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Found 302 results
  1. Content Article
    Two years after his 13-year-old child died needlessly in hospital, Paul Laity reflects on life without her. Martha Mills died of septic shock due to a series of serious failures in her care after she injured her pancreas in a cycling accident. Her father Paul talks about the ongoing pain of grief, and the additional burden of knowing that Martha's death was preventable, caused by the complacency of her doctors and a culture in the hospital that meant consultants were reluctant to ask expert advice from paediatric ICU. "Martha’s avoidable death was unusual in that the prime causes weren’t overwork or a lack of resources, but complacency, overconfidence and the culture on the ward. What upsets me most was that the consultants – a different one most days – took a punt that she was going to be OK over the weekend. No one assumed responsibility; they hoped for the best rather than playing safe. Was everything done for Martha that could have been done? Emphatically not. It’s very hard to live with this knowledge. But just as hard is the recognition that I, too, didn’t do enough." Further reading ‘We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death (The Guardian, 3 September 2022) Prevention of Future Deaths Report: Martha Mills (28 February 2022)
  2. News Article
    A critical report into how a mental health trust mismanaged its mortality figures was edited to remove criticism of its leadership, the BBC has found. In June, auditors Grant Thornton revealed how the Norfolk and Suffolk NHS Foundation Trust (NSFT) had lost track of patient deaths. But earlier drafts included language around governance failures that were missing in the final version. NSFT and Grant Thornton said the changes were due to fact-checking. A number of drafts of the report were produced, with the first dated 23 February this year. The first version described "poor governance" in the way deaths data was managed, with governance also being called "weak" and "inadequate". But many of these critical words were missing from the report released to the public, with "governance" also being replaced with "controls", according to leaked documents. After losing her son Tim in 2014, Caroline Aldridge has been highlighting what she and others claimed had been the trust's undercounting of deaths. "I think people need to know what was removed and what was changed, because I suspect that the first report is a lot nearer to the truth," she said. Ms Aldridge added: "It takes all responsibility from governance, removing the words 'inadequate', 'poor', 'weak' governance, removing significant pieces of information that's not factual accuracy. "We cannot have people watering it [the report] down when it's about deaths." Read full story Source: BBC News, 29 August 2023
  3. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them.  Kath talks to us about why she set up Sling the Mesh and the significant impact that campaigning has on her life. She also highlights the need to establish systems that will identify and prevent avoidable harm, including long term tracking to investigate trends of harm, reporting of industry payments to clinicians and making logging side effects mandatory for healthcare professionals.
  4. Content Article
    In this blog post, Charlotte Augst looks at the impact of the Lucy Letby conviction on views of patient safety and accountability. The case has brought debates about patient safety into the mainstream media and public consciousness, and rather than focus simply on one extreme case, she believes it is important to look into common patterns in the NHS that lead to harm. She highlights that while such an awful case—where a healthcare professional caused deliberate harm to the most vulnerable patients—is shocking, it is also rare. She outlines a need to focus on the systemic issues that are resulting in repeated harm to patients, particularly in maternity services. Patients continue to be harmed because of rifts between management and clinical staff, the inability of the healthcare and regulatory system to really listen to patients, systemic discrimination and cognitive bias. Charlotte argues that while we may find ourselves focusing on the character of a nurse who committed such heinous crimes, we need to pay equal attention to the normalised behaviours and attitudes that harm patients and take place every day throughout the NHS.
  5. Content Article
    My last blog, "Forgotten heroes" – the sequel, built upon a very moving BBC Panorama programme Forgotten heroes of the Covid front line. The BBC documentary told the sad story of healthcare workers (HCWs) who had bravely and knowingly put themselves in harm's way to care for their patients during the darkest days of the pandemic. Many lost their lives, while many more were rendered so severely injured by the disease (Long Covid) that they were (and remain) unable to work and have been unceremoniously sacked by their NHS Health Trusts/Boards. The way that an organisation manages its activities is known as 'governance'. Good governance will lead to high standards of ethics, morality, care and compassion for the people who work within it and those who may be affected by its acts and omissions. Hence, when applied to a whole country, it is known as 'Government', its departments and agencies. In this blog, I propose a possible hypothetical scenario that may have led to the tragic situation revealed by the BBC documentary. I hope this will lead you to consider the standards of 'governance' that apply to the 'duty of care' which a Government owes to its HCWs during a pandemic and what, morally and ethically, should be done to support those "forgotten heroes" if the Government’s governance should be found to be severely lacking. But is the scenario I am asking you to imagine hypothetical or is it real? I shall leave that to your judgement – and that of the Covid-19 Public Inquiry. 
  6. Content Article
    Some of the same people that noted surgical masks were useless for airborne viruses also made decisions to limit the use of effective respirator masks: a decision that had devastating ramifications when the pandemic struck. In this article in the Byline Times, Josiah Mortimer delves deeper into a hub blog written by David Osborn: 'The pandemic – questions around Government governance' and questions the decisions made by the Government during the pandemic.
  7. News Article
    NHS England could have gone further to insist that errors and failures by senior NHS leaders are disclosed to future employers, according to the leading barrister who reviewed the NHS’s fit and proper person test (FPPT). Tom Kark KC’s review of the FPPT was delivered to government five years ago and made public the following year, and changes were finally proposed by NHSE earlier this month. In an interview with HSJ, Mr Kark said he broadly welcomed the plans, and that the revised framework should provide greater consistency across NHS boards “if applied correctly”; and could “strengthen the hand” of chairs and chief executives. Part of the purpose of the regime is to prevent senior managers and other board members who make big errors in one role, from keeping this secret from a future employer. Mr Kark told HSJ he had heard evidence that when “someone leaves under a cloud, they pop up somewhere else, and the information is lost.” Read full story (paywalled) Source: HSJ, 16 August 2023
  8. News Article
    The mother of a woman who took her own life weeks after being discharged from a mental health ward fears a "culture of cover up" within the NHS trust. Hannah Roberts, 22, died by suicide in 2018 and her mother Sally said there were "discrepancies" in the accounts of the talented musician's discharge. She feels an ongoing internal review into all Cambridgeshire & Peterborough NHS Foundation Trust (CPFT) suicides since 2017 should be independent. CPFT did not respond to her comments. The trust's chief executive Anna Hills previously said the internal review into 63 suicides would "be an important piece of work". Its announcement came after the trust was accused of adding to the records of Charles Ndhlovu, 33, the day after he took his own life to, in his mother's words, "correct their mistakes". Read full story Source: BBC News, 15 August 2023
  9. Content Article
    The UK has a transparency problem with doctors’ conflicts of interests; this summer a public consultation will revisit the issue. But, behind the scenes, declaring and managing conflicts is a complex business that can lead to more questions than answers, finds Margaret McCartney.
  10. Content Article
    In this blog post, Kath Sansom, founder of the Sling the Mesh campaign, looks at the issue of payments being made to doctors and lobby groups by pharma and medical tech companies. She argues that these payments are a patient safety concern as it can lead to doctors displaying bias in advising treatments, with benefits being overstated and risks downplayed. This is especially concerning when industry money is given to consultants or researchers trialling new treatments. Kath highlights an investigation carried out by the Observer into the issue and explains why Sling the Mesh have lobbied the UK Government for a UK Sunshine style payment act, which would allow the public to look up the names of doctors, surgeons and researchers to see if they have taken money from industry.
  11. News Article
    An ambulance trust accused of hiding information from a coroner about patients that died is keeping a damning internal report about the deaths secret, the Guardian can reveal. A consultant paramedic implicated in the alleged cover-ups continues to be involved in decisions to keep the report from the public. Earlier this month, North East Ambulance Service (NEAS) apologised to relatives after a review into claims it covered up errors by paramedics and withheld evidence from the local coroner about the deceased patients. But a bereaved family left in the dark about mistakes made before their daughter’s death have rejected the apology. Now, it has emerged that a 2020 internal interim report on the alleged cover-up continues to be kept secret by the trust. The damning report by consultants AuditOne has been leaked to the Guardian after first being exposed by the Sunday Times. Paul Aitken-Fell, a consultant paramedic blamed in the report for amending information sent to the coroner and removing crucial passages about mistakes by the trust’s paramedics, remains in post. He also holds the gatekeeper role of FoI review officer, and as such has endorsed decisions to refuse to release the report to members of the public who ask for it. Read full story Source: The Guardian, 24 July 2023
  12. Content Article
    This constructive commentary reflects on two recent related publications, the Healthcare Safety Investigation Branch (HSIB) report, Variations in the delivery of palliative care services to adults, and an article from Sarcoma UK, Family insights from Dermot’s experience of sarcoma care. Drawing from these publications, Richard, brother-in-law of Dermot, gives a family perspective, calling for a more open discussion around how we can improve palliative care and sarcoma services, and why we must listen and act upon family and patient experience and insight.
  13. News Article
    The bodies of people who died with Covid were treated like "toxic waste" and families were left in shock, a bereaved woman has told the inquiry. Anna-Louise Marsh-Rees said her father Ian died "gasping for breath" after catching the virus while in hospital. Ms Marsh-Rees, who leads Covid-19 Bereaved Families for Justice Cymru, said he was "zipped away", and his belongings put in a Tesco carrier bag. Ian Marsh-Rees died after catching the virus while in hospital, aged 85. His daughter said finding information regarding his care in hospital and how he became infected was "almost like an Agatha Christie mystery". She said no GP ever suggested he might have Covid, although she now knows his discharge notes said he had been exposed to Covid. "It wasn't until we saw his notes some months later that we saw the DNA CPR (do not attempt CPR) placed on him, and this was without consultation with us," she said. "It kind of haunts us all that… people used to say 'well they're in the right place' when they go to hospital. I'm not sure they would say that any more," Ms Marsh-Rees said. She now wants to change the way deaths are handled by health boards. She said it was important to prepare families before and support them after the death of a loved one, from palliative care to dignity in death. Read full story Source: BBC News, 18 July 2023
  14. Content Article
    Patient engagement refers to “meaningful and active collaboration in governance, priority setting, conducting research and knowledge translation,” where patient partners are members of the teams, rather than participants in research or those seeking clinical care. It appears more has been written on the benefits rather than the risks of patient engagement and the authors in this study feel it is important to document and share what they call ‘patient engagement gone wrong.’ The authors anonymised these examples and sorted them into four statements: patient partners as a check mark, unconscious bias towards patient partners, lack of support to fully include patient partners, and lack of recognizing the vulnerability of patient partners. These statements and their examples are meant to show that patient engagement gone wrong is more common than discussed openly, and to simply bring this to light.
  15. Content Article
    The Safe Care at Home Review is an important reminder that people with care and support needs may experience abuse and neglect, sometimes under the guise of ‘care’. Older people, or people with disabilities, may be particularly vulnerable to harm because of their dependence on others and the complexity of their care needs. They might rely on other people for physical, mental or financial support, and may face difficulties recognising or reporting harm. The review draws on a range of evidence, including the Home Office funded Vulnerability Knowledge and Practice Programme, which has highlighted that one in six domestic homicides involved people who were cared for by, or caring for, the suspect.
  16. Content Article
    Following an extensive process of internal and external engagement, the Medicines and Healthcare products Regulatory Agency has published their corporate plan for the next 3 years. Their priorities are: Maintain public trust through transparency and proactive communication Enable healthcare access to safe and effective medical products Deliver scientific and regulatory excellence through strategic partnerships Become an agency where people flourish alongside a responsive customer service culture.
  17. News Article
    The government’s national review of mental health hospitals must urgently address the “lack of sympathy and compassion” towards patients if safety is to improve, the health ombudsman has said. Rob Berhens said the investigation, prompted by The Independent’s reporting on deaths and abuse of vulnerable patients, must look at three key issues, including a lack of empathy for those with mental health challenges, a lack of resources and poor working conditions for staff. Health Secretary Steve Barclay announced last week that a new safety body, the Health Services Safety Investigations Body (HSIB), would look into the care of young people, examine staffing levels and scrutinise the quality of care within mental health units. Mr Berhens said: “I trust [HSIB] to be able to understand what are the key issues, they’re about the lack of sympathy and compassion for people who have mental health challenges, which to me is a human rights issue." Read full story Source: The Independent, 1 July 2023
  18. Content Article
    This article forms a section of A guide to good governance in the NHS, published by NHS Providers. Mary Dixon-Woods and Graham Martin contrast problem-sensing with comfort-seeking, confront structural complacency and a lack of eagerness to use hard and soft intelligence, and discuss the crucial importance of openness.
  19. Content Article
    Our heavily curated Instagram society has become very intolerant of error. In an era where everything we present is airbrushed, tweaked, filtered and polished before being released into the wild, we labour under the misapprehension that the real world is similar. We are sadly mistaken. The real world is messy, imperfect and error-prone. In this blog, Niall Downey talks about his book, Oops! Why Things Go Wrong, which explores why error is inevitable, how it affects many different industries and areas of society, sometimes catastrophically, how it is sometimes actually quite efficient from a physiological standpoint and, most importantly, what we can do about it.
  20. Content Article
    Disclosure UK is part of a Europe-wide initiative to increase transparency between pharmaceutical companies and the doctors, nurses, pharmacists and other health professionals and organisations it works with. They want to ensure that patients and others have confidence that this relationship is open and transparent and this is why the pharmaceutical industry is taking the lead on disclosing details of payments and other benefits in kind made by industry to healthcare professionals and healthcare organisations. This information will be published on the database - Disclosure UK. 
  21. Content Article
    There have been significant developments in patient safety over the last decade. But there is a concerning disconnect between increasing activity and progress made to embed a just and learning culture across the NHS. Recognising the challenging operational context for the NHS, this report from the Parliamentary and Health Service Ombudsman (PHSO) draws on findings from their investigations. It asks what more must be done to close the gap between ambitious patient safety objectives and the reality of frontline practice. PHSO identified 22 NHS complaint investigations closed over the past three years where they found a death was – more likely that not – avoidable. It analysed these cases for common themes and conducted in-depth interviews with the families involved.
  22. Content Article
    Over time and across the world, the need to be transparent with patients and families when care has not gone well is now recognised as a key element of high-quality, safe and patient-centred healthcare. However, a significant gap still persists and some organisations have yet to welcome a transparent and accountable approach, while others fail to turn these principles into reliable actions. This editorial in BMJ Quality & Safety highlights the vulnerable position patient and families are in after error disclosure and looks at how data on processes around error disclosure are key to improvement. The authors call for healthcare organisations to redouble their engagement with patients and families who have been harmed by their healthcare and use the principles of accountability, compassion and transparency to drive their response.
  23. Content Article
    This report by the charity INQUEST, which provides expertise on state related deaths and their investigation to bereaved people, highlights that families are facing persistent challenges following the death of a loved one in mental health services. Based on conversations at one of INQUEST’s Family Consultation Days, the report shows that families face numerous hurdles during investigations and inquests into their loved ones’ deaths, and that processes are not delivering the change required. The Family Consultation Day heard from 14 family members who were bereaved by deaths in the care of mental health services or settings for people with learning disabilities and/or autism, and had faced or were going through inquests and investigations.
  24. Content Article
    The final report on the Transvaginal Mesh Case Record Review.
  25. Content Article
    There has been growing concern about doctors’ conflicts of interests (COIs) but it is unclear what processes and tools exist to enable the consistent declaration and management of such interests. This study in the Journal of the Royal Society of Medicine mapped existing policies across a variety of organisations and settings to better understand the degree of variation and identify opportunities for improvement. The analysis of organisational policies revealed wide variation in what interests should be declared, when and how. This variation suggests that the current system may not be adequate to maintain a high level of professional integrity in all settings and that there is a need for better standardisation that reduces the risk of errors while addressing the needs of doctors, organisations and the public.
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