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News Article
1 in 5 American adolescents have gone to an AI chatbot for mental health guidance
Patient Safety Learning posted a news article in News
Would you trust an AI chatbot to be your therapist, medical professional or confidante? New research shows that one in five American adolescents between the ages of 12-21 (around 8.2 million) are turning to Big AI’s chatbots for help with their mental health. That marks a more than 40% increase in the past year, rising from just one in eight the previous year, a 1,009-person survey from the non-profit research institute RAND found. The findings may not come as that much of a shock following the rise of chatbot use in schools and data showing that nearly half of U.S. teens used the platform multiple times each month. Still, they raise many questions about the impact of asking AI for mental health guidance. Mental health among U.S. teenagers has been at crisis levels in recent years, and suicide is the second leading cause of death for that age group, according to Johns Hopkins Medicine. AI chatbots have also been involved in investigations of the deaths of several U.S. teenagers who died by suicide, according to reports. Read full story Source: The Independent, 2 June 2026 -
Content Article
Core Needs project (neurodivergence)
Craig.russo posted an article in Innovation programmes in health and care
Craig Russo outlines the Core Needs School Pilot, a needs-led, school-based early intervention model for young people with neurodevelopmental needs. He describes how embedding clinicians in schools enables rapid, functional assessment and support without waiting for diagnosis, improving outcomes while significantly reducing costs and demand on specialist services. It demonstrates impact and support expansion, highlighting strong value for money, improved access and alignment with national SEND reform principles. The Core Needs provides a clear, practical example of how a needs‑led model can be operationalised at scale within mainstream education, moving beyond theory into delivery. It demonstrates how embedding clinical expertise directly into schools transforms access, shifting support closer to children and young people and enabling real-time assessment, observation and intervention in their everyday environment. This approach not only improves timeliness but strengthens relationships between health, education and families, creating a more joined-up system that is easier to navigate. A key learning point is the power of intervening early with functional, strengths-based support rather than relying on diagnostic thresholds. The model shows that many young people can be effectively supported through a single, well-structured intervention, supported by a period of watchful waiting and clear step-up pathways when required. This has important implications for demand management, demonstrating a credible route to reducing pressure on specialist services while maintaining safe and appropriate escalation. The pilot also highlights the importance of building capability within schools. By working alongside SENCOs and staff, clinicians are not only supporting individual children but leaving a lasting legacy of increased confidence, skills and consistency within the wider workforce. This creates a multiplier effect, where impact extends beyond the initial intervention and contributes to longer-term system resilience. From an operational perspective, the pilot identifies critical enablers of success, including strong multi-agency partnership working, clear referral processes, dedicated workforce capacity and a structured delivery model. It also makes clear the risks of not investing, particularly around increasing demand, widening inequity of access and continued reliance on costly statutory pathways. For decision-makers, the key action is to consider how this model can be embedded as part of the core local offer, rather than as a time-limited pilot. The evidence presented supports scaling through a phased approach, ensuring quality and consistency are maintained while expanding reach. It also prompts a wider reflection on how services can redesign pathways to prioritise early intervention, improve flow and ensure that resources are directed where they have the greatest impact. Overall, this pilot offers a compelling, evidence-informed case for system change, showing not just what should be done differently, but how it can be delivered in practice in a way that is sustainable, equitable and centred on the needs of children and young people. More blogs on the hub from Craig Russo: Partnership working between A&E, the police and custody healthcare -
News ArticleNew figures have revealed a record surge in referrals to children and young people’s mental health services in March, alongside unprecedented waiting times. The charity YoungMinds, analysing NHS England data, reported 932,822 under-18s had an active mental health referral during the month. YoungMinds warned the data highlights the "sheer scale of the mental health emergency" facing youngsters. New referrals climbed 11% from February and were up 2% compared to the same time last year. The analysis also found that the average waiting time topped 300 days for the eighth consecutive month. Abigail Ampofo, interim chief executive at YoungMinds, said: “These alarming figures highlight the sheer scale of the mental health emergency. “While waiting lists for the treatment of physical health problems are going down, the time young people are spending trying to access specialist support for their mental health continues to rise. “So many pressures are harming young people’s mental health, including academic demands, rising living costs and inequality. “We need more investment in mental health services, but we also need to tackle these root causes of poor mental health. Read full story Source: The Independent, 28 May 2026
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News ArticleA 16-year-old boy killed himself after asking ChatGPT for the “most successful” way to take your own life, an inquest has been told. Luca Cella Walker, a private school pupil from Yateley, Hampshire, died on 4 May last year. An inquest at Winchester coroner’s court heard on Tuesday that, hours before his death, Walker had asked the generative AI chatbot for the “most successful” way for someone to kill themself on a railway line. At the time of his death, he was studying at Sixth Form College Farnborough. He had recently graduated from Lord Wandsworth College near Hook, Hampshire. The court heard that the school had a “bully or be bullied” culture, which had been a “formative” factor in his mental health struggles. His parents, Scott Walker and Claire Cella, told the inquest they had had no idea about their son’s mental health struggles and described it as an “invisible battle”. DS Garry Knight from the British Transport Police, who investigated Walker’s death, told the inquest: “They found he had been on ChatGPT the night before, at about 12.30am, asking for advice on the most successful ways to commit suicide on the railway. It makes quite chilling and upsetting reading.” Knight added: “It is built in to say you can contact organisations for help such as Samaritans, but Luca had sidestepped that, which ChatGPT accepted and gave the most effective ways people can [kill themselves] on the railway.” Coroner Christopher Wilkinson told the inquest of his concerns about the impact of AI software but added he felt unable to act due to its growing scope. Wilkinson said: “It’s clear from what I’ve read that he was asking for specifics. Thankfully, perhaps the only good thing is that ChatGPT does seem to be applying an element of worry about why these questions are being asked, but it certainly doesn’t stop the conversation. “It’s sidestepped by the individual saying he’s not looking for himself but he’s looking for research purposes.” Read full story Source: The Guardian, 31 March 2026
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News Article
School student is second person to die from Kent meningitis outbreak, says MP
Patient Safety Learning posted a news article in News
A school pupil has been confirmed as the second person to have died after an outbreak of meningitis in Kent, an MP has said. Over the weekend it was reported that a University of Kent student was one of two people to have died after contracting the disease, while 11 more people were seriously ill in hospital. On Monday, Helen Whately, the MP for Faversham and Mid Kent, said: “The meningitis outbreak in our area is a huge shock. Feeling so deeply sad for the young lives lost – a year 13 pupil at QEGS [Queen Elizabeth’s grammar school] and a uni of Kent student. My heart goes out to their families.” In a post on Facebook, she added: “It’s incredibly worrying too for the families of the young people in hospital, and others at risk. I am asking the NHS urgently for more information and guidance, especially given the rumours going round about where they may have picked it up.” The UK Health Security Agency (UKHSA) said it had provided antibiotics to students in the Canterbury area after it detected 13 cases of invasive meningococcal disease; a combination of meningitis and septicaemia. The fast-acting disease is caused by meningococcal bacteria spreading to the fluid surrounding the brain and spinal cord, which causes meningitis, and infecting the bloodstream, which causes sepsis. The UKHSA said anyone with meningitis and septicaemia symptoms should seek medical help urgently, and that it could help save lives. Read full story Source: The Guardian, 16 March 2026 -
News ArticleThe NHS is pausing new referrals for masculinising or feminising hormone treatment for 16 and 17-year-olds after an in-depth review found there was insufficient evidence to support its continued use. Prescriptions for hormones had been available in England for under-18s with a diagnosis of gender incongruence or dysphoria who met certain criteria. But after the Cass review, NHS England commissioned its own review of all the available clinical evidence. That review has now concluded and found the evidence did not back the continued use of the treatment for 16 and 17-year-olds. In her review of children’s gender care, Hilary Cass had recommended “extreme caution” in providing such treatment and a “clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18”. NHS England said patients under 18 currently receiving cross-sex hormones may continue to receive treatment. However, that treatment must now be reviewed individually with clinicians. On Monday, NHS England launched a 90-day consultation on plans to remove the treatment as a routine procedure. New referrals for the treatment will be paused during the consultation period. Read full story Source: The Guardian, 9 March 2026
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News Article
Puberty blockers: Controversial trial paused over safety concerns
Patient Safety Learning posted a news article in News
The controversial Pathways trial assessing the effect of puberty blockers on young people with gender incongruence has been paused owing to “concerns related to the wellbeing of participants.” The UK medicines watchdog the Medicines and Healthcare Products Regulatory Agency (MHRA) has written to King’s College London, which is leading the trial, “to discuss potential amendments that we believe will strengthen the trial protocol.” The move comes after a concerted effort by campaigners to stop the trial going ahead. In December the Bayswater Support Group, which represents 800 parents of children and young adults who identify as transgender, sent a pre-action letter to the MHRA threatening judicial review unless the study is halted. But the MHRA emphasised that the pause is related to scientific and wellbeing issues and not a direct result of the potential legal action. The Pathways study was set up after a review of gender services for children and adolescents by the paediatrician Hilary Cass in 2024 found extremely limited data on the harms of puberty blockers and recommended further research. Read full story (paywalled) Source: BMJ, 24 February 2026 -
News ArticleOne in four UK students leaves high school without the protection of the HPV vaccine, putting them at higher risk of several cancers, experts have warned. The UK Health Security Agency (UKHSA)’s latest data for the 2024/25 academic year shows that although uptake has remained steady since last year, a quarter of students are still missing the jab that can give vital protection against cervical, mouth and throat cancers. The report found that year 10 students in England had an HPV uptake of 75.5% for girls and 70.5% for boys, well below the pre-pandemic rates of around 90%. Regionally, the uptake for year 10 students was the lowest in London (with 61% for girls and 56.9% for boys) and the highest in east England (82.8% for girls and 78.2% for boys). Dr Sharif Ismail, UKHSA consultant epidemiologist, said: “The HPV vaccine is one of the most effective cancer-preventing vaccines available. Now, just a single dose given in school, it protects against cervical cancer and several cancers caused by HPV that affect both boys and girls, helping to save thousands of lives and the terrible stress on families.” Health minister Stephen Kinnock said: “Every child deserves protection against cancers caused by HPV, and it's concerning that too many young people are leaving school without this vital vaccine. “I'd urge any parent whose child has missed their HPV vaccine not to wait – speak to your GP or local NHS service today.” Read full story Source: The Independent, 29 January 2026
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News Article
The downside of young people learning about ADHD on TikTok
Patient Safety Learning posted a news article in News
Less than half of the claims made about symptoms of attention deficit hyperactivity disorder (ADHD) in the most popular videos on TikTok align with clinical guidelines, a new study has found. Two clinical psychologists with expertise in ADHD also found that the more ADHD-related TikTok content a young adult consumes, the more likely they are to overestimate both the prevalence and severity of symptoms in the general population. People with ADHD are known to suffer inattention, hyperactivity and impulsivity – and may struggle to concentrate on a given task, or suffer extreme fidgeting. Prescriptions for drugs for ADHD have jumped 18% year-on-year in England since the pandemic, which underscores the need for accurate and reliable information, particularly on platforms popular with young people. In this latest study, published in the journal Plos One, the two psychologists evaluated the accuracy, nuance, and overall quality in the top 100 #ADHD videos on TikTok. They found the videos have immense popularity (collectively amassing nearly half a billion views), but fewer than 50 per cent of the claims made were robust. Read full story Source: The Independent, 31 March 2025 -
News Article
Teen died from asthma attack after she was wrongly discharged from hospital
Patient Safety Learning posted a news article in News
A coroner has voiced serious concerns over a recurring "lack of observations" at London's Royal Free Hospital following the death of a teenager. Sixteen-year-old Billie Wicks died after suffering her first ever asthma attack. Her parents rushed her to the Hampstead hospital on 17 September last year, but a new report reveals the A&E department was "understaffed" that night. The coroner's concerns highlight a potential systemic issue at the hospital regarding patient monitoring. Senior coroner for Inner North London, Mary Hassell, said that Billie should have had routine checks, or observations, taken every hour. If she had these observations, then medics would have recognised the severity of Billie’s illness, Ms Hassell said. “Billie was inappropriately discharged at approximately 3.30am without adequate repeat observations or senior clinical review, and so her asthma was not diagnosed or treated. If it had been, she probably would have survived,” she wrote in a prevention of future deaths report. “Billie should have had observations every hour. If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review. “That senior medical review would have changed the course of her management and saved her life.” Read full story Source: The Independent, 18 March 2025 -
News Article
Nurses at psychiatric unit called teens 'pathetic'
Patient Safety Learning posted a news article in News
Former patients at Scotland's biggest children's psychiatric hospital have spoken out about a culture of cruelty among nursing staff. Patients who were teenagers when they were admitted to Skye House, a specialist NHS unit in Glasgow, told BBC Disclosure some nurses called them "pathetic" and "disgusting" - and even mocked their suicide attempts. "It was almost as if I was getting treated like an animal," one young patient, being treated for anorexia, said. NHS Greater Glasgow and Clyde said it was "incredibly sorry" and has launched two inquiries into the allegations uncovered by the BBC's investigation. Programme-makers spoke to 28 former patients while making BBC Disclosure's Kids on The Psychiatric Ward documentary. One said the 24-bed psychiatric hospital, which sits in the grounds of Glasgow's Stobhill hospital, was like "hell". "I'd say the culture of the nursing team was quite toxic. A lot of them, to be honest, were quite cruel a lot of the time," she added. Read full story Source: BBC News, 10 February 2025 -
News ArticleWhen Sharren Bridges talks about her daughter’s last summer, in 2021, she chokes up and has to pause. In some ways, it was a good summer. Jen Bridges-Chalkley had a boyfriend and, like most parents of teenagers, Sharren would occasionally act as a taxi driver, taking them down to the local river to swim. On 12 October 2021, Jen killed herself at her mother’s home. She was 17. At the inquest, which concluded in April 2024, the coroner said her suicide could have been avoided if she had received the support she needed “in a timely manner”. It was “a multi-agency failure”, he concluded in the report, which is a devastating document: 81 pages of missed opportunities, bad communication and poor decision-making. “There was a failure of the agencies to work effectively together to ensure that Jen’s needs were met,” the coroner wrote. Safeguarding failure; failure by educational establishments; failure by child and adolescent mental health services (Camhs). “For much of the time between May 2018 and June 2020, she was on a waiting list for therapy from the psychology team and was awaiting assessment.” He concluded that Camhs had failed “properly to assess, diagnose and treat Jen … in order to manage her conditions and minimise her risk of suicide”. Camhs is the NHS service for children with emotional, behavioural and mental health issues. Its staff includes psychiatrists, psychologists, nurses, therapists and social workers. It aims to provide support and treatment, including therapy, medication and in-hospital care. Sharren’s assessment of Camhs, provided in Jen’s case by Surrey and Borders Partnership NHS foundation trust, is simple: “It’s not fit for purpose.” Sharren is angry when she speaks about Camhs. “Jen is a person, she’s my daughter, she’s my everything, and she’s not here any more because people didn’t do their job. They didn’t do their job when she was five, they didn’t do their job when she was 11, they didn’t do their job when she was 14, 15, 16, 17, and now she’s not going to get older than 17.” In a statement, Graham Wareham, the chief executive of Surrey and Borders Partnership NHS foundation trust, said: “We remain deeply saddened by Jennifer’s tragic death and we have expressed our deepest condolences to her family. Our investigation into the support we provided Jennifer found that while we gave care and consideration into delivering a person-centred therapeutic approach to meet Jennifer’s mental health needs, we acknowledge that there were shortcomings. Read full story Source: The Guardian, 6 February 2025
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Content ArticleThere are reports of increasing incidence of paediatric diabetes since the onset of the COVID-19 pandemic. This study by D'Souza et al. compares the incidence rates of paediatric diabetes during and before the COVID-19 pandemic. The study found that incidence rates of type 1 diabetes and diabetic ketoacidosis at diabetes onset in children and adolescents were higher after the start of the COVID-19 pandemic than before the pandemic. Increased resources and support may be needed for the growing number of children and adolescents with diabetes. Future studies are needed to assess whether this trend persists and may help elucidate possible underlying mechanisms to explain temporal changes.
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Content ArticleOn 3 August 2022 an investigation was carried out into the death of Allison Vivian Jacome Aules. Allison was 12 years old when she passed away on the 19 July 2022. The investigation concluded at the end of the inquest on the 17 August 2023. The conclusion was that Allison died as a result of suicide, contributed to by neglect. Allison Aules was referred to the mental health team in May 2021 with concerns around evidence of self-harm, low mood, anxiety and enuresis. Her case was inappropriately screened as routine and the referral was triaged 8 weeks later. Allison was not communicated with at this time, but her mother shared a full account of concerns with the triage psychologist. Additional concerns were raised during triage and the matter was taken to a multi-disciplinary team. The team decided that Allison should be assessed face to face. They determined the case to be low risk and placed it in the green zone. The concerns shared with the service should have resulted in a more urgent face to face assessment. The assessment of Allison took place 9 months later. This was not a face-to-face assessment, as directed by the multi-disciplinary team. There was a telephone discussion, initially with Allison’s mother alone. Allison later spoke to the assessor but there was no full assessment of her mental state. There was no full exploration of the concerns raised in the referral and in the triage discussion. There was no evidence of the assessor determining the cause of Allison’s worrying presentation. There was no carefully documented assessment of risk. There was no carefully devised risk management plan. A decision was made to discharge Allison from the mental health team, with no multi-disciplinary review or liaison with the referrer. Allison continued to receive counselling provided at her school, but this concluded at the end of term, on the 15 July 2022. On the 18 July 2022 Allison was found suspended in her bedroom. The failure to provide basic mental healthcare to Allison contributed to her death. Matters of Concern The Inquest identified multiple failings in the care provided to Allison. The failings occurred within a children and adolescent mental health service which was significantly under resourced. The Inquest heard evidence that the under resourcing of CAMHS services is not confined to this local Trust but is a matter of National concern. The under resourcing of CAMHS services contributed to delays in Allison being assessed by the mental health team. The delay between triage to assessment was 9 months. The Inquest heard evidence that this delay is not unusual within CAMHS teams across the country. There was very little evidence of any consultant psychiatrist leadership within the CAMHS team. The Inquest heard of the difficulties in recruiting suitably qualified psychiatrists to CAMHS teams. The Inquest heard that funding for CAMHS teams within the allocation of funding for general mental health is poor. The Inquest heard that the number of children presenting to CAMHS teams is increasing significantly. The number of referrals of children to the local CAMHS team in the early 2010s was between 10 – 12 per week. The current number of referrals is in the region of 140 patients per week. There is a concern that ongoing under resourcing of CAMHS services (whilst demand continues to increase), will result in future similar deaths.
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News Article
Suicide prevention drive launched in England amid concern for young people
Patient Safety Learning posted a news article in News
Ministers have vowed to reduce suicide rates in England with the launch of more than 100 new initiatives amid particular concerns over rising deaths and self-harm among children and young people. The pledge to reverse the trends within two and a half years came as the government launched its first prevention strategy in more than a decade. In 2022, there were 5,275 suicides in England, equivalent to 10.6 suicides per 100,000 people, according to the Office for National Statistics. “While overall the current suicide rate is not significantly higher than in 2012, the rate is not falling,” a new government document says. “We must do all we can to prevent more suicides, save many more lives and ultimately reduce suicide rates.” It highlights how rates of suicide among children and young people have increased in recent years, despite being low overall, adding: “Urgent attention is needed to address and reverse these trends.” The new measures being launched will also aid other specific groups at risk of suicide, including middle-aged men, autistic people, pregnant women and new mothers. Steve Barclay, the health secretary, said: “Too many people are still affected by the tragedy of suicide, which is so often preventable. This national cross-government strategy details over 100 actions we’ll take to ensure anyone experiencing the turmoil of a crisis has access to the urgent support they need.” Read full story Source: The Guardian, 11 September 2023 -
News Article
Antidepressants: I wasn't told about the side-effects
Patient_Safety_Learning posted a news article in News
About one in seven people in the UK now take medication to treat depression but some say they are not being given appropriate advice about the potential side-effects of the drugs they have been prescribed. Seonaid Stallan's son Dylan was a teenager when he began receiving treatment for body dysmorphia and depression. "He was struggling with the way he felt about himself, the way he looked," Seonaid said. "He was extremely anxious. He would be physically sick. He would be unable to leave the house." Dylan, from Glasgow, was treated with the antidepressant Fluoxetine from the age of 16. But when he turned 18, his medication was changed to Sertraline. Within two months of his prescription change he had taken his own life. Read full story Source: BBC, 9 August 2023 -
News ArticleTeens who have been bullied by their peers, or who have considered or attempted suicide, may be more likely to have more frequent headaches than teens who have not experienced any of these problems, according to a study published in the August 2, 2023, online issue of Neurology®, the medical journal of the American Academy of Neurology. The study does not prove that bullying or thoughts of suicide cause headaches; it only shows an association. “Headaches are a common problem for teenagers, but our study looked beyond the biological factors to also consider the psychological and social factors that are associated with headaches,” said study author Serena L. Orr, MD, MSc, of the University of Calgary in Canada. “Our findings suggest that bullying and attempting or considering suicide may be linked to frequent headaches in teenagers, independent of mood and anxiety disorders.” The study involved more than 2.2 million teens with an average age of 14 years. Read the full article here: https://www.eurekalert.org/news-releases/997216
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EventuntilNHS England (NHSE) and Picker are pleased to announce a National Insight Webinar designed to unpick the results of the 2021 Under 16 Cancer Patient Experience Survey (U16 CPES). The webinar is dedicated to helping NHS teams, providers, charities, commissioners, and the wider public to better understand their results, identify areas for action, and place person centred care at the heart of operations. Register
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News Article
Funding overhaul for mental health beds revealed
Patient Safety Learning posted a news article in News
National NHS officials have proposed a major shift in the funding model for inpatient mental health beds for children and young people, information seen by HSJ reveals. A report on child and adolescent mental health services by Getting it Right First Time (GIRFT), an NHS England national programme, recommends a move away from the current ‘payment per bed day’ model to a system which funds particular outcomes or “therapeutic models”. It appears the proposal in the GIRFT recommendations seen by HSJ would apply to both NHS and independent provision, although some NHS providers are already less likely to receive funding on a ”per bed day” basis. Ananta Dave, consultant CAMHS psychiatrist at Lincolnshire Partnership Foundation Trust, told HSJ that having agreed therapy and outcome measures as recommended by the report would not only boost patient experience but also lead to better results. “One inpatient bed can actually be the equivalent of 100 young people being looked after in the community. So these are precious resources we are talking about, hence the quality of inpatient units is really important. “It should not just be a tick-box exercise that a bed exists. Instead, it is about the quality of that service. If you simply go by the number of bed days, you’re unlikely to meet your target or meet your ambition of reducing the spend on inpatient services.” Read full story (paywalled) Source: HSJ, 16 May 2022 -
Content ArticleA Parliamentary and Health Service Ombudsman (PHSO) report of an investigation that found that Averil Hart's tragic death from anorexia would have been avoided if the NHS had cared for her appropriately. Ignoring the alarms: How NHS eating disorder services are failing patients highlights five areas of focus to improve eating disorder services.
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Content ArticleThe RCNi (the publishing company of the Royal College of Nursing) have brought together a selection of their most popular articles on the topic of sepsis from across their journals to inform your practice. Sepsis remains a significant cause of death – it is estimated that 44,000 people die from ‘the silent killer’ every year. RCNi has a wide range of resources available to help nurses improve diagnosis and early management of the condition. The resources include peer-reviewed content on identifying and managing sepsis in the community, in older people and in children from Emergency Nurse, Nursing Children and Young People, Nursing Older People and Primary Health Care.
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Content ArticleThe creation of a national network of medical examiners (MEs) was recommended in the Shipman inquiry and was alluded to in the Mid-Staffordshire and Morecambe Bay public inquiries. The Parliamentary Under-Secretary of State for Health, Lord O’Shaughnessy, confirmed in October 2017 that a national system of medical examiners will be introduced from April 2019. The ME reforms set out in the 2009 Coroners Act will be implemented nationally in two phases. By April 2019, NHS trusts should set up non-statutory schemes, based upon the national pilots (particularly in Leicester, Sheffield and Gloucester), funded in part from cremation form fees, in preparation for the commencement of a statutory scheme in 2020/21. A National Medical Examiner will be appointed, reporting directly to the National Director of Patient Safety. MEs are a key element of the death certification reforms, which, once in place, will deliver a more comprehensive system of assurances for all non-coronial deaths, regardless of whether the deceased is buried or cremated. MEs will be employed in the NHS system, ensuring lines of accountability are separate from NHS Acute Trusts but allowing for access to information in the sensitive and urgent timescales to register a death. This case study outlines the approach of South Tees Hospitals NHS Foundation Trust as one of the early adopter sites. To date, the following learning points have been identified and explored: End of Life Care, ceilings of care and avoidable admissions Some investigations have highlighted cases where the End of Life Care pathway could have either been established or fully implemented, where this would have been of benefit to patients and their families. Some patients may not have been cared for in the right location, and some admissions could have been avoided if the End of Life Care pathway had been suitably established and followed. Early detection and response to physiological deterioration, and effective communication Response stretched by implementation of National Early Warning Score (NEWS) but still learning around effective communication of escalation. The use of standardised communication tools is essential. Record keeping and organisation of medical records Some learning was identified in relation to the accuracy and completeness of medical records. It was evident that not all records are reflective of the clinical picture. Discussion with specialty teams is vital to support the investigation An independent review by the ME should be further supported by speciality ‘experts’, and if possible, peer review from other trusts can be sought to allow for full independent review. Seeking speciality opinion from those not directly involved with the case within STHFT has also been shown to be effective. Pathways for links to wider clinical governance processes have been strengthened.
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Content ArticleEpilepsy12 was announced as the winner of the 2018 Richard Driscoll Memorial Award for outstanding patient involvement in clinical audit at the annual Healthcare Quality Improvement Partnership (HQIP) AGM in London. The submission from the Royal College of Paediatrics and Child Health (RCPCH) demonstrated Epilepsy12’s overarching goal to improve NHS healthcare services for children and young people with seizures and epilepsy. Between April and June 2018, the RCPCH Children and Young People’s Engagement Team met with over 130 children, young people and families to collect their views on ‘service contact ability’ and family mental health. Over 2335 questionnaires were submitted by children, young people and their carers. This submission demonstrates: patient-led activity impact from patient and public involvement embedded involvement to sustain QI
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Content ArticleOn 17 September 2024, Edwin Buckett, commenced an investigation into the death of Billie Wicks aged 16 years. The investigation concluded at the end of the inquest on 6 March 2025. Billie had been brought to the Royal Free Hospital just before midnight the night before her death with an asthma attack. A first presentation of asthma at the age of 16 years without any family history is unusual, and it was a busy night in the accident and emergency department. Billie was inappropriately discharged at approximately 3.30am without adequate repeat observations or senior clinical review, and so her asthma was not diagnosed or treated. If it had been, she probably would have survived. The MATTERS OF CONCERN are as follows: On the night Billie attended, the Royal Free emergency department was understaffed, and that it remains understaffed of doctors, nurses, and even a healthcare assistant who could take basic observations. Billie should have had observations every hour. If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review. That senior medical review would have changed the course of her management and saved her life. The registrar who saw Billie the night before her death prescribed an antibiotic, but he was not in the habit of giving the first dose in the department and he did not on this occasion. This meant that Billie’s infection was not tackled as quickly as it could have been. This seems to indicate a training and potentially a guideline need. At the time of Billie’s presentation, the registrar was unaware of the possibility of adult onset asthma. This seems to indicate a training and potentially a guideline need. I heard that Billie was safety netted when she was discharged. Her parents were told to bring her back if they had any concerns. I have heard this safety netting advice being described many, many times in different inquests. What worries me about it in this context is that Billie’s parents had brought her to hospital because they were concerned. They were then reassured by hospital staff. It is therefore difficult to see how this particular advice could be a meaningful instruction. In reality, her parents’ initial concern was well placed and they had responded to it appropriately by bringing Billie to hospital. When Billie began to deteriorate again, her parents’ natural instinct had been blunted by their first visit to the hospital. Whilst I doubt that it would have made a difference in this case, I understand that blood pressure is not yet an observation included in the national paediatric early warning score (PEWS).
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Content ArticleDespite the well documented consequences of obesity during childhood and adolescence and future risks of excess body mass on non-communicable diseases in adulthood, coordinated global action on excess body mass in early life is still insufficient. Inconsistent measurement and reporting are a barrier to specific targets, resource allocation, and interventions. This article reports current estimates of overweight and obesity across childhood and adolescence, progress over time, and forecasts to inform specific actions. The authors found both overweight and obesity increased substantially in every world region between 1990 and 2021, suggesting that current approaches to curbing increases in overweight and obesity have failed a generation of children and adolescents. Beyond 2021, overweight during childhood and adolescence is forecast to stabilise due to further increases in the population who have obesity. Increases in obesity are expected to continue for all populations in all world regions. Because substantial change is forecasted to occur between 2022 and 2030, immediate actions are needed to address this public health crisis.
