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Found 161 results
  1. Content Article
    This 5 minute video, from MedStar Health, focuses on the human cost to our healthcare workforce when we fail to cultivate a just culture and systems approach overall, but especially when managing unfortunate harm events. This story has inspired conversation and can be used widely as a teaching tool. When patient harm occurs, caregivers involved are often devastated along with the patient and family, yet many have had to navigate this storm alone. A systems approach in our healthcare workplace, along with the just culture, cultivates the sharing of knowledge and helps prevent patient harm from occurring altogether. If you'd like to share your thoughts on Annie's Story, the systems approach and building a just culture, please comment below or join the conversation in our forum – Analysing events without blame or shame.
  2. Content Article
    The benefits of Continuity of Carer (CoC) within antenatal and postnatal care, and the implications for patient safety are well reported. As a midwife, to know the person from booking to postnatal means I am aware when their mental health may be deteriorating, or when they may be experiencing relationship difficulties. It also makes me feel more confident to challenge situations, including potential safeguarding concerns or welfare issues. If a person trusts in their relationship with their midwife, they are more likely to confide that they are struggling, and we'll be better placed to support their health needs. Supporting people within their wider context Community midwifery is not just caring for a person’s physical needs. It’s knowing their family, their housing situation, their past social history, understanding their vulnerabilities and hearing them when they tell us that something isn’t right – whether that be in relation to their pregnancy, their relationship or their mood. This is incredibly difficult to achieve without CoC and is frustrating for both midwives and pregnant people. Midwives want to offer excellent care and pregnant people deserve excellent care. I recently visited a family who were struggling financially. Although I was aware of their financial predicaments, I had no idea the extent of the issue. I went one afternoon for an antenatal visit. The atmosphere was very tense, and I had heard raised voices upon approaching the house. When I entered the house, their child was crying and shouting, and the parents were distressed. Because of the strength of the relationship we had developed during the pregnancy, I felt able to challenge the couple about what was happening and what I was experiencing with regard to the tension between them. I was informed they had no food and had to get through the weekend with nothing to eat. The mother had been too scared to tell anyone in case her children were taken away from her. This opened up a conversation about their welfare generally and we were able to work together, with other support services, to meet the immediate crisis and attempt to start dealing with the ongoing issues. Monitoring mental health Another person disclosed at booking some historical mental health issues. She had been fine for a few years and had not required treatment recently. During an appointment a few months later, I felt I wasn’t experiencing her like I usually did. It wasn’t anything obvious just a ‘sense’ that she was holding something back. I gently probed her, and she informed me she had been struggling with anxiety in relation to hypervigilance regarding the baby’s movements. We spent some time working on strategies to manage this anxiety and, aware of the clock ticking during a short antenatal appointment, I arranged to see her for a double appointment at my next clinic and referred her to the mental health midwife for ongoing support. In times of loss Something we rarely talk about as midwives is loss. Caring for a family from booking, to finding out the baby had died, to birth and beyond, taught me a lot about the power of CoC. Being present when the couple met their baby and supporting them for as long as they needed postnatally was an enormous privilege. Although challenging because of the depth of grief, knowing I could make a small difference to their experience, because I knew them and they trusted me, meant we were able to discuss very difficult decisions over a cup of tea whilst the other children ran around us bringing a level of normality to a very awful situation. Relationships matter I have received some amazing feedback from families regarding CoC. Recently a woman said that the strength of our relationship was important to her because she trusted my judgement and ability to advocate for her. She said her experience of CoC had made something that was terrifying to her “not so scary”. Thank you cards I have received always comment on the strength of the relationship. Over and above any other element of care a person has received during the pregnancy continuum, the relationship and the patient feeling like I ‘know’ them is what they reflect on when we are saying goodbye (which is the hardest part of this model of care!). As a midwife I get amazing job satisfaction from taking a family from booking to birth to discharge. The privilege of being present during such a life altering time in a family’s life whether it be a first baby or tenth baby, leaves a mark. Every family I look after leaves a footprint. If you'd like to share your thoughts on the Midwifery Continuity of Carer model, you can join the conversation here.
  3. Content Article
    In the two weeks before his death Robbie was seen seven times by five different GPs. The child was seen by three different GPs four times in the last three days when he was so weak and dehydrated he was bedbound and unable to stand unassisted. Only one GP read the medical records, six days before death, and was aware of the suspicion of Addison's disease, the need for the ACTH test and the instruction to immediately admit the child back to hospital if he became unwell. The GP informed the Powells that he would refer Robbie back to hospital immediately that day but did not inform them that Addison's disease had been suspected. The referral letter was not typed until after Robbie had already died and was backdated to the day following the consultation. In a statement after Robbie's death this GP stated: "An Addisonian crisis is precipitated by an intercurrent illness and the stress it induces." Dyfed-Powys Police investigated Robbie's death between 1994 and 1996 but asserted, supported by the Crown prosecution Service in Wales, that there was no evidence of crimes committed by the GPs who, incidentally, were retained by this police force as police surgeons. Following a complaint by Will Powell (Robbie's father) in 1998 against the Deputy Chief Constable of Dyfed-Powys Police, regarding the inadequacies of the criminal investigation, a second criminal investigation was agreed, which commenced in January 1999. As with the first criminal investigation, there was a gross failure to adequately investigate the criminality of the doctors. This resulted in Will Powell making a formal complaint against the Chief Constable of Dyfed-Powys Police in late 1999. This complaint against the Chief Constable resulted in Dyfed-Powys Police appointing an outside police force to review Robbie's case in 2000. Detective Chief Inspector Robert Poole [DCI Poole] from West Midlands Police was appointed. DCI Poole’s investigation report, entitled 'Operation Radiance', which was based on the documents provided to Dyfed Powys Police in March 1994, by Will Powell and his solicitor, was submitted to CPS York in March 2002. This report put forward 35 suggested criminal charges against five GPs and their medical secretary. The listed charges were: gross negligence manslaughter forgery attempting to pervert the course of justice conspiracy to pervert the course of justice. DCI Poole's investigation also resulted in a disciplinary inquiry by Avon & Somerset Constabulary into Will Powell's allegations of misconduct against Dyfed-Powys Police officers with regards to their two inept criminal investigations between 1994 and 2000. Dyfed-Powys Police was found to have been 'institutionally incompetent' but no police officer was made accountable. In April 2003, Will Powell met representatives from the CPS in London, who accepted there was sufficient evidence to prosecute two GPs and their secretary for forgery and perverting the course of justice. However, they would not prosecuted because of (1) the passage of time, which was caused by a decade of cover ups between 1990 and the appointment of DCI Poole in 2000, (2) Dyfed Powys Police had provided the GPs with a letter of immunity, and (3) the available evidence had been initially overlooked by the police and the CPS, between 1994 and 2000, for a variety of reasons. Following a 2013 adjournment debate, in the House of Commons, the Director of Public Prosecutions subsequently agreed, in October 2014, that there would be an independent review of the decisions made by Crown Prosecution Service, in 2003, not to prosecute, when there was sufficient evidence to do so. The reviewing Queen's Counsels have been provided with a report, written by myself ( a healthcare IT professional, former head of IT in an NHS trust and clinician) on major anomalies in Robbie's Morriston Hospital computerised records, which were erased during the first criminal investigation between 1994 and 1996. The review has not been concluded six years on. The letter below (and also attached) from the English and Welsh Ombudsman was sent on 10 November 2020 sets out the case for a Public Inquiry.
  4. Content Article
    The presentation covered: What is Human Factors and ergonomics (HFE) and what it’s not The basic principles Complexity Why things go wrong (and right) Systems approachesH Human-centred design Medical error’ What’s happening in Scotland? Practical human factors thinking How to get involved
  5. Content Article
    Summary of the four themes from the CQC: PEOPLE: We want to be an advocate for change, ensuring our regulation is driven by what people expect and need from services, rather than how providers want to deliver them. We want to regulate to improve people’s experience so they move easily between different services. SMART: We want to be smarter in how we regulate, with an ambition to provide an up-to-date, consistent, and accurate picture of the quality of care in a service and in a local area. SAFE: We want all services to promote strong safety cultures. This includes transparency and openness that takes learning seriously – both when things go right and when things go wrong, with an overall vision and philosophy of achieving zero avoidable harm. IMPROVE: We want to play a much more active role to ensure services improve. In our engagement over the next two months we’ll explore what each of these areas mean in detail as part of an open conversation about the future direction of CQC. Follow the link below to access the draft strategy (the section on safety begins on page 11) and to contribute your feedback.
  6. Content Article
    I believe all clinicians should read this latest report. There is so much to be learned and so many changes in clinical practice that can be made right away. Since 2018, I have been teaching using Oliver's tragic story to promote reflection on best practice in prescribing and in implementing the Mental Capacity Act. I could write a lot here; however, I believe this is a report all clinicians, and especially all prescribers, need to read in full. A summary of how I see this (or indeed how any individual sees it) it will not be adequate.
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