increasingly unwell over a period of time in the community, yet their deterioration either went unnoticed or was not acted upon promptly. Sometimes their condition had become so serious that they were very ill before acute medical intervention was sought”. Other findings included delays in the community in the taking of wound swabs to determine if the wound was infected and by which bacteria. It said in one case nine days elapsed before the requested swab took place. Even after Public Health England asked for all wounds to be swabbed following the initial outbreak, this was only conducted on a single patient. In other cases there were delays in patients being given antibiotics and this “could have had an adverse impact on the treatment for infection”. It also found that sepsis guidelines were not accurately followed, wounds were not uncovered for inspection in A&E, and some patients were given penicillin-based antibiotics despite penicillin allergies being listed in their health records. Read full story (paywalled) Source: HSJ, 17 September 2020
  5. News Article
    Some hospitals are using an out of date triaging tool for emergency patients suffering from sepsis that could leave them at risk of harm. A warning has been issued to NHS trusts to make sure their triage tools are up to date with the latest advice after several reported incidents in accident and emergency departments. The Royal College of Emergency Medicine flagged the risk to NHS England in a letter seen by The Independent warning patients could come to harm if action wasn’t taken. NHS England and NHS Digital has issued an alert to hospital chief executives warning of a potential safety risk. It told members: “The latest version of the system has updated treatment priorities especially in relation to the treatment of adult and paediatric sepsis. It is therefore crucial that if your organisation uses the Manchester Triage System clinical risk management triage tool, please ensure that the most recent version is being used and where this is not the case, specific local mitigation for the risks is in place.” It added that hospitals should ensure the latest versions of any clinical systems were being used to safeguard patient care. Read full story Source: The Independent, 8 April 2021
  6. News Article
    A young NHS patient suffering a sickle cell crisis called 999 from his hospital bed to request oxygen, an inquest into his death was told. Evan Nathan Smith, 21, died on 25 April 2019 at North Middlesex Hospital, in Edmonton, north London, after suffering from sepsis following a procedure to remove a gallbladder stent. The inquest heard Smith told his family he called the London Ambulance Service because he thought it was the only way to get the help he needed. Nursing staff told Smith he did not need oxygen when he requested it in the early hours of 23 April, despite a doctor telling the inquest he had “impressed” on the nurses he should have it. Smith’s sepsis is thought to have triggered the sickle cell crisis – a condition that causes acute pain as blood vessels to certain parts of the body become blocked. Barnet Coroner's Court heard Smith, from Walthamstow in east London, might have survived if he had been offered a blood transfusion sooner but the hospital’s haematology team were not told he had been admitted. Read full story Source: The Independent, 3 April 2021
  7. Event
    The 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
  8. Event
    The 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 from the Royal College of Physicians 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 not only in an acute setting but also in the community 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 member receive a 20% discount. Email info@pslhub.org for the code. Follow on Twitter @HCUK_Clare #deterioratingpatient
  9. Event
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  10. Content Article
    NHS 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.
  11. Content Article
    Sarah 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.
  12. Content Article
    This 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.
  13. Content Article
    This 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
  14. Content Article
    On 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.
  15. Content Article
    Sharing 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.
  16. Content Article
    Ryan 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.
  17. Content Article
    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.
  18. Content Article
    When 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.
  19. Content Article
    Sepsis 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.
  20. Event
    The 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 from the Royal College of Physicians 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 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. Follow the conference on Twitter #deterioratingpatient Register
  21. Event
    This year’s programme brings together highly ranked representatives of international and national healthcare authorities, NGOs, policymakers, clinical scientists, researchers, and pioneers in healthcare improvement with the unified goal of improving AMR and sepsis healthcare around the world. The objectives of this free Spotlight online congress are to review achievements, challenges, and potential solutions to combat the threats posed by AMR and sepsis globally. Speakers will describe the current global epidemiology and burden of sepsis and AMR, explore a future research agenda, provide an overview of lessons and challenges from the COVID-19 pandemic and recent Ebola outbreaks, and ultimately explore innovative and cost-effective approaches to preventing and combating sepsis and AMR. The WSC Spotlight is a free online congress and is attended by a large number of clinicians, health decision-makers, and other health workers. For example, more than 40,000 people from 160 countries tuned in to the 2017 WSC Spotlight on maternal and neonatal sepsis (and accessed more than 300,000 times on YouTube and Apple Podcasts in the following weeks). Moreover, at the occasion of this congress, WHO will launch the first Global report on the epidemiology and burden of sepsis. The report describes results from original research and existing published evidence, the methodologies and limitations of the studies, and identifies gaps and priorities for future research. Programme and registration
  22. Event
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    A FREE and LIVE virtual event made up of five educational webinars, Tuesday 8th - Thursday 10th September 2020. Co-produced by BD and Health Plus Care. Looking at the blood culture pathway is relevant to all of us right now. The crossover in symptoms between coronavirus and sepsis, means early diagnosis is even more urgent. We are all moving away from the mentality of 'just in time' to 'just in case'. Our speakers have been handpicked for their expertise in diagnostics, in clinical settings, and as known advocates for patient safety. They will examine what methods and best practices are available, as well as reflecting on the current mood and change in priorities within healthcare. This is against a backdrop of UKI guidelines, the UK’s diagnostic strategy and what the future of blood cultures could look like. You will have the chance to hear real life UK customer stories, and our final session will end with a panel discussion chaired by Ed Jones, former Chief of Staff to the UK Foreign Secretary, Jeremy Hunt MP. The panel features Lord O’Shaughnessy, and Dr Ron Daniels, and will tackle the issues around blood cultures and testing in the current COVID-19 climate. Further information and registration
  23. Content Article
    This blog, from the US-based Patient Safety Movement, tells the story of Gabriella Galbo who died of preventable causes. The systems that were supposed to keep her safe and bring her back to health were established on an unreliable, fragmented foundation with no checks and balances and certainly no person-centered culture of safety. Gabby’s full story can be read via the link below, as told by her father, Tony. Included are tips from Tony for using your voice to prompt tangible action and to ensure policies are in place to prevent medical errors, like those experienced by Gabby.
  24. Content Article
    This Take, Treat and Test webinar took place on 10 September 2020, presented by Dr Ron Daniels, Founder, and Executive Director – Clinical – Sepsis Trust UK and Consultant in Critical Care and Anaesthesia, University Hospitals Birmingham NHS Foundation Trust.
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