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Showing results for tags 'Transparency'.
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News ArticleHysteroscopy Action says thousands of women are in extreme pain during and following the invasive procedures to treat problems in the womb, with many suffering for days. It says some are left with symptoms of post-traumatic stress and subsequently feel unable to have intimate relationships with partners. Others avoid important examinations such as smear tests. The group has written to Women’s Minister, Maria Caulfield, to raise its concerns. In its letter, it claims women are not always given the choice of intravenous sedation or general anaesthetic to reduce pain because of an NHS drive to cut costs. Some are given local anaesthetic which is often painful and doesn’t work. Others are given no drugs at all and expected to cope with distraction techniques - known as “vocal locals.” Hysteroscopy Action has urged Ms Caulfield to open more theatre space for women to have procedures under general anaesthetic as well as offering women the choice of intravenous sedation. Yet Hysteroscopy Action, which has been in touch with thousands of patients who have undergone such examinations, says women are not made aware of this. Last week RCOG President Dr Edward Morris, said it was “working to improve clinical practice around outpatient hysteroscopy”. He added: “No patient should experience excruciating pain and no doctor should be going ahead with outpatient hysteroscopy without informed consent.” "Hysteroscopy Action has collated more than 3,000 accounts of “brutal pain, fainting and trauma during outpatient hysteroscopy.” Hysteroscopy Action's spokeswoman, Katharine Tylko said: “We are counselling hundreds of patients with PTSD, who for various medical reasons find the procedure extremely painful, some even find it torturous." “This does not happen for other invasive procedures such as colonoscopy. We urge the Women’s Minister to act and are demanding an end to this gender pain-gap.” The letter, which has over 20 signatories, including Helen Hughes, Chief Executive of the Patient Safety Learning charity, Baroness Shaista Gohir, civil rights campaigner, and women’s rights activist, Charlotte Kneer MBE, calls for women to be given informed consent and choice about whether and what type of sedation they want. Read full story Source: Express, 6 November 2022 Read hub members experiences of having a hysteroscopy in the Community thread and Patient Safety Learning's blog on improving hysteroscopy safety.
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Content ArticleThe third leading cause of death in the US is its own healthcare system—medical errors lead to as many as 440,000 preventable deaths every year. To Err Is Human is an in-depth documentary about this silent epidemic and those working quietly behind the scenes to create a new age of patient safety. Through interviews with leaders in healthcare, footage of real-world efforts leading to safer care, and one family’s compelling journey from being victims of medical error to empowerment, the film provides a unique look at the US healthcare system’s ongoing fight against preventable harm.
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Content ArticleMedical records include any information about your physical or mental health recorded by a healthcare professional. This includes hospital staff, GPs, dentists and opticians. This page on The Patients Association website explains how to get copies of your medical records in England and Wales. It provides information on: How to get your GP records Using the NHS App to access records A guide to formally requesting medical records Requesting the records of someone who has died Seeing a child’s medical records Requesting the records of a vulnerable adult More information on medical records Complaints
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Content Article
How to complain to the NHS
Patient Safety Learning posted an article in Complaints
You have the right to make a complaint about any aspect of NHS care, treatment or service The information on this NHS page will guide you through the NHS complaints process, as well as the core requirements for NHS complaints handling. -
Content Article
BD - Voices of safety videos
Patient-Safety-Learning posted an article in Patient stories
This series of videos produced by pharmaceutical company BD features patients, caregivers and healthcare professionals telling their stories about patient safety. Each video highlights an experience of avoidable harm, with topics including sepsis, antimicrobial resistance, medication errors and healthcare associated infections. -
Content ArticleWe need a public register to show if healthcare professionals are in the pay of industry – or more patients will suffer, writes Margaret McCartney following the publication of the Independent Medicines and Medical Devices Safety Review. Hospitals in England are meant to publish registers of interest of staff – but a 2016 study shows that only a minority give the details they should. A publicly accessible digital register, updated at least annually and compelled by the regulator, would create transparency and get rid of the huge amount of work that campaigners have had to do to untangle where conflicts lie. Declarations alone can’t sort the problems of conflicted medicine. But a public register would allow us to know whose advice isn’t independent. We will still need to be alert to the unintended consequences of a register, and research will be needed. The UK is lagging behind. Kath Sansom, a journalist who founded the Sling the Mesh campaign, told Margaret: “I had no idea that I couldn’t trust my doctor or surgeon to give the best advice. It is essential that medics declare industry funding.”
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Content ArticleThe Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. In this video, Megan Pontin, Patient Safety Incident Investigator at West Suffolk NHS Foundation Trust, talks about her experience as an early adopter of PSIRF. She describes the process of engaging staff, patients and families in incident investigations, and how PSIRF enables people to share what happened from their perspective. She talks about the open way in which investigation reports are compiled and reviewed to ensure everyone involved is happy with the way events are presented.
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Content ArticleOn 19 October 2022, the long-awaited findings of Dr Bill Kirkup’s independent investigation into maternity services at East Kent were published. This blog outlines the response of the charity Birthrights to the investigation. It focuses on how breaches of mothers' human rights contributed to negative experiences of care and affected outcomes. Lack of informed consent, the use of disrespectful and discriminatory language and a failure to listen to mothers' concerns all contributed to many cases of avoidable harm. It argues that there is a desperate need for proper funding and real commitment to improving staff recruitment and retention, coupled with a culture shift in maternity care that embeds human rights at the centre of care.
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Content ArticleWhen a loved one dies, any delay in the registration or release of a deceased patient’s body can be distressing for the bereaved. The medical examiner system is being introduced in England and Wales to provide bereaved families with greater transparency and opportunities to raise concerns, improve the quality and accuracy of medical certification of cause of death, and ensure referrals to coroners are appropriate. These good practice guidelines set out how the National Medical Examiner expects medical examiner offices to operate during the non-statutory phase of the programme.
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Content ArticleCo-production is a way of working that involves people who use health and care services, carers and communities in equal partnership; and which engages groups of people at the earliest stages of service design, development and evaluation. This poster by NHS England and the Coalition for Personalised Care outlines five values and seven practical steps to help create a culture where co-production becomes an integral part of health systems and organisations.
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Content ArticleClinical trials are the foundation of modern medicine, but regulators, doctors and patients often do not get to see the full picture about how safe and effective drugs and treatments are. The results of around half of all clinical trials remain hidden and there are international efforts to resolve this issue; even government agencies often lack access to the information they need to decide whether treatments are safe and effective. The paper analyses six case studies in which lack of transparency in medical research has directly harmed patients, taxpayers and/or investors. It illustrates how these harms could have been avoided through three simple solutions promoted by the AllTrials campaign: trial registration, results posting, and full disclosure of trial reports.
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Content ArticleA toxic organisational culture has been shown to contribute more to staff leaving and reporting ill health, than pay and other factors. In this blog, Brandi Neal, Director of Content Creation & Marketing at the consultancy Radical Candor, looks at three traits of a toxic company culture: obnoxious aggression, ruinous empathy and manipulative insincerity. She highlights the value of the radical candor approach, which involves caring personally for staff while challenging them directly, and building genuine relationships with your team,
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Content ArticleSafety communication refers to the sharing of safety information within organisations in order to mitigate hazards and improve risk management. External stakeholders, such as patients and carers, also communicate safety information to healthcare organisations. This article in the Journal of Risk Research examines the nature of safety communication behaviours seen in patients and their families by identifying and examining 410 narrative accounts. The author found that the success of patient and family safety communication in reducing risk was variable. Problems in hospital safety culture such as high workloads and downplaying safety problems, meant that information provided was often not acted upon.
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News Article
'No-one joined the dots' - grandad who exposed an NHS scandal
Patient Safety Learning posted a news article in News
More than 200 families in south-east England will learn today the results of a major inquiry into the maternity care they received from a hospital trust. The investigation into East Kent Hospitals NHS Trust follows dogged campaigning by one determined bereaved grandfather. Derek Richford's grandson Harry died at East Kent Hospitals after his life support system was withdrawn. Sixty one-year-old Derek had never campaigned for anything in his life. His initial approach was to wait for East Kent Hospitals Trust to investigate the death, as it had promised. However, one nagging issue that was to become central to Derek's view of the trust, was the hospital's continual refusal to inform the coroner of Harry's death. The family repeatedly requested it, but the trust said it was unnecessary as it knew the cause, namely the removal of the life support system. The hospital also recorded Harry's death as "expected" - again because his life support system had been withdrawn. On both points, the family were left confused and increasingly angry. In early March 2018, some four months after Harry's death, the family finally received the outcome of the trust's internal investigation - known as the Root Cause Analysis (RCA). The RCA indicated multiple errors had been made in Harry and Sarah's care and treatment, and his death was "potentially avoidable". Prior to the meeting, Derek wrote to the Kent coroner's office outlining in general the circumstances of Harry's case, asking if that was the type they would expect to be notified of. The email response from the coroner's office was clear. It said: "Based on the facts you have presented, this death should have been reported to the coroner." Despite this, at the meeting with the trust, the lead investigator into Harry's death told the family: "If we have a clear cause of death by and large we do not involve the coroner." The family's insistence eventually paid off - five weeks after that meeting, the trust informed the coroner of Harry's death. While his son and daughter-in-law started trying to recover from the trauma of losing Harry, Derek turned his attention to investigating East Kent, one of the largest hospital trusts in England. "When I started investigating what was going on with Harry, it was very much like peeling back an onion. 'Hang on a minute, that can't be right, that doesn't add up.' Ever since I was a small kid, justice has been so important to me. "What I found was that, up to that point, no-one had ever joined the dots. And that's so important. I think this had to happen, someone had to do it. There will be families before us that wish they did it. We will be saving a level of families after us." Read full story Source: BBC News, 19 October 2022 -
News Article
NHS logging baby deaths as stillbirths ‘to avoid scrutiny’
Patient Safety Learning posted a news article in News
NHS hospitals have claimed that babies born alive were stillborn, a Telegraph investigation has found, prompting accusations they were trying to avoid scrutiny. Six children who died before they left hospital were wrongly described as stillborn. Several of the children lived for minutes and one lived for five days. Coroners are not able to carry out inquests into stillbirths, leaving some families unable to get answers until the error was corrected. In one case, an obstetrician told a coroner in Stockport that he had been pressured by an NHS manager to say a baby he had delivered had definitely been stillborn, in order to be “loyal” to the trust. His comments are likely to raise fears that some NHS trusts in England have used the stillbirth label to avoid having coroners examine any errors that may have been made by staff. The revelations raise questions over transparency at some NHS trusts. The babies identified by The Telegraph should have been recorded as neonatal deaths, but staff claimed they were stillbirths – babies that never had any signs of life outside the mother’s body, even for a single moment. All the NHS trusts that wrongly classified neonatal deaths as stillbirths have apologised to the babies’ parents, and say they have changed their practices. Read full story (paywalled) Source: The Telegraph, 16 October 2022 -
News Article
Deaths inquiry will exclude dozens of concerning cases, says whistleblower
Patient Safety Learning posted a news article in News
An inquiry into alleged efforts to cover up care failings at an ambulance trust has been criticised by a key whistleblower for being too limited in scope. NHS England recently commissioned the inquiry into North East Ambulance Service, which has been accused of withholding key details from coroners in a number of deaths. Whistleblowers have raised concerns about disclosure in more than 90 cases. Draft terms of reference for the review, seen by HSJ, say it will examine cases which occurred over a 12-month period up until December 2019. Paul Calvert, a coroners’ officer at NEAS who raised concerns about the issues, said this effectively means only five cases will be scrutinised. He added: “The terms of reference are clearly designed to not include the ongoing malpractice, only focusing on a limited time period and limited cases." “The fact that the [inquiry] has chosen such a narrow time window and a handful of cases, is designed to perpetuate that after 2018 and 2019, the mistakes of the past were remedied. This is simply incorrect, misleading and dishonest to suggest.” He said concerns about information being withheld continued “well into 2021” and the terms of reference risked “continuing the cover up of univestigated deaths”. Read full story (paywalled) Source: HSJ, 13 October 2022 -
Content Article
AvMA case study: Chloe's story
Patient-Safety-Learning posted an article in Risk management and legal issues
This article tells the story of two-year-old Chloe, who died after hospital staff failed to recognise that she had meningitis, sending her home after her parents first took her to A&E. The NHS Trust carried out an internal investigation which identified many areas where care should have been better and set out a range of recommendations for improving care of children in A&E in the future. The Trust only apologised to the family after an out-of-court settlement was made. -
Content ArticleIn this blog, Ted Baker, Former Chief Inspector of Hospitals at the Care Quality Commission, suggests that a false view that health services are intrinsically safe leads to defensive responses to safety concerns and perpetuates a culture of blame. He argues that the mismatch between safety as described and the reality of safety in practice prevents healthcare professionals being able to speak up about safety concerns. By taking an alternative approach that accepts the risk inherent in healthcare and the fallibility of individuals, he believes we can build organisations and systems that really learn from safety events. In order to do this, we need staff to feel able and supported to speak up, something that can be achieved through widespread understanding of safety society and building a supportive culture. Ted argues that this open culture is still lacking within many services.
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Content ArticleIt won’t come as a surprise but more than in 9 in 10 of almost 200 NHS leaders that responded to the latest NHS Confederation survey said that risk to patient safety is going to increase as we approach winter. Almost all of them identified the biggest risks being demand for urgent and emergency care and ambulance waits. And most expect to have to make difficult decisions and compromises around safe staffing ratios and delayed transfers of care. As the health and care sector braces for a challenging winter, three key steps could support systems to manage risk and minimise harm, writes Matthew Taylor, chief executive at NHS Confederation: The need for a robust and honest assessment of harm. The role of systems in minimising harm. The role of the centre in providing a helping hand.
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Content ArticleIn this position statement, the National Quality Board (NQB) outlines: Key requirements for quality oversight in Integrated Care Systems (ICSs) The role of System Quality Groups (formally Quality Surveillance Groups) NQB work to support quality oversight in ICSs
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News Article
Tribunal told of 'failure' over girl's blood tests
Patient Safety Learning posted a news article in News
If doctors had tested a nine-year-old girl's blood sooner they may have changed the treatment she received before her death, an expert witness has confirmed to a medical tribunal. The hearing was told this was a "significant failure" in the care of Claire Roberts. Claire died at the Royal Belfast Hospital for Sick Children in 1996. In 2018 a public inquiry concluded she died from an overdose of fluids and medication caused by negligent care. At the time, her parents were told a viral infection had spread from her stomach to her brain. The General Medical Council (GMC) said one of the doctors involved in Claire's care, Dr Heather Steen, acted dishonestly in trying to conceal the circumstances of her death. Dr Steen denied allegations that she acted dishonestly and engaged in a cover-up. The Medical Practitioners Tribunal Service (MPTS) heard from a defence expert witness on Monday who said doctors not checking the sodium levels in Claire's blood earlier was a "significant failure" in her care. Dr Nicholas Mann told the tribunal he would have ordered more blood tests on Claire on the morning after she was admitted to hospital but he said he did not know if this would have prevented her death. "There should have been more attention to her fluids and electrolytes on the day after admission. Whether that would have altered the final outcome I don't know but certainly it would have been sensible to do that," he said. The tribunal also heard that Claire's death was not referred to a coroner, despite this being something all of the doctors caring for her would have had a duty to do. It was also told that a letter sent to Claire's parents from the hospital in 2005 contained inaccuracies. During questioning of Dr Mann, a barrister for the GMC highlighted the involvement of Dr Steen in compiling the letter which was signed by another doctor. Tom Forster KC said it was the GMC's case that Claire's family were given incorrect information about potential causes of her death despite these not being definitively diagnosed. Read full story Source: BBC News, 3 October 2022 -
News ArticleHospital authorities in Wales have been accused of attempting to cover up failings in the delivery of a baby born with significant brain damage. Gethin Channon, who was born on 25 March 2019 at Singleton Hospital, in Swansea, suffers from quadriplegic cerebral palsy, a severe disability that requires 24/7 care. There were complications during his birth, due to him being in an abnormal position that prevented normal delivery, and he was eventually born via caesarean section. An independent review commissioned by Swansea Bay University Health Board (SBUHB), which manages Singleton Hospital, found “several adverse features” surrounding Gethin’s delivery that were omitted from or “inaccurately specified” in the hospital’s internal report. The investigation, carried out by obstetrician Dr Bill Kirkup, said SBUHB had “significantly” downplayed the “suboptimal” care received by Gethin and his mother, Sian, and had erroneously attributed his condition to a blocked windpipe. It also suggests that amendments were retrospectively made to examination notes taken by staff during the course of Ms Channon’s labour. The family said that SBUHB, which was flagged by national inspectors in the months after Gethin’s birth due to “concerns” over its ability to deliver “safe and effective” maternity care, had “covered up” the failings in their case. SBUHB said it had been “working tirelessly” with the family to investigate and address their concerns, and that it would be inappropriate to comment on specific allegations as the process was ongoing. Read full story Source: The Independent, 2 September 2022
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Content ArticleThe National Quality Board (NQB) has refreshed its Shared Commitment to Quality to support those working in health and care systems. The publication provides a nationally-agreed definition of quality and a vision for how quality can be effectively delivered through ICSs. The refresh has been developed in collaboration with systems and people with lived experience and has a stronger focus on population health and health inequalities. The NQB was set up in 2009 to promote the importance of quality across health and care on behalf of NHS England and Improvement, NHS Digital, the Care Quality Commission, the Office of Health Promotion and Disparities, the National Institute for Health and Care Excellence, Health Education England, the Department of Health and Social Care and Healthwatch England.
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Content Article
Nine specialist mesh centres have been set up by NHS England to offer removal surgery and other treatment to women suffering from complications and pain as a result of vaginal mesh surgery, but women are reporting that they are not operating effectively. In this opinion piece, Kath Sansom highlights ten problems with these specialist mesh centres, evidenced by the real experiences of women who are part of the Sling the Mesh campaign Facebook group. -
Content Article
AvMA case study: Rod's story
Patient-Safety-Learning posted an article in Risk management and legal issues
This article tells the story of Rod, who underwent a dorsal column stimulator implant for chronic pain in 2007. However, following surgery Rod realised something was wrong, and X-rays confirmed that the surgeon had applied the electrodes to the wrong side of his body, resulting in the need for several follow-up surgeries. This left Rod's chronic pain untreated, as well as giving Rod scarring, additional pain and mental stress. He has been unable to gain any financial compensation or admission of liability from the NHS Trust that made the error.
