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Found 59 results
  1. News Article
    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
  2. News Article
    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
  3. Content Article
    This 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.
  4. 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.
  5. Content Article
    This 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.
  6. Content Article
    Sickle cell disease is the name for a group of inherited red blood cell disorders that affect haemoglobin, which is a protein in red blood cells that carries oxygen through a person’s body. It mainly affects people from African or Caribbean backgrounds, though it can affect anyone. It affects approximately 15,000 people in the UK. In November 2021, the All-Party Parliamentary Group for Sickle Cell and Thalassaemia published a report detailing the issues that people with sickle cell disease experience in relation to their care. The report made 31 recommendations to organisations across the healthcare system to help address these issues. The Healthcare Safety Investigation Branch (HSIB) launched two investigations (see also: Invasive procedures for people with sickle cell disease) to find out what additional learning or knowledge could be added in this area and to provide further insights into the practical challenges patients with sickle cell disease may face when receiving NHS care. HSIB used a real patient safety incident, referred to as ‘the reference event’, to explore how sickle cell crises are managed within hospital settings. In particular, the investigation considered: the knowledge nursing staff may have about the care of patients in sickle cell crisis how patient-controlled analgesia (PCA) – where a patient can use a device to give themself doses of pain relief medication – is considered holistically, such as monitoring the patient and staff workload.
  7. News Article
    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
  8. News Article
    A 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
  9. News Article
    A 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
  10. News Article
    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
  11. Content Article
    A new multinational survey, on more than 1,300 patients, caregivers and healthcare professionals in 10 countries, shines a needed light on the misunderstood realities, unseen burden and care challenges of sickle cell disease. The Sickle Cell Health Awareness, Perspectives and Experiences (SHAPE) survey, one of the largest global burden of disease surveys conducted in sickle cell disease, identified long-term health complications of sickle cell disease as a key concern among 1,300 patients and healthcare professionals surveyed from 10 countries The survey also revealed that sickle cell disease patients' caregivers face profound physical, psychosocial, and economic burdens resulting from taking care of people living with the disease. The findings of the survey were presented during a poster presentation at the European Hematology Association (EHA) 2022 Hybrid Congress. “Sickle cell disease is a lifelong condition that causes damage in the body and has a profound impact on the quality of life of those who suffer from it and their caregivers. The SHAPE survey is important because it illustrates how vital it is that we understand our patients’ needs, and it suggests what we within the medical community can do to help change perspectives, increase education and awareness, and improve care,” said Dr. Baba Inusa, professor and consultant of paediatric haematology, Guy’s and St Thomas’ NHS Foundation Trust, London and chair of the National Haemoglobinopathy Panel in England. “These results are a wake-up call, and I believe that the actions that follow can enable us to help drive a better dialogue and improved conversations around the management and care of this long-neglected and devastating disease.”
  12. Content Article
    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.
  13. 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.
  14. Content Article
    Sean Mansell had a medical history of alcohol dependence syndrome. On the 5 July 2021, the West Midlands Ambulance Service received a 999 call at 19.23 hours from a neighbour of who reported that Shaun couldn't walk. The call was allocated a category 3 disposition which had a target response time frame of 120 minutes. An ambulance arrived on scene at 03.38 on the 6 July which was 8 hours and 15 minutes later and not within the response time frame. This was due to the fact that demand outstripped available resources. A welfare call was undertaken at 21.28 hours by a paramedic who had been asked to go into the control room to assist with welfare calls due to the high volume of 999 calls outstanding. The paramedic had not received prior training on how to complete these calls. The welfare call was conducted with the neighbour. No contact was made directly with Shaun during the 8 hour delay which led to a missed opportunity to identify a change in his condition. When the ambulance arrived, Shaun had passed away on the sofa in his front room. There was evidence of blood loss on the floor next to him and around his mouth. The police did not find any suspicious circumstances. A post mortem examination found the cause of death to be acute gastrointestinal haemorrhage and liver disease due to chronic alcoholism. The medical evidence was not able to determine if the delay in the arrival of the ambulance contributed to the death because there was no certainty of timeline about the bleeding. 
  15. Content Article
    The House of Commons Health and Social Care Select Committee has published a report highlighting the current health and social care workforce crisis in England.  The 'Workforce: recruitment, training and retention' report, which calls for a robust workforce strategy, states that within the NHS in England there’s a shortage of over 50,000 nurses and midwives, while in April this year hospital waiting lists reached an all-time high of almost 6.5 million. 
  16. Content Article
    On 24 October 2019 coroner Lydia Brown commenced an investigation into the death of Asher William Robert Sinclair, age 3. The investigation concluded at the end of the inquest on 24 January 2022. The conclusion of the inquest was: His medical cause of death was: 1a Hypoxic ischaemic brain injury 1b out of hospital cardiac arrest 1c displaced tracheal tube (trachael tube dependant) II Neonatal enterviral myocarditis and encephalitis (trachael ventilator dependant and cardiac pacemaker). Asher died on 8th October 2019 in Great Ormond Street hospital when his life support mechanisms were withdrawn.
  17. Content Article
    Inadequate 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
  18. Content Article
    Annie'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.
  19. Content Article
    The ‘c’ word, 'cost' is often used to defend the status quo in patent safety. This article, published by PatientSafe Network, highlights the importance of assessing the financial loss in not introducing the safety intervention. It includes examples on how to overcome barriers like 'we don't have the money for that' when it comes to delivering safer care.  After all, the price of safer care is priceless
  20. Content Article
    The PatientSafe Network is a registered non for profit charity in Australia. It has been developed by front line healthcare staff and is for anyone who wants to improve patient safety. Their combined commitment is to improve patient safety through the transparent review of medical mistakes and the generation of transparent networked projects. Hundreds of patients die every year from avoidable central line related air emboli. This animation explains what air emboli are and how they may be avoided.
  21. Content Article
    Antibiotic 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.
  22. Content Article
    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.
  23. Content Article
    A report from the Royal College of Nursing (RCN) and Queen’s Nursing Institute (QNI) calls for urgent investment in District Nursing, as new figures show the number of District Nurses working in the NHS has dropped by almost 43 percent in England alone in the last ten years.
  24. Content Article
    In this commentary, I reflect on how we may all suffer from some degree of professional complacency. Healthcare professionals do not get up in the morning intending to harm anyone, but normal human liabilities can impair our performance. We may often fail to recognise environmental and situational risks, and, more importantly, to admit to our own personal liabilities and, thus, the risks we bring into the healthcare environment.
  25. Content Article
    This 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.
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