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Showing results for tags 'Skills gap'.
Found 59 results
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News Article
Care home resident died after unqualified nurse administered wrong medication
Patient Safety Learning posted a news article in News
A nurse with no qualifications gave a care home resident a fatal dose of the wrong drug, leading to her death before she then tried to cover up her mistake. Katherine Hutchinson gave Fiona Jayne Thorne a fatal overdose of a powerful anti-psychotic drug, which was meant for another patient, an inquest heard. She then tried to cover up her errors which contributed to the death of the 36-year-old with learning difficulties, Derbyshire Live reported . Ms Hutchinson had, at the time, been the nurse in charge at Whitwell Park Care Home, in Whitwell, Derbyshire despite not having any qualifications. She gave Miss Thorne clozapine, which had been intended for another resident, on October 6, 2010. Instead of owning up to what she did, Ms Hutchinson then tried to cover up her mistake by taking Miss Thorne to bed and leaving her there until she was discovered, Senior Coroner Dr Robert Hunter said. Miss Thorne was "found by the care support worker around midnight, when undertaking routine checks on residents”, the inquest heard. And then Ms Hutchinson’s mistake was only discovered after an audit was carried out of the medication trolley and a dosage of clozapine was found. Read full story Source: Mirror, 8 April 2022 -
News ArticleHospital inspectors have uncovered repeated maternity failings and expressed serious concern about the safety of mothers and babies in Sheffield just days after a damning report warned there had been hundreds of avoidable baby deaths in Shrewsbury. The Care Quality Commission (CQC) found Sheffield teaching hospitals NHS foundation trust, one of the largest NHS trusts in England, had failed to make the required improvements to services when it visited in October and November, despite receiving previous warnings from the watchdog. As well as concerns across the wider trust, a focused inspection on maternity raised significant issues about the way its service is run. When it came to medical staff at the Sheffield trust, the “service did not have enough medical staff with the right qualifications, skills, and experience to keep women and babies safe from avoidable harm and to provide the right care and treatment”, the report said. Inspectors found that staff were not interpreting, classifying or escalating measures of a baby’s heart rate properly, an issue that was raised by Donna Ockenden in her review of the Shrewsbury scandal. Despite fetal monitoring being highlighted as an area needing attention in 2015 and 2021, the most recent inspection “highlighted that the service continued to lack urgency and pace in implementing actions and recommendations to mitigate these risks, therefore exposing patients to risk of harm”. Read full story Source: The Guardian, 5 April 2022
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News Article
Learning disability training for all nurses set to be mandated in law
Patient Safety Learning posted a news article in News
Members of the House of Lords have passed an amendment to the Health and Care Bill to enshrine mandatory training for health and care staff on learning disabilities and autism in law. The Oliver McGowan Mandatory Training in Learning Disabilities and Autism programme is being developed by Health Education England in partnership with organisations such as Skills for Care and the Department of Health and Social Care, and alongside Oliver’s family. “It means that organisations have no choice but to free up their staff to attend this training” The training is named after Oliver whose death shone a light on the need for health and social care staff to have better training on learning disabilities and autism, and has been campaigned for by his parents Paula and Tom McGowan who believe his death was avoidable. The 18-year-old, who had mild hemiplegia, focal partial epilepsy, a mild learning disability and high-functioning autism, died in November 2016 after he was given antipsychotic medication even though he and his family warned it could be harmful to him. Following campaigning efforts and a consultation on training proposals for health and care staff, in November 2019, the government committed to developing a standardised training package. It draws on existing best practice, the expertise of people with autism, people with a learning disability and family carers and subject matter experts. Read full story Source: Nursing Times, 18 March 2022 -
News ArticleStaff failed to provide kind and compassionate care and did not treat children with respect at a private hospital downgraded from ‘good’ to ‘inadequate’, a report by health inspectors has revealed. Huntercombe Hospital Stafford was placed in special measures in 2016, but was rated “good” by the Care Quality Commission two years later. Now, its first inspection under provider Huntercombe Young People Ltd in October 2021 has exposed a raft of safety concerns and instances of poor care. Huntercombe Young People Ltd took over the service in February 2021. Heavy reliance on agency staff, workers spotted with their “eyes closed” on observations, and staff not respecting young people’s pronouns were among concerns inspectors flagged. Staff observation of patients was also found to be “undermined” by a blind spot where people could self-harm unseen, the CQC report, published today, said. Children also told the CQC they felt staff did not always understand their mental health condition or know how to support them, particularly those on the psychiatric intensive care ward with eating disorders or autism. Read full story (paywalled) Source: HSJ, 10 March 2022
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Content ArticleThis investigation by the Healthcare Commission examined the cases of ten women who died during pregnancy or within 42 days of delivery at Northwick Park Hospital, North West London Hospitals NHS Trust, between April 2002 and April 2005. This number of maternal deaths was significantly higher statistically when compared with other trusts that serve similar populations.
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Content ArticleThis resource by the mental health charity Mind is for people who want to change the practice of restraint in mental health services and end reliance on force, particularly on adult mental health wards. It is mainly aimed at people who use mental health services, carers, advocates and campaigners. It provides information about restraint, people’s experiences, official guidance, good practice and campaigners’ stories.
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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 -
Content Article
This blog calls for action on the careful review of established pain medication when a patient is admitted to hospital. Richard describes the experience of two elderly patients who suffered pain due to their long term medication being stopped when they were admitted to hospital. Pain control needs must not be ignored or undermined, there needs to be carer and patient involvement and their consent, and alternative pain control must be considered.- Posted
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News ArticleA hospital trust has been told to "immediately improve" its maternity and surgical services. The Care Quality Commission (CQC) made unannounced inspections in September and October at four of the hospitals run by University Hospitals Sussex NHS Foundation Trust. Inspectors raised concerns about staff shortages, skills training and risk management. At the trust's four maternity services, inspectors found departments "did not have enough staff to keep women and babies safe" and staff were "not up to date" with training. Infection prevention measures in surgical services at the Royal Sussex County Hospital were "not consistently applied" and managers were not running services well, inspectors noted. The report also said morale was low and often staff "did not have time to report incidents". The trust said it has taken "urgent action" to make improvements. Read full story Source: BBC News, 10 December 2021
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Content ArticleThis study in Anaesthesia reviewed accidental spinal administration of tranexamic acid. The review identified 20 cases of accidental administration resulting in life-threatening neurological or cardiac complications and 10 patient deaths. These cases were analysed using a Human Factors Analysis System Classification model to identify contributing factors. Ampoule error was the cause in 20 incidents, and all were classified as skills-based errors. Organisational policy, storage of medication and preparation for anaesthesia were all identified as contributing factors. The authors concluded that all of these events could have been avoided if four published recommendations for the prevention of spinal medication administration were implemented.
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News ArticleA Liverpool NHS trust has been rated as "requires improvement" by the health service watchdog due to concerns over care and safety. The moves comes following inspections at Aintree University Hospital and Royal Liverpool University Hospital. Inspectors said Liverpool University Hospitals NHS Foundation Trust required improvement in safety while it was classed as inadequate for leadership. The trust said "immediate action" had been taken to address the concerns. Ted Baker, chief inspector of hospitals at the Care Quality Commission, said the inspections in June and July highlighted concerns that the trust's leadership team "had a lack of oversight of what was happening on the frontline". Mr Baker said "lengthy delays" and "poor monitoring" were putting patients at serious risk of harm, and the trust was rated as requires improvement overall. He added: "We were particularly concerned about how long people were waiting to be admitted onto medical wards and by the absence of effective processes to prioritise patients for treatment based on their conditions. "There weren't always the right number of staff with the right skills and training to treat people effectively or keep them safe in the trust's emergency departments and on medical wards." Read full story Source: BBC News, 27 October 2021
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Content Article
This competency framework has been developed and updated to support prescribers in expanding their knowledge, skills, motives and personal traits, to continually improve their performance, and work safely and effectively. -
News Article
England’s Covid test and trace relying on inexperienced and poorly trained staff
Patient Safety Learning posted a news article in News
England’s test and trace service is being sub-contracted to a myriad of private companies employing inexperienced contact tracers under pressure to meet targets, a Guardian investigation has found. Under a complex system, firms are being paid to carry out work under the government’s £22bn test and trace programme. Serco, the outsourcing firm, is being paid up to £400m for its work on test and trace, but it has subcontracted a bulk of contact tracing to 21 other companies. Contact tracers working for these companies told the Guardian they had received little training, with one saying they were doing sensitive work while sitting beside colleagues making sales calls for gambling websites. One contact-tracer, earning £8.72 an hour, said he was having to interview extremely vulnerable people in a “target driven” office that encouraged staff to make 20 calls a day, despite NHS guidance saying each call should take 45 to 60 minutes. Another call centre worker, who had no experience in healthcare or emotional support, said she suffered a nervous breakdown during an online tutorial about phoning the loved ones of coronavirus victims in order to trace their final movements. Read full story Source: The Guardian, 14 December 2020- Posted
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News Article
Maternity unit death 'lessons not learned'
Patient Safety Learning posted a news article in News
High-risk women at a maternity unit were not monitored closely enough and there was a "lack of learning" from a mother's death, inspectors found. A Care Qualtiy Commission (CQC) report rated the unit at Basildon University Hospital as inadequate with "failings" found in six other serious cases. Inspectors carried out unannounced checks in June after a whistleblower voiced fears about patient safety. The unit was criticised following the deaths of baby Ennis Pecaku in September 2018 and mother Gabriela Pintilie, 36, in February 2019. The CQC previously carried out an inspection of the department the month Mrs Pintilie died and said the unit, which had once been rated outstanding, required improvement. Inspectors returned for the surprise "focused" inspection after being contacted by an anonymous whistleblower. The report found babies were born in a poor condition and then transferred for cooling therapy, which can be offered for newborn babies with brain injury caused by oxygen shortage during birth. During their visit, inspectors found: High-risk women giving birth in a low-risk area. Not enough staff with the right skills and experience. "Dysfunctional" working between midwives, doctors and consultants, which had an impact on the "increased number of safety incidents reported". Concerns over foetal heart monitoring. Women being referred to by room numbers instead of their names. A "lack of response by consultants to emergencies" resulting in delays The CQC also referred to issues relating to the death of Mrs Pintilie, who was not named in the report, and said five serious incidents "identified the same failings of care". Read full story Source: BBC News, 18 August 2020 "This demonstrated there had been a lack of learning from previous incidents and actions put in place were not embedded." -
Content Article
Prevention of Future Deaths: Sebastian Hibberd (23 August 2019)
Sam posted an article in Coroner reports
Sebastian Hibberd, 6 years old, became ill on Saturday 10 October having developed intussusception of the bowel. He deteriorated over the weekend. His father sought medical advice on the Monday from NHS 111 and from his GP's surgery. Sebastian's condition went unrecognised as being life threatening. There were several missed opportunities for him to receive life saving treatment. Sebastian suffered a cardiac arrest and transferred to Derriford Hospital where he sadly died in the Emergency Department shortly after his arrival on the 12 October. -
News Article
Stroke consultant shortage 'hurtling towards crisis'
Patient Safety Learning posted a news article in News
Almost half of hospitals have a shortage of specialist stroke consultants, new figures suggest. One charity fears "thousands of lives" will be put at risk unless action is taken, with others facing the threat of a lifelong disability. In 2016, Alison Brown had what is believed to have been at least one minor stroke, but non-specialist doctors at different hospitals repeatedly told her she did not have a serious health condition. One even described it as an ear infection. Ten months later, aged 34, she had a bilateral artery dissection - a common cause of stroke in young people, where a tear in a blood vessel causes a clot that impedes blood supply to the brain. She was admitted to hospital - but again struggled for a diagnosis. A junior doctor found an issue with blood flow to the brain but she says their comments were dismissed and she was told it was a migraine. It was only when she collapsed again, days later, and admitted herself to a hospital with a dedicated stroke ward that a specialist team was able to give her the care she needed. Alison's case highlights the importance of being seen by stroke specialists. However, according to new figures from King's College London's 2018-19 Snapp (Sentinel Stroke National Audit Programme) report, 48% of hospitals in England, Wales and Northern Ireland have had at least one stroke consultant vacancy for the past 12 months or more. This has risen from 40% in 2016 and 26% in 2014. The Stroke Association charity - which analysed the data - says the UK is "hurtling its way to a major stroke crisis" unless the issue is addressed. Read full story Source: BBC News, 17 January 2020 -
News Article
Toddlers died after NHS 111 helpline said they were not in danger
Patient Safety Learning posted a news article in News
The NHS 111 helpline for urgent medical care is facing calls for an investigation after poor decision-making was linked to more than 20 deaths. Experts say that inexperienced call handlers and the software used to highlight life-threatening emergencies may not always be safe for young children. At least five have died in potentially avoidable incidents. Professor Carrie MacEwen, Chairwoman of the Academy of Medical Royal Colleges, said: “These distressing reports suggest that existing processes did not safeguard the needs of the children in these instances.” Since 2014 coroners have written 15 reports involving NHS 111 to try to prevent further deaths. There have been five other cases where inquests heard of missed chances to save lives by NHS 111 staff; two other cases are continuing and one was subject to an NHS England investigation. Read full story (paywalled) Source: The Times, 5 January 2020- Posted
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Content ArticleInadequate access to anaesthesia and surgical services is often considered to be a problem of low- and middle-income countries. However, affluent nations, including Canada, Australia, and the United States, also face shortages of anesthesia and surgical care in rural and remote communities. Inadequate services often disproportionately affect indigenous populations. A lack of anaesthesia care providers has been identified as a major contributing factor to the shortfall of surgical and obstetrical care in rural and remote areas of these countries. In this report, Orser et al. summarises the challenges facing the provision of anaesthesia services in rural and remote regions
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News Article
Coroner and friends criticise NHS treatment of 24-year-old anorexia victim
Patient Safety Learning posted a news article in News
A coroner has criticised health professionals for failing to give a young woman who died after suffering severe anorexia the support and care she needed. Maria Jakes, 24, died of multiple organ failure in September 2018 after struggling for years with the eating disorder. Coroner Sean Horstead last week concluded that the agencies involved in the Peterborough waitress’s care missed several key opportunities to monitor her illness properly. Mr Horstead said that there had been insufficient record-keeping and a failure to notify eating disorder specialists in the weeks before her death, following treatment at Addenbrooke’s and Peterborough City Hospital. He also criticised the lack of specialist eating disorder dieticians at Addenbrookes and Peterborough hospitals, “together with a nursing team insufficiently trained and knowledgeable of eating disorder patients”, both of which had contributed to the lack of monitoring of Maria. Despite the criticism the father of another anorexia victim, whose death was described in a Parliamentary and Health Service Ombudsman’s report as an “avoidable tragedy”, has said the inquest failed to properly address or challenge the “lack of care” that Maria received from the NHS. Nic Hart, whose daughter Averil died in 2012 at the age of 19, criticised the inquest as “a very one sided process”. He told The Telegraph: “No real challengers were made of the clinical evidence or indeed of the lack of care that poor Maria received.” Read full story Source: The Telegraph, 21 December 2019 -
Content ArticleSTOMP stands for: stopping over medication of people with a learning disability, autism or both with psychotropic medicines. It is a national project involving many different organisations which are helping to stop the over use of these medicines. STOMP is about helping people to stay well and have a good quality of life. Psychotropic medicines can cause problems if people take them for too long. Or take too high a dose. Or take them for the wrong reason. This can cause side effects like: putting on weight feeling tired or ‘drugged up’ serious problems with physical health.
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Content ArticleSTOMP stands for stopping over medication of people with a learning disability, autism or both with psychotropic medicines. It is a national project involving many different organisations which are helping to stop the over use of these medicines. STOMP is about helping people to stay well and have a good quality of life.
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Content ArticlePublic Health England have estimated that on an average day in England, between 30,000 and 35,000 adults with a learning disability, autism or both are taking a prescribed antipsychotic, an antidepressant or both without appropriate clinical indications (psychosis or affective/anxiety disorder). A substantial proportion of people with a learning disability, autism or both who are prescribed psychotropic drugs for behavioural purposes can safely have their drugs reduced or withdrawn. This research showed that among adults known to their GP to have a learning disability, (excluding only those in hospital as inpatients) on any average day: 17.0% were taking prescribed antipsychotic drugs, 16.9% antidepressants, 7.1% drugs used in mania and hypomania, 4.2% anxiolytics and 2.7% hypnotics. STOMP stands for stopping over medication of people with a learning disability, autism or both with psychotropic medicines. It is a national project involving many different organisations which are helping to stop the over use of these medicines. STOMP is about helping people to stay well and have a good quality of life.
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Content Article
PHE: Become an antibiotic guardian
Claire Cox posted an article in Medicine management
The Antibiotic Guardian campaign is led by Public Health England (PHE) in collaboration with the Devolved Administrations (Scotland, Wales and Northern Ireland); the Department for Environment Food and Rural Affairs (DEFRA) and professional bodies/ organisations towards the ‘One Health’ initiative. Antibiotic resistance is one of the biggest threats facing us today. Without effective antibiotics many routine treatments will become increasingly dangerous. Setting broken bones, basic operations, even chemotherapy and animal health all rely on access to antibiotics that work. To slow resistance we need to cut the unnecessary use of antibiotics. The Antibiotic Guardian invite the public, students and educators, farmers, the veterinary and medical communities and professional organisations, to become Antibiotic Guardians. -
Content ArticleAntibiotic resistance is an increasingly serious threat to global health and human development. It is rising to dangerously high levels in all parts of the world, compromising our ability to treat infectious diseases and putting people everywhere at risk.
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Content ArticleAnnie's story is an example of how healthcare organisations seeking high reliability embrace a just culture in all they do. This includes a system's approach to analysing near misses and harm events – looking to analyse events without the knee-jerk blame and shame approach of old.
