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Found 300 results
  1. Content Article
    Traditionally, recommendations regarding responding to medical errors focused mostly on whether to disclose mistakes to patients. Over time, empirical research, ethical analyses and stakeholder engagement began to inform expectations — which are now embodied in communication and resolution programmes (CRPs) — for how healthcare professionals and organisations should respond not just to errors but any time patients have been harmed by medical care (adverse events). CRPs require several steps: quickly detecting adverse events, communicating openly and empathetically with patients and families about the event, apologising and taking responsibility for errors, analysing events and redesigning processes to prevent recurrences, supporting patients and clinicians, and proactively working with patients toward reconciliation. In this modern ethical paradigm, any time harm occurs, clinicians and health care organisations are accountable for minimising suffering and promoting learning. However, implementing this ethical paradigm is challenging, especially when the harm was due to an error.
  2. Content Article
    In this BMJ Leader article, Roger Kline discusses the failings of the Countess of Chester NHS Boards in 2022 following the arrest of Lucy Letby. Roger highlights that this is not unique to the Counter of Chester: Reputation management that avoids timely decisive action is familiar to staff in many NHS organisations. Primacy of finance at a time of gross NHS under-resourcing has roots in Government policy and a national failure to challenge it. The failure of the Countess of Chester Board to be curious and create a culture where staff who raised concerns were seen as “gold dust” not troublemakers, is commonplace not unique. Roger acknowledges that there are no simple solutions but says that the regulation for managers is a performative gesture unless accompanied by other measures. He suggests that we "Make patient safety the prime litmus test for all initiatives and 'stop the line' (from Board to ward) when it is not. Do not allow organisational reputation to ever influence decision making in response to concerns. Be relentlessly 'problem sensing' not “comforting seeking'”.
  3. Content Article
    In this infographic, the Patient Safety Commissioner for England, Dr Henrietta Hughes, sets out her strategy for supporting the development of a new culture for the health system centred on listening to patients.
  4. 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.
  5. Content Article
    As part of the 21st Century Cures Act (April 2021), electronic health information (EHI) must be immediately released to patients in the USA. This study in the American Journal of Surgery sought to evaluate clinician and patient perceptions regarding this immediate release of results and reports. Interviews with patients and clinicians found differences in perceived patient distress and comprehension, emphasising the impersonal nature of electronic release and necessity for therapeutic clinician-patient communication.
  6. Content Article
    In this blog, Scott Ellner, a general surgeon from the US, describes the case of a surgeon colleague who unintentionally harmed a patient, Sarah, during surgery. Sarah ended up in the surgical intensive care unit from septic shock due to a missed bowel injury. Her recovery from what should have been a straightforward procedure was long and complicated. Scott recalls how the surgeon was shocked by the way Sarah's husband responded to him when he explained what had happened—instead of an anger and blame, Sarah's husband expressed compassion for the doctor and reiterated his trust in him. Scott highlights the importance of creating a Just Culture in healthcare systems and outlines challenges to this in the current climate, referring to the case of nurse RaDonda Vaught. He also outlines the impact patient safety incidents and medical errors can have on healthcare professionals, calling on the healthcare community to embrace shared humanity. All of us come with imperfections, vulnerabilities and the capacity for healing and growth.
  7. News Article
    A mother who endured a botched surgery at the hands of a disgraced neurosurgeon claims NHS Tayside tried to silence her against making complaints. Professor Sam Eljamel removed Jules Rose's tear duct during a failed attempt to operate on a brain tumour - setting the 55-year-old on a path to becoming a prolific campaigner for patients' rights. Ms Rose, however, has received sight of documents that show NHS Tayside writing to the then-health minister Humza Yousaf to say she had been "aggressive" and "vulgar" and they would no longer communicate with her. In a letter in response, Mr Yousaf says he sees no evidence of any such conduct by the mother-of-two and tells the health board to enter into mediation with her. Ms Rose said: "In the letter I have been given, Humza Yousaf writes back and say, 'She's quite right to feel aggrieved at the treatment she's received. "'Therefore, I suggest that you continue liaising with Miss Rose and enter into mediation.' "This was last November but I've only just had copies of the letters sent to me and when I saw them I thought, 'They've tried to shut me down, they're tried to silence me'." The ongoing dispute with NHS Tayside is as a result of Ms Rose's long-running campaign for justice for patients - thought to be as many as 270 - harmed by Eljamel while he was in the health board's employ. Read full story Source: The Herald, 16 December 2023
  8. Content Article
    The review into the statutory duty of candour has been established by the Department of Health and Social Care to consider the design of operation of this requirement, assess its effectiveness and make advisory recommendations. The duty of candour is about people’s right to openness and transparency from their health or care provider. It means that when something goes wrong during the provision of health and care services, patients and families have a right to receive explanations for what happened as soon as possible and a meaningful apology.
  9. Content Article
    How would you feel if your doctor offered you a treatment your health condition with good results and very little risk? You might snap it up. But what if you subsequently found out your doctor took thousands of pounds from the treatment makers to write a scientific paper promoting it, attend an all-expenses paid conference to talk about it, or spent time working as their expert consultant? In America, industry must log payments which are published on the open database system. Reporting to this is backed up by law following the American Sunshine Payment Act (2013). Sling the Mesh is calling for similar legislation in the UK to provide up-to-date evidence on industry money exchanging hands we Kath Sansom discusses in a blog on the Patient Safety Commissioner website.
  10. Content Article
    Whistleblowing presentation from Peter Duffy to the Association for Perioperative Practice, September 2022. York University.
  11. Content Article
    Would you know what to do if something went wrong with your medical treatment in private/independent healthcare? This guide from PHIN tells what you should understand before choosing where to have your treatment and what to do if everything doesn’t go to plan.
  12. Content Article
    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.
  13. Content Article
    This blog provides an overview of a Patient Safety Management Network (PSMN) meeting discussion on 27 October 2023. At this meeting, members of the network were joined by Dr Ted Baker, Chair of the Health Services Safety Investigations Body (HSSIB). The PSMN, created in June 2021, is an innovative voluntary network for patient safety managers and everyone working in patient safety. It provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. Find out more about the Network.
  14. News Article
    Peter Marshall was delighted when he finally got an appointment after calling his GP surgery for several days. On the day, he saw a young medic who said his excruciating stomach pain was caused by irritable bowel syndrome (IBS) and suggested over-the-counter peppermint tablets to ease the discomfort. And off the 69-year-old retired IT specialist went, happy to have a diagnosis and treatment. In fact, Peter hadn't had an appointment with a GP — he had been seen by a physician associate (PA). This is a type of healthcare worker whose numbers are about to soar in the NHS in order to reduce the pressure on doctors so that they can concentrate on the most complex and seriously ill patients. It all sounds like a great idea. Indeed, PAs are now being employed across areas that are particularly stretched, with around a third of PAs working in GP surgeries and 10% in A&E departments, according to the latest census by the Royal College of Physicians. But they are actually spread across 46 NHS specialties, from urology and surgery to cardiology and mental health. In this role, they are permitted to carry out a range of medical tasks, from performing physical examinations, diagnosing patients and analysing test results to running clinics and performing minor procedures — as well as doing home visits — all under the supervision of a doctor. However, in the case of Peter Marshall, although he was reassured by his diagnosis, his symptoms were, in fact, a sign of bowel cancer — and he died nine months later, in January this year. His sister, who has told Good Health his story, says: 'My brother had no idea that he had seen a PA and not a qualified doctor — he didn't know the word physician associate even existed, no one does.' The family, from London, later received an apology from the PA. 'Patients are so desperate to get an appointment with their GP, you are grateful to see anyone and whatever they say, you accept,' she says. Read full story Source: Daily Mail, 9 October 2023
  15. News Article
    Staff without medical training who fill gaps in the NHS workforce must tell patients they are “not a doctor” when introducing themselves, under new guidance. The advice has been issued to “physician associates” (PAs), a type of clinical role that requires less training than doctors receive, amid a row over their use in the NHS. PAs complete a two-year postgraduate qualification, but no medical degree, and can diagnose and treat patients. They can work in A&E or GP surgeries. NHS England has set out plans to expand the number of PAs to deal with staff shortages, with a workforce of 10,000 PAs wanted over the next decade. The plan has been met with opposition from doctors’ leaders, who say the growing use of PAs instead of fully qualified doctors is leading to missed diagnoses and deaths. Guidance published by the Faculty of Physician Associates, a part of the Royal College of Physicians, said that PAs must not mislead patients into thinking they are doctors. Read full story (paywalled) Source: The Times, 6 October 2023
  16. Content Article
    Paula Goss had surgery to implant rectopexy and vaginal meshes which left her with severe pain and other serious complications. In this blog, Paula talks about why she set up Rectopexy Mesh Victims and Support to campaign for adequate treatment, redress and justice for people injured by surgical mesh. She outlines the need for greater awareness of mesh injuries amongst both healthcare professionals and the public and talks about what still needs to be done to enable people to access the treatment and support they need.
  17. Content Article
    Physician associates (PAs) are healthcare professionals who work as part of a multidisciplinary team under the supervision of a named senior doctor (a General Medical Council (GMC)-registered consultant or GP). While they are not medical doctors, PAs can assess, diagnose and treat patients in primary, secondary and community care environments within their scope of practice. PAs are part of NHS England’s medical associate professions (MAPs) workforce grouping. MAPs add to the breadth of skills within multidisciplinary teams, to help meet the needs of patients and enable more care to be delivered in clinical settings. PAs do not fall under the allied health professions (AHPs) or advanced practice groups. The Faculty of Physician Associates has created this guidance to provide clarity around the role of PAs. It provides practical examples of how physician associates should describe their role and is aimed at increasing understanding for patients, employers, other healthcare professionals and the public. It is important that PAs take all reasonable steps to inform patients and staff of their role and to avoid confusion of roles. This includes considering the potential for verbal and written role titles to be misunderstood and taking the time to explain their role in any clinical interaction.
  18. News Article
    The NHS ombudsman has told a health trust chief to withdraw “not accurate” remarks about him amid an alleged attempt to play down up to 1,000 avoidable patient deaths. Rob Behrens wrote to Stuart Richardson, the head of the Norfolk and Suffolk mental health NHS trust, over remarks he made about him to Norfolk county council’s health scrutiny committee. The councillors on the committee were questioning Richardson over claims reported by the BBC’s Newsnight programme that his trust had “watered down” a report into what are thought to be the avoidable deaths of up to 1,000 patients. The changes between different versions of the document toned down criticism of the trust’s leadership, a move that drew criticism from Behrens and bereaved relatives. For example, the auditors, Grant Thornton, removed references included in the first version to the trust’s governance being “poor, … weak [and] inadequate”, after discussions with trust bosses. The trust and Grant Thornton said the changes were part of a normal factchecking process. Referring to the changes, Behrens had told Newsnight that “the differences in the texts at key points are so huge that this is not just a bureaucratic drafting issue”. Read full story Source: The Guardian, 5 October 2023
  19. Content Article
    Previously well, Gaia died aged 25 years of an unexplained brain condition hours after admission to University College Hospital London. Her death has been the subject of hospital investigations and an inquest. Over one year later her death remains unexplained. Why? This is her mother’s (Dorit) search for the truth: information is provided to stimulate medical crowd thinking – to ask the right questions and to get the right answers. Read the narrative of Gaia’s final illness in her mother’s story and in the memorandum from the link below. See also: Serious Incident Report: Unexpected deterioration of a young woman on the Acute Medical Unit: updated report (February 2022)
  20. Content Article
    Harry's Story is a website set up by Derek Richford, the grandfather of Harry Richford, who died in November 2017 at just a week old following failures in care during and after his birth. The site outlines how Harry's family worked tirelessly to uncover what happened to Harry and the poor standard of care at the maternity unit at East Kent University Hospitals Foundation Trust (EKUHFT). It covers the following aspects of the family's experience: Our Investigation The Inquest Cover Up? - You Decide HSIB Involvement What Happened Next The Kirkup Inquiry Accountability Harry's Legacy The site also contains a section offering advice for parents whose babies die or suffer harm in hospital during the perinatal period.
  21. Content Article
    This Newsnight report looks at the case of Rebecca Wight, an advanced nurse practitioner who raised concerns about a colleague at at Manchester’s Christie cancer hospital and felt her treatment by Trust management as a whistleblower was poor. She is now taking The Christie to an employment tribunal for constructive dismissal. The video also features an interview with Helené Donnelly, a nurse who tried to raise the alarm more than 100 times at Mid Staffs and went on to be a key witness in the subsequent Francis inquiry. She calls for failing NHS managers to be struck off, highlighting that a decade on from one of the worst failings in NHS history, those raising concerns were still not being listened to.
  22. Content Article
    Derek Richford’s grandson Harry died in November 2017 at just a week old. Since Harry’s death, Derek has worked tirelessly to uncover the truth about what happened at East Kent Hospitals University Foundation Trust (EKHUFT) to cause Harry’s death. His efforts resulted in a three-week Article 2 inquest that found that Harry had died from neglect. In addition, the Care Quality Commission (CQC) successfully prosecuted the Trust for unsafe care and treatment and Derek’s work has contributed to a review into maternity and neonatal care services at EKHUFT. In this interview, we speak to Derek about how EKHUFT and other agencies engaged with his family following Harry’s death. As well as outlining how a culture of denial at the Trust affected his family, he talks about individuals and organisations that acted with respect and transparency. He highlights what still needs to be done to make sure bereaved families are treated with openness and dignity when a loved one dies due to avoidable harm.
  23. Content Article
    In this consultation, the Department of Health and Social Care (DHSC) is seeking views on the possible introduction of regulations mandating the disclosure of industry payments to the healthcare sector. The consultation concerns the possible introduction of new secondary legislation that would place a duty on manufacturers and commercial suppliers of medicines, devices and borderline substances to report details of the payments and other benefits they provide to healthcare professionals and organisations. This consultation aims to address the second part of recommendation 8 in the Independent Medicines and Medical Devices Safety (IMMDS) Review, regarding real and perceived conflicts of interest in the health system. The proposals will enable respondents to share views on: the information they would need to provide recipients in scope payments that would potentially need to be reported the timing and content of reporting alternatives to regulation. The consultation closes at 11:59pm on 16 October 2023.
  24. Content Article
    Learn Together is a resource website that equips patients and families with the knowledge and resources to be involved effectively in patient safety investigations. The resources have been designed, together with people who have experienced patient safety incidents and investigations, to provide the information and support patients might need following a patient safety incident. Information is provided in a range of formats including downloadable guides, videos and infographics. The site also provides information and resources for engagement leads. Learn Together is a partnership between Sheffield Hallam University, the University of Leeds, Bradford Teaching Hospitals NHS Foundation Trust, Bradford District Care NHS Foundation Trust, Leeds and York Partnership NHS Foundation Trust and York and Scarborough Teaching Hospitals NHS Foundation Trust, and is funded by the National Institute for Health and Care Research (NIHR).
  25. Content Article
    The case of Lucy Letby, who was convicted of the murder of seven babies and attempted murder of another six in August 2023, has shocked both the public and the healthcare community. In this BMJ editorial, independent investigator Bill Kirkup and James Titcombe, Chief Executive of Patient Safety Watch, outline how the failure to listen to healthcare professionals raising concerns in the case may have contributed to further deaths. They highlight that when doctors at the Countess of Chester Hospital had concerns that they were seeing more deaths than expected, managers failed to take seriously their instinct that there might be a specific underlying cause. The doctors were even pressured into apologising to Letby. They argue that in spite of efforts by the NHS to create a culture where it is safe for staff to speak up about concerns, whistleblowers are still often ostracised and threatened when they highlight patient safety concerns. The article calls for health organisations to adopt the voluntary charter around candour currently being signed by police services and other bodies, pending the implementation of the proposed Public Authorities (Accountability) Bill, which would place a much-needed enduring duty of candour on NHS staff and organisations.
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