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Content ArticleThis Heathcare Huddle video focuses on key themes that came out of the First Do No Harm report. You can watch it in two parts or as one full video. PART ONE (with Darren Thorne, Managing Director of Facere Melius) - Theme 1: ‘No-one is listening’ – The patient voice dismissed - Theme 2: ‘I’ll never forgive myself’ – Parents living with guilt - Theme 3: ‘I was never told’ – the failure of informed consent PART 2 - Theme 4: Redress – ‘We want justice’ - Theme 5: ‘We do not know who to complain to’ – Complaints - Theme 6: Duty of Candour – ‘preventing future errors’ - Theme 7: Conflicts of interest – ‘we deserve to know’.
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News ArticleTheresa May has urged the government to consider “redress” for the victims of a hormone pregnancy test blamed for causing serious birth defects. The former prime minister said that while Primodos victims had received an apology, “lives have suffered as a result” of the drug’s use. In an interview for a Sky News documentary, she praised campaigners who had been “beating their head against a brick wall of the state” which tried to “stop them in their tracks”. A review in 2017 found that scientific evidence did “not support a causal association” between the use of hormone pregnancy tests such as Primodos and birth defects or miscarriage. But Ms May ordered a second review in 2018, because, she said, she felt that it “wasn’t the slam-dunk answer that people said it was”. “At one point it says that they could not find a causal association between Primodos and congenital anomalies, but neither could they categorically say that there was no causal link,” she said. The second review concluded last month that there had been “avoidable harm” caused by Primodos and two other products – sodium valproate and vaginal mesh. An interview for Bitter Pill: Primodos, which will air on Sky Documentaries, Ms May said: “I think it’s important that the government looks at the whole question of redress and about how that redress can be brought up for people. Read full story Source: The Independent, 28 August 2020
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Content ArticleIn this BMJ Opinion article, Helen McKeown talks asks why the menopause is still a taboo topic when it comes to the well being of healthcare colleagues and argues more could be done to help staff.
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Content ArticleWorldwide, cervical cancer is one of the leading causes of death from cancer in women. Cervical cancer accounts for 2% of all new cancer cases in females in the UK (Cancer Research UK 2016) and is, generally, a preventable disease. The primary cause of cervical abnormalities and cancer is persistent or chronic infection with one or more of the high-risk (oncogenic) types of human papillomavirus (HPV). In most women and men who become infected with HPV, these infections will resolve spontaneously (without treatment). However, for a minority of women, the infection leads to abnormal changes to the cervix, which, if not treated, may progress to cancer 10 to 20 years later. Both understanding and identifying HPV are important public health concerns and form part of the UK National Screening Programme.
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News ArticleMillions of women and girls around the world have been left unable to access contraception and abortions amid the coronavirus crisis, a new report has found. A study by Marie Stopes International, which provides abortion and contraception services worldwide, warns 1.9 million women and girls lost their usual access to its contraception and safe abortion services in the first half of the year as a result of the global public health emergency. The abortion provider is preparing for 900,000 additional unintended pregnancies, 1.5 million extra unsafe abortions, and 3,100 additional pregnancy-related deaths after the disruption to services in the first half of the year. Dr Rashmi Ardey, of Marie Stopes, said: “Women’s needs do not suddenly stop or diminish during an emergency – they become greater. And as a doctor, I have seen only too often the drastic action that women and girls take when they are unable to access contraception and safe abortion. “This pandemic has strained healthcare services all over the world, but sexual and reproductive healthcare was already so under prioritised that once again women are bearing the brunt of this global calamity.” Read full story Source: The Independent,19 August 2020
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News Article
Breast screening women in their 40s 'could save lives'
Patient Safety Learning posted a news article in News
Screening women for breast cancer from their 40s rather than their 50s could save lives without adding to the diagnosis of harmless cancers, a UK study has found. The research was based on 160,000 women from England, Scotland and Wales, followed up for around 23 years. Lowering the screening age could save one life per 1,000 women checked, the scientists say. But experts caution there are many other considerations, including cost. Cancer Research UK says it is still "not clear if reducing the breast screening age would give any additional benefit compared to the UK's existing screening programme". The charity says the priority should be getting cancer services "back on track" for women aged 50-70, after disruption caused by the pandemic. Read full story Source: BBC News, 13 August 2020 -
Content ArticleIn this editorial for the British Medical Journal, Helen Haskell summarises the findings and recommendations of the Cumberlege Review, First Do No Harm. Helen argues that while the report has the potential to be a powerful tool for change in and beyond the UK, patients and families now need to see evidence of action.
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News ArticleLike most women affected by incontinence, 43-year-old Luce Brett has her horror stories. As a 30-year-old first time mum she recalls wetting herself and bursting into tears in the “Mothercare aisle of shame”, where maternity pads and adult nappies sit alongside the baby nappies, wipes and potties. But, she adds, these isolated anecdotes don’t really do justice to what living with incontinence is really like. “It’s every day, it’s all day. People talk about leaking when you sneeze or when you laugh, but for me it was also when I stood up, or walked upstairs. It was always having two different outfits every time I left the house to go to the shops. Incontinence robbed me of my thirties; it made me suicidally depressed,” Luce explains. “Everyone kept telling me it was normal to be leaky after a vaginal birth. It took quite a long time for me to find the courage or the words to stop them and say: ‘Everybody in my NCT (National Childbirth Trust) class can walk around with a sling on, and I can’t do that without wetting myself constantly’,” she adds. Read full article here.
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Content ArticlePSNet publish a case of a misdiagnosed pelvic mass in a pregnant woman with an accompanying commentary from Leiserowitz and Hedriana discussing the diagnostic errors and the systems change needed.
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Content ArticleThis document was drafted on the basis of the Transparency Committee opinion, French National Authority for Health, dated 27 February 2019. It found insufficient clinical benefit of ESMYA* for the treatment of uterine fibroids to justify reimbursement. They conclude: The actual clinical benefit of ESMYA is insufficient to justify its reimbursement by public funding in its two indications. Not approved for non-hospital pharmacy reimbursement or for hospital treatment. *ESMYA - (ulipristal acetate), progesterone receptor modulator.
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Content Article
In this guest blog, Sarah Graham, award winning journalist, founder of Hysterical Women and author of Rebel Bodies, talks about gender bias within healthcare. Sarah draws on research, anecdotal evidence and the recent Cumberlege report to highlight how widespread mistreatment of women can have a negative impact on their safety as a patient. -
Content Article
The Yentl syndrome is alive and well (March 2011)
PatientSafetyLearning Team posted an article in Women's health
More women than men die annually from ischaemic heart disease (IHD) in the developed world. This represents a reversal of fortune from previous decades and places women firmly as the new majority now impacted. Notably, the adverse IHD gender gap is the widest in relatively young women, where myocardial infarction (MI) mortality is 2-fold higher in women under 50 years compared with age-matched men. While it is now clear that there are many gender differences in IHD outcomes, including more frequent angina diagnosis, more office visits, more avoidable hospitalisations, higher MI mortality, and higher rates of heart failure in women compared with men, the aetiologies contributing to these differences are less clear. -
Content ArticleSince the release of the report Hearing and Responding to the Stories of Survivors of Surgical Mesh in December 2019, the New Zealand Ministry of Health, in collaboration with other health sector agencies, has been working to progress the agreed actions and support those who have been affected and minimise future harm. An update on each of the actions is detailed in the report is provided below.
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Content ArticleIn this article for Stylist, Sarah Graham, founder of the Hysterical Women blog, looks at the statistics around gender and heart attacks and gender. She highlights the worrying disparities and argues that sexism plays a dangerous role. The term Yentl Syndrome is used to describe the different ways men and women are treated after heart attacks.
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Content ArticleChaired by Baroness Julia Cumberlege, the Independent Medicines and Medical Devices Safety Review, First Do No Harm, examines how the healthcare system in England responds to reports about the harmful side effects from medicines and medical devices. In this blog, Patient Safety Learning reflects on one of the key patient safety themes featured in the Review – patient complaints.
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Content ArticleFor 10 years, 29-year-old historian Robyn battled extreme endometriosis pain, but was continuously dismissed by doctors when she went to them for help. She was finally diagnosed with the condition – but five surgeries later, it was clear the damage had already been done. In this article published by Stylist, she asks why women’s health issues aren’t being taken seriously enough.
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Content ArticleIn this article, published by BBC Future, Jennifer Billock highlights the gender disparities that exist within healthcare.
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Content ArticleIn this article, published by Refinery 29, author Sarah Graham talks about gender bias in healthcare and the risk to patient safety.
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Content ArticleIn our final 2-minute Tuesday session of July 2020, Patient Safety Learning's Chief Executive, Helen discusses Baroness Cumberlege’s report ‘First Do No Harm’. She focuses on how the report amplifies the voices of women, identifying the scale and severity of harm going back decades to thousands of women. She adds: "This has been a problem hidden in plain sight that is now being exposed." Helen asks listeners whether they agree that transformational change is needed in the health and social care system to address these issues. Read more on our thoughts and the actions in response to the Cumberlege Review.
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Content ArticleIn this briefing the British Heart Foundation highlights the stark inequalities in awareness, diagnosis and treatment of heart attacks that are leading to women needlessly dying every day in the UK.
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Content ArticleChaired by Baroness Julia Cumberlege, the Independent Medicines and Medical Devices Safety Review report, First Do No Harm, examines how the healthcare system in England responds to reports about the harmful side effects from medicines and medical devices. In this blog, Patient Safety Learning reflects on one of the key patient safety themes featured in the Review – informed consent.
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Content ArticleOn Wednesday 8 July 2020 the Independent Medicines and Medical Devices Safety Review published its report First Do No Harm, examining how the healthcare system in England responds to reports about the harmful side effects from medicines and medical devices. Chaired by Baroness Julia Cumberlege, the review focused on looking at what happened in relation to three medical interventions: hormone pregnancy tests, sodium valproate and pelvic mesh implants. In this blog Patient Safety Learning consider the reports findings in more detail, highlighting the key patient safety themes running through this, which are also found in many other patient safety scandals in the last twenty years. It also looks at what needs to change to prevent these issues recurring and asks whether NHS leaders stick with the current ways of working, make a few improvements, or take this opportunity for transformational change.
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News ArticleThe NHS have duped thousands of women into believing the most common incontinence mesh operation is safe, by not adding loss of sex life into its risk figures, campaigners say. The move keeps figures low so surgeons can reassure women that it is a safe day case operation. The discovery is buried in a report from five years ago, and when questioned on it, the MHRA, tasked with making sure implants are safe for patients, passed the buck and blamed the report authors. The revelation comes after a debate in Westminster, where health minister Jackie Doyle Price said there was not enough evidence to suspend the plastic implants and quoted a risk of 1-3%. However, those figures were blown out of the water just weeks before the debate in a landmark study using the NHS’s own hospital re-admission figures which show TVT mesh tape risk is at least 10%. Campaigners say even that is not a reflection of the true scale of the mesh disaster because it does not take into account women going to doctors for pain medication or those suffering in silence. Read full story Source: Cambs Times, 31 October 201t
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Content Article
The MBRRACE-UK Saving Lives, Improving Mothers' Care report found that black women in the UK are five times as likely as white women to die during pregnancy or childbirth. -
Content ArticleThis Review was announced in the House of Commons on 21 February 2018 by Jeremy Hunt, the then Secretary of State for Health and Social Care. Its purpose is to examine how the healthcare system in England responds to reports about harmful side effects from medicines and medical devices and to consider how to respond to them more quickly and effectively in the future. The Review was asked to investigate what had happened in respect of two medications and one medical device: hormone pregnancy tests (HPTs) – tests, such as Primodos, which were withdrawn from the market in the late 1970s and which are thought to be associated with birth defects and miscarriages; sodium valproate – an effective anti-epileptic drug which causes physical malformations, autism and developmental delay in many children when it is taken by their mothers during pregnancy; and pelvic mesh implants – used in the surgical repair of pelvic organ prolapse and to manage stress urinary incontinence. Its use has been linked to crippling, life- changing, complications; and to make recommendations for the future. The Review was prompted by patient-led campaigns that have run for years and, in the cases of valproate and Primodos over decades, drawing active support from their respective All-Party Parliamentary Groups and the media.
