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Showing results for tags 'Skill-based issue'.
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News Article
Unregulated ‘eating disorder coaches’ putting people at risk, say experts
Patient Safety Learning posted a news article in News
Vulnerable mental health patients are being put at risk by unregulated “eating disorder coaches” who do not have the necessary qualifications, experts have said. As demand for eating disorder support soars – hospital admissions for eating disorders increased by 84% in the last five years – more people are filling gaps in NHS care. So-called eating disorder coaches, who tend to be personal trainers or dietitians recovering from the illness themselves, are charging as much as £1,000 a month for sessions to offer support to others despite having little or no training and expertise. The Guardian has found that many coaches cite short courses, which are intended as professional development for psychologists, as a qualification to practise. The National Centre for Eating Disorders (NCED) offers a number of professional training courses, accredited by the British Psychological Society (BPS). The Guardian found a number of coaches were using these courses to claim they were qualified to offer professional services to people with eating disorders. Agnes Ayton, chair of the Royal College of Psychiatrists’ eating disorders faculty, said she was “amazed” to see people “advertising themselves as experts after going on one course”. “Eating disorders sit between physical and mental health so the risks associated with eating disorders can be physically debilitating and potentially fatal,” Ayton said. “I don’t know why there is not better regulation on that because there is lots of regulation for a medical professional – but therapy is the first line of treatment for eating disorders, and if it is not delivered properly, it can be harmful or misleading.” Read full story Source: The Guardian, 21 March 2023- Posted
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Two health watchdogs have issued safety warnings after junior staff were left to work unsupervised on maternity wards previously criticised after a baby’s death. Training regulator, Health Education England (HEE), criticised the “unacceptable” behaviour of consultants who left junior doctors to work without any superiors at South Devon and Torbay Hospital Foundation Trust’s wards. The maternity safety watchdog Healthcare Safety Investigation Branch (HSIB) also raised “urgent concerns” over student midwives and “unregistered midwives” providing care without supervision. The latest criticism comes after the trust was condemned over the death of Arabella Sparkes, who lived just 17 days in May 2020 after she was starved of oxygen. According to a report from December 2022, seen by The Independent, the HEE was forced to review how trainees were working at the trust’s maternity department after concerns were raised to the regulator. It was the second visit carried out following concerns about the department, and reviewers found there had been “slow progress” against concerns raised a year earlier. Read full story Source: The Independent, 16 February 2023- Posted
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Surgeon given warning over life-changing injuries
Patient Safety Learning posted a news article in News
A Norfolk surgeon who left two patients with life-changing injuries has received a formal warning by a disciplinary panel. Camilo Valero Valdivieso was found guilty of "serious misconduct" by an independent medical panel after two operations went wrong in six days. One of his patients, Paul Tooth, 65, said his life was "a constant struggle" since his operation in January 2020. However, the panel found the surgeon had "learned from these events". The findings from the Medical Practitioners Service (MPTS) panel said that his actions had "risked damaging public confidence in the profession". It heard that he twice "misinterpreted the anatomy" - on one occasion severing a patient's gallbladder. The panel also concluded Mr Valero's fitness to practise was not currently impaired, allowing him to continue working. Read full story Source: BBC News, 7 February 2023- Posted
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Content Article
How to undertake intravenous infusion calculations
Patient Safety Learning posted an article in Nursing
Key points Medication errors are the most common type of error affecting patient safety and the most common single, preventable cause of adverse events. Medicines calculations can assist in preventing an inaccurate medicines dose from being administered to the patient, which could result in suboptimal therapeutic benefit and/or possible harm to the patient. It is crucial for IV infusion calculations to be accurate, because these medicines directly enter the venous system and generally have a prompt action. Therefore, there is limited possibility of removing the medicine if an error is made. Individual nurses and healthcare organisations must ensure that medicines calculation skills are developed and maintained in practice.- Posted
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Put an end to cannula site infections!
Claire Cox posted an article in Other hospital-based clinical areas
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This document from the Faculty of Intensive Care Medicine (full and abridged versions) plus the accompanying lay summary provides recommendations for effective decision-making and resources for clinical teams and the general public. It hopes to encourage open, clear, honest discussions with patients and families enabling improved advance care. Such arrangements will enhance care planning and empower patients, carers and clinical teams to better engage in shared decision-making processes that respect both the philosophical and physiological aspects of individuals’ lives.- Posted
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The aim of the UK-wide survey was to obtain a snapshot of the structure of, and role-specific training and CPD provision for, the non medical, non-midwifery maternity workforce. The objectives were to: determine the ratio of unregistered staff to registered midwives in the maternity services determine the number of maternity services where nursing associates were employed determine the number of maternity services where registered nurses were employed in areas other than neonatal care determine the areas of work for registered nurses in maternity care gather information about the role-specific training offered to non-midwives at induction and as CPD during employment. This survey is intended to add to the conversation on some aspects of the workforce and skill mix in maternity services. As a result of the findings the following recommendations are made: the opportunity should be created for a stakeholder engagement event to disseminate findings and consider aspects requiring further exploration, which may include: future training needs analysis work to explore role-specific training for non-midwifery staff (registered or unregistered) in maternity services, to clarify what should be provided. to look at utilising these findings in the wider work being carried out within the RCN safe and effective staffing campaign (RCN 2019). Although the RCN campaign is focused on nursing, these survey results may inform work on both midwifery and nursing staffing.- Posted
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News Article
Governance scandal trust failing to manage complaints
Patient Safety Learning posted a news article in News
A trust which is facing major governance issues is failing to respond to hundreds of complaints properly, with patients and families waiting more than twice as long as the NHS target for responses to their concerns, an external review has found. Cornwall Partnership Foundation Trust, which is subject to regulatory action by NHS England, was found to be “not classifying complaints, concerns and comments accurately”, while staff had “no formal training”, meaning complaints were “not investigated appropriately”. Last year, the trust was embroiled in a governance scandal in which NHSE investigated multiple allegations of finance and governance failings, resulting in the departure of former CEO Phil Confue. Rachel Power, chief executive of the advocacy group Patients Association, told HSJ patient complaints often contain “vital intelligence” on how trusts can improve services and “essential warnings about any area where things might be going wrong”. According to the review, the backlog had stemmed from several factors. These included more work being needed on investigations that had not been thorough enough, and the relevant service teams not responding to enquiries by the complaints team. Additionally, there was a “lack of formal monitoring and review” to ensure complaint points were reported appropriately and consistently, and an “apparent lack of accountability by local teams for complaints” triaged through the trust’s patient liaison and complaints team. Read full story (paywalled) Source: HSJ, 12 April 2022- Posted
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Five hospital wards run with one registered nurse each
Patient Safety Learning posted a news article in News
Five wards at Scotland's largest hospital had to operate with one registered nurse on duty each. Staff at the Queen Elizabeth University Hospital in Glasgow experienced the shortage on Monday night. It is an example of the severe pressure affecting health services across the country, which has intensified due to the Covid-19 pandemic. Greater Glasgow and Clyde health board said nurses were supported by a number of other staff. Originally reported in the Daily Record, the shortage was described to staff in an email sent on Monday afternoon. The email said nurse staffing levels across medicine were critical, despite attempts to seek support from bank or agency workers. It said admin staff had been asked to stay on to offer support including answering phones and door buzzers for the rest of the week. As well as staffing problems, the pandemic has caused more bed blocking in Scotland's hospitals and longer waits for both emergency and outpatient treatment. Norman Provan, associate director at the Royal College of Nursing Scotland said the shortage had an impact on patient safety as well as staff wellbeing - concerns that had been raised with the health board and the Scottish government. He added: "We're in this situation largely because of the failure of Scottish government to address the nursing workforce crisis, which has seen registered nurse vacancies reach a record high. "Urgent action is needed to protect patient safety, address staff shortages and demonstrate that the nursing workforce is valued as a safety critical profession." Read full story Source: BBC News, 24 July 2022- Posted
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News Article
Gloucestershire maternity service failures 'putting women and babies at risk'
Patient Safety Learning posted a news article in News
A shortage of maternity staff is putting women and babies at risk in Gloucestershire, inspectors have said. The county's maternity services have been downgraded by two levels, from good to inadequate, by the Care Quality Commission (CQC). Its report highlighted staff shortages, missed training, exhaustion among workers and concerns over equipment. Gloucestershire Hospitals NHS Foundation Trust issued an apology and said improvements have been made. CQC inspectors visited maternity wards, birth units and community midwives in Gloucester, Cheltenham and Stroud in April after receiving concerns about the "culture, safety and quality of services". They found the service did not have enough midwifery staff with the "right qualifications, skills, training and experience to keep women safe from avoidable harm or to provide the right treatment all the time". Read full story Source: BBC News, 22 July 2022- Posted
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- Maternity
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News Article
Student paramedics are missing out on learning how to save lives because they are wasting hours in ambulances outside A&E instead of attending calls, it has been revealed. The College of Paramedics and ambulance directors say the hold-ups mean trainees are missing vital on-the-job experience, leading to fears over the safety of patients. Will Boughton, of the College of Paramedics Trustee for Professional Standards, said handover delays had become a problem for trainees’ development and exposure to real-life experience, meaning training had become “unpredictable”. If steps weren’t taken to increase training opportunities and address wider quality concerns in education, “it is very possible that patient safety may be at risk due to missed experience during practice education”, he warned. “A student could complete a regular shift and see lots of patients, getting lots of things in their portfolio signed off, or they could be the unlucky ambulance that joins the back of a queue and is then at hospital X for however many hours waiting to release that patient, so and it varies from county to county and service to service,” he said. Read full story Source: The Independent, 22 June 2022 -
News Article
UK’s biggest GP chain replacing doctors with less qualified staff
Patient Safety Learning posted a news article in News
The UK's biggest chain of GP practices lets less qualified staff see patients without adequate supervision, an undercover BBC Panorama investigation has found. Operose Health is putting patients at risk by prioritising profit, says a senior GP. The company, with almost 600,000 NHS patients, is owned by US healthcare giant Centene Corporation. BBC Panorama sent undercover reporter Jacqui Wakefield to work as a receptionist at one of the UK company's 51 London surgeries. A GP working at the practice said they were short of eight doctors. The practice manager said they hired less qualified medical staff called physician associates (PAs), because they were "cheaper" than GPs. Physician associates were first introduced by the NHS in 2003, so that doctors could deal with more complex patient needs. PAs are healthcare professionals who have completed two years of post-graduate studies on top of a science degree, as opposed to 10 years education and training for GPs. They support GPs in the diagnosis and management of patients, but should have oversight from a doctor. Panorama gathered evidence that PAs were not being properly supervised at the Operose practice. The PAs told the undercover reporter they saw all sorts of patients, sometimes without any clinical supervision. They said the practice treated them as equivalent to GPs. Prof Sir Sam Everington, a senior practising GP at an unconnected partner-run practice, reviewed BBC Panorama's undercover footage and said he was concerned for patient safety. During the undercover investigation at the London practice, administrative workers also revealed a backlog of thousands of medical test results and hospital letters on Operose computer systems. One worker said they were tasked with getting through 200 documents a day, deciding which were important enough to be seen by a GP or pharmacist and which would be filed to the patient's records. One member of staff, worried about making mistakes said they sometimes used Google to help them work out what to do with the documents. Read full story Source: BBC News, 11 June 2022- Posted
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News Article
Retired consultant is struck off over treatment of young transgender patients
Patient Safety Learning posted a news article in News
A retired consultant gastroenterologist has been struck off the UK medical register for “wide ranging failings” in treating young transgender patients and in prescribing testosterone for men. Michael Webberley, who was charged with failing to provide good care to 24 patients, acted outside the limits of his expertise, a medical practitioners tribunal concluded. Through the private online clinic GenderGP, which he ran with his wife Helen, a GP, Webberley prescribed puberty blockers to a child of nine and cross sex hormones to a teenager who died by suicide a few months later. He faced charges over his care of seven transgender patients, and the tribunal found that he had provided treatment that was not clinically indicated or that had been prescribed without adequate tests, assessments, or examinations. Read full story (paywalled) Source: BMJ, 30 May 2022- Posted
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Urgent patient safety warning at hospital facing police probe
Patient Safety Learning posted a news article in News
A private hospital facing a police investigation following a patient’s death has been given an urgent warning by the care regulator due to concerns over patient safety. The Huntercombe Hospital in Maidenhead, which treats children with mental health needs, was told it must urgently address safety issues found by the Care Quality Commission (CQC) following an inspection in March. The CQC handed the hospital a formal warning due to concerns over failures in the way staff were carrying out observations of vulnerable patients. The move comes as The Independent revealed police are investigating the hospital in relation to the death of a young girl earlier this year. In a report published last week, the care watchdog said it had received “mainly negative” feedback from young people at the hospital’s Thames ward, a psychiatric intensive care unit which treats acutely unwell children. Commenting on the hospital overall, the report said: “Young people told us that staff did not follow the care plans in relation to their level of observations. They told us that if there was an incident the staff stopped doing intermittent observations. Staff in charge of shifts on wards asked new staff members to do observations before they understood how to do it. Staff had to ask the young person how to carry out their observations as they did not always understand what was expected of them in carrying out different levels of observations.” Read full story Source: The Independent, 19 May 2022- Posted
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News Article
Concerns flagged over exploitation and poor treatment of overseas nurses
Patient Safety Learning posted a news article in News
A “shocking” number of nurses from overseas are winding up “in trouble” or sanctioned within their first few months of working in the UK partly because of a lack of induction and support, a conference has heard. The issue was raised during a panel session at the Unison health conference in April discussing the importance of ethical recruitment practices in nursing and midwifery. According to Unison, it is supporting “many” overseas nurses who have been “exploited, unfairly treated and subject to racism” since their move. Among the panel was Gamu Nyasoro, a clinical skills and simulation nurse manager in the NHS and an elected member of Unison’s nursing and midwifery occupational group committee. Ms Nyasoro, who is from Zimbabwe and has been working in the NHS for the past two decades, said she herself had been discriminated against and had faced several challenges during her migration. She raised concern that overseas nurses were not given enough information about how to live and work in the UK, including about how to access healthcare services themselves, or about country specific rules and regulations. There was also the issue that UK employers “don’t look at their skills beforehand”, which means nurses were being put in roles or areas they were not confident in. She cited examples of staff who had been specialising in neonatal services before moving, who were then being asked to work with older people, and those who had been practising as a midwife in their home nations and then being required to work in emergency departments in the UK. Read full story Source: Nursing Times, 28 April 2022- Posted
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Staff warn of ‘worsening’ culture at beleaguered trust
Patient Safety Learning posted a news article in News
The culture at a long-troubled ambulance trust is ‘worsening, not improving’, its staff have told a health watchdog. Concerns about culture and patient safety at East of England Ambulance Service Trust (EEAST) were raised to inspectors at the Care Quality Commission (CQC) during an inspection of the trust last month, according to public documents. In a feedback letter to the trust following the inspection, the CQC said staffing at EEAST’s control room was below planned levels, and the inspectors were “not assured that staffing levels met the demands within the service and this may impact on patient safety when managing the high volume of calls”. The trust, which is in the equivalent of special measures and currently rated “requires improvement” by the CQC, has had long-standing cultural problems and last year signed a legal agreement with the Equality and Human Rights Commission on how it would protect staff from sexual harassment. According to the feedback letter, staff described a “worsening, not improving, culture” and said the workforce was “tired” and not receiving mandatory training, one-to-ones with managers or appraisals. The letter, published in the trust’s latest board papers, also reported inspectors raising concerns about potential risks to patients over the management of the trust’s call stack and a lack of consistency over “standard operating procedures”. Additionally, some staff in the control room on an accelerated training programme were unable to undertake full patient assessments and had to call for assistance from others. Read full story (paywalled) Source: HSJ, 11 May 2022- Posted
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Content Article
In this report, the Coroner states her concerns as follows: There is no robust patient pathway to ensure that all patient factors relevant to the clinical indication for, and safety of, ERCP are identified in advance of the procedure and discussed with the patient. The lack of robust system for the recording of the vetting of the procedure, capturing information that has been considered as part of this process. Consent is not personalised, contrary to recommendations made by the European Society of Gastrointestinal Endoscopy in December 2019. A lack of accountability between professionals for ensuring robust vetting and consent. This report was sent to Nottingham University Hospitals NHS Trust, the British Society of Gastroenterology, the Joint Advisory Group on GI Endoscopy and the European Society of Gastrointestinal Endoscopy.- Posted
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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- Posted
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The 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- Posted
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News Article
Nearly 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- Posted
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Staff 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- Posted
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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- Posted
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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- Posted
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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- Posted
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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- Posted
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- Arthritis
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