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Showing results for tags 'Skill-based issue'.
Found 65 results
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News Article
Resident died after treatment at failing care home
Patient Safety Learning posted a news article in News
A resident at an inadequate care home died after their blood glucose increased to high levels and staff acted too slowly, a report found. Inspectors said The Berkshire Care Home in Wokingham breached guidelines in nine areas and must improve. They found residents were put at risk after medicines were not used properly and that records were not up to date. The Care Quality Commission (CQC) said an ambulance was only called for the person who died when they were found to be unresponsive. They later died in hospital. Its report said staff were "not sufficiently skilled" to safely care for people with diabetes. A resident was given paracetamol and co-dydramol eight times over three days, when they should not be used together because they both contain paracetamol, the report said. Another person was burned by a cup of tea and staff did not treat the injury properly, leading to the person developing an infection and later being admitted to hospital. Staff sometimes felt "rushed and under pressure", the report found. Read full story Source: BBC News, 18 December 2021 -
News ArticleThe deaths of three adults with learning disabilities at a failed hospital should prompt a review to prevent further "lethal outcomes" at similar facilities, a report said. The report looked at the deaths of Joanna Bailey, 36, and Nicholas Briant, 33, and Ben King, 32, between April 2018 and July 2020. It found here were significant failures in the care of the patients at Jeesal Cawston Park, Norfolk. Ms Bailey, who had a learning disability, autism, epilepsy and sleep apnoea, was found unresponsive in her bed and staff did not attempt resuscitation, while the mother of Mr King said he was "gasping and couldn't talk" when she last saw him. Mr Briant's inquest heard he died following cardiac arrest and obstruction of his airway after swallowing a piece of plastic cup. The report found: "Excessive" use of restraint and seclusion by unqualified staff. Concerns over "unsafe grouping" of patients. Overmedication of patients. High levels of inactivity and days of "abject boredom". Relatives described "indifferent and harmful hospital practices" and said their questions and "distress" were ignored Joan Maughan, who commissioned the report as chairwoman of the Norfolk Safeguarding Adults Board, said: "This is not the first tragedy of its kind and, unless things change dramatically, it will not be the last." Read full story Source: BBC News, 9 September 2021
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News ArticleNearly 500 women had to have their cervical smear tests redone after it emerged the nurse who carried them out was not qualified. 'Dishonest' Alison Watts failed to tell her bosses at an NHS surgery that she failed her course and continued screening women for almost two and a half years. When it was discovered Watts had not passed the qualification, 461 women had to be recalled to have the cervix test again so they could have 'quality assured' tests. Now Watts has been struck off for the shocking breach of trust, with a tribunal ruling that she put patients at 'significant risk of harm'. A Nursing and Midwifery Council [NMC] report said: 'This was not a single instance of misconduct but involved 461 patients over a two year period. There is evidence of sustained dishonesty and deep-seated attitudinal issues.' Read full story Source: Daily Mail, 26 January 2021
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News ArticleStaff at a specialist care unit did not attempt to resuscitate a woman with epilepsy, learning difficulties and sleep apnoea when she was found unconscious, an inquest heard. Joanna Bailey, 36, died at Cawston Park in Norfolk on 28 April 2018. Jurors heard she was found by a worker whose CPR training had expired, and the private hospital near Aylsham - which care for adults with complex needs - had been short-staffed that night. Support worker Dan Turco told the coroner's court he went to check on Ms Bailey just after 03:00 BST and found she was not breathing and had blood around her mouth. The inquest heard he went to get help from colleagues, including the nurse in charge, but no-one administered CPR until paramedics arrived. It was heard Mr Turco's CPR training had lapsed in the weeks before Ms Bailey died, unbeknown to him. Mr Turco said he had since received training and has had his first aid qualifications updated. Cawston Park, run by the Jeesal Group, a provider of complex care services within the UK, is currently rated as "requires improvement" by the Care Quality Commission. Read full story Source: BBC News, 23 November 2020
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News Article
Barnsley care agency 'recruitment procedures unsafe'
Patient Safety Learning posted a news article in News
A care agency which left people "at risk of avoidable harm" by not ensuring staff had been properly trained has been put into special measures. Stars Social Support, which provides personal care to people living in their own home, was inspected by the Care Quality Commission earlier this year. Inspectors found safe recruitment procedures were not in place to make sure suitable staff were employed. A report following the inspection states that "safe recruitment procedures were not in place to ensure only staff suitable to work in the caring profession were employed." It said people's references had not been followed up after they had been requested, according to the Local Democracy Reporting Service. The report added: "When the disclosure and barring service (DBS) identified concerns, a risk assessment had not been completed to assess staff suitability." Inspectors also found not all staff who provided care had received appropriate training or training updates to ensure they were competent. Read full story Source: BBC News, 21 November 2020 -
News Article
Alfreton's Field House mental health unit in special measures
Patient Safety Learning posted a news article in News
A mental health unit where a patient was found dead has been placed into special measures over concerns about safety and cleanliness. Field House, in Alfreton, Derbyshire, was rated "inadequate" by the Care Quality Commission (CQC) following a visit in August. A patient died "following use of a ligature" shortly after its inspection, the CQC said. Elysium, which runs the unit for women, said it was "swiftly" making changes. The inspectors' verdict comes after the unit was ordered to make improvements, in January 2019. Dr Kevin Cleary, the CQC's mental health lead, said: "There were issues with observation of patients, a lack of cleanliness at the service and with staffing. "There were insufficient nursing staff and they did not have the skills and experience to keep patients safe from avoidable harm. Bank and agency staff were not always familiar with the observation policy." "It was also worrying that not all staff received a COVID-19 risk assessment, infection control standards were poor, and hand sanitiser was not available in the service's apartments." The CQC said a follow-up inspection on Monday had showed "areas of improvement" but it would continue to monitor the service. Read full story Source: BBC News, 22 October 2020 -
News Article
NHS 'failing' patients living with HIV
Patient Safety Learning posted a news article in News
The failure to address the mental-health needs of people with HIV could lead to an increase in infections, a cross-party group of MPs suggests. People with HIV are twice as likely to experience mental-health difficulties. However, in those with depression, support raises adherence to medication by 83%. But most HIV clinics have no mental-health professionals on staff, which, the MPs say, could be reversing progress made over the past decade toward ending the epidemic in the UK. The All-Party Parliamentary Group (APPG) on HIV and AIDS met with patients living with HIV at a range of hospital trusts throughout England, as well as numerous healthcare professionals. Unless serious mental-health treatment shortfalls are addressed, the government will fail to achieve its target of zero transmissions by 2030, its report says. Read full story Source: BBC News, 5 March 2020 -
News Article
Children with arthritis 'facing delays to diagnosis'
Patient Safety Learning posted a news article in News
Delays diagnosing and treating children with arthritis are leaving them in pain and at a higher risk of lifelong damage, a national charity has warned. Arthritis is commonly thought to affect only older people, but 15,000 children have the condition in the UK. Versus Arthritis says many children are not getting help soon enough. The NHS said: "Arthritis in young people is rare and diagnosing it can be difficult because symptoms are often vague and no specific test exists." Zoe Chivers, Head of Services at Versus Arthritis, said: "We know that young people often face significant delays getting to diagnosis simply because even their GPs don't recognise that it's a condition that can affect people as young as two. It's often considered that they're just going through growing pains or they've just got a bit of a viral infection and that's not the case." Read full story Source: BBC News, 12 February 2020 -
News ArticlePatients were harmed at a Midlands trust because of delays in receiving outpatients and diagnostics appointments, the Care Quality Commission (CQC) has warned. Following the inspection at Northern Lincolnshire and Goole Foundation Trust in September and October last year, the CQC has lowered the trust’s rating in its safety domain from “requires improvement” to “inadequate”. It warned there were insufficient numbers of staff with the right skills, qualifications and experience to “keep patients safe from avoidable harm”. The report noted the trust had identified incidents in 2018 and 2019 where patients had come to harm due to delays in receiving appointments in outpatients, particularly in ophthalmology. Ten patients were found to have come to low harm, one patient moderate harm and two patients severe harm. The CQC also issued a Section 31 letter of intent to seek further clarification in relation to incidents where patients had come to harm because of delays to receiving appointments in outpatients and diagnostic imaging, although it has confirmed the trust has provided details on how it is going to manage the issues raised. The watchdog said it would continue to monitor the issue. Read full story (paywalled) Source: HSJ, 7 February 2020
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News Article
Cosmetic nurse leaders issue warning over Scottish regulation plans
Patient Safety Learning posted a news article in News
Proposals by the Scottish Government to give a licence to unregistered professionals to carry out cosmetic procedures are “fundamentally flawed” and put lives at risk, leading nurses in the field have warned. A consultation has been launched seeking views on plans for a new regulatory regime of non-surgical aesthetic treatments that pierce or penetrate the skin like dermal fillers or lip enhancements. Ministers want to bring non-health professionals under existing legislation allowing them to obtain a licence to perform these procedures in unregulated premises such as beauty salons and hairdressers. The move comes after a UK-wide review carried out in 2013, by then NHS medical director Sir Bruce Keogh, identified that little regulation existed within the cosmetic industry. Since then there has been growing concern that people are coming to physical and psychological harm from treatments gone wrong. Leaders at the British Association of Cosmetic Nurses (BACN) told Nursing Times that they were “totally opposed” to non-medical practitioners carrying out injectable beauty procedures. BACN Chair Sharon Bennett said holding a medical, nursing or dentistry qualification should be a “basic prerequisite” before being accepted to an aesthetics training course. SHe said BACN believed even clinically trained practitioners, including nurses, needed further training in aesthetics before working in this “specialist” area. “[This is] because there is no educational framework, training or statutory provision to establish or task beauty therapists to detect disease, care for patients or carry out medical treatment, so to do so would breach public health safety and endanger lives.” Read full story Source: The Nursing Times, 20 January 2020 -
Content Article
How to undertake intravenous infusion calculations
Patient Safety Learning posted an article in Nursing
As part of the Nursing Standard's 'How to' series, Jane Brindley, a senior lecturer in adult nursing, provides a step-wise, practical approach to undertaking intravenous (IV) infusion calculations. The article also explores the evidence base behind medication errors in relation to calculations. -
News Article
Somerset care home failed to notify health watchdog of deaths
Patient Safety Learning posted a news article in News
A residential care home failed to notify the health watchdog about the deaths of people they were providing a service to, its report has found. Kingdom House, in Norton Fitzwarren, run by Butterfields Home Services, was rated "requires improvement". The home cares for people with conditions such as autism. The Care Quality Commission (CQC) said the registered manager and provider lacked knowledge of regulations and how to meet them. Inspectors found the provider failed to notify the CQC about the deaths of people which occurred in the home, as required by Regulation 16 of the Health and Social Care Act 2008. The report also found people were at "increased risk" because the provider had not ensured staff had the qualifications, competence, skills and experience to provide people with safe care and treatment. Inspectors did, however, praise the "positive culture" at the home, that is "person-centred", and noted the provider was "passionate about their service and the people they cared for". Read full story Source: BBC News, 2 January 2020 -
Content Article
Put an end to cannula site infections!
Claire Cox posted an article in Other hospital-based clinical areas
This presentation written by Dr Gordon Caldwell, a Consultant Physician at Lorn and Islands Hospital, Oban, Argyll, Scotland, highlights the importance of surveillance and actions to be taken around prevention of infection of cannlula sites. -
Content ArticleCritical care teams frequently have to deal with uncertainty of prognosis and outcome, simultaneously react to changing physiology with resuscitative measures, consider palliative interventions and communicate (with empathy) rapidly changing situations to patients and families during very distressing times. Shared decision-making is regarded as best practice but lack of capacity often precludes this. If more information about patients’ wishes and beliefs were available ICU teams would be better positioned to make Best Interests decisions, enabling individualised care, thereby minimising confusion and conflict due to clear communications about advance care planning.
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Content ArticleThis report by the Royal College of Nursing has been produced from the analysis of a workforce survey designed to explore the employment and role-specific training and continuing professional development (CPD) of registered nurses and unregistered support staff working in maternity services across the UK.
