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Found 53 results
  1. Content Article
    Everyone who works in health and social care should listen to this podcast in full. I've followed Will's search for justice and I am proud to know Will. A man of great integrity who is campaigning for an individual #dutyofcandour in #healthcare, for the benefit of us all. I remain shocked, when I teach on this, how few know Robbie's story. There has been so much lost learning, a failure of accountability, and a failure to deliver an effective statutory duty of candour. For me, this appalling story of failure and cover up highlights clearly why we have to recognise the value of w
  2. Content Article
    Key findings The maternal deaths and incidents were not the result of deficiencies of care. Standards of care when a woman is admitted to the delivery suite are well above average. Incident reporting and investigation systems are of a high quality. There are examples of excellent practice which should be widely disseminated. Governance systems are fit for purpose and generally well applied. Recommendations The review panel made the following essential recommendations to further reduce risks for the large proportion of vulnerable and high risk women atte
  3. Content Article
    The review found repeated failures in the quality of care and governance at the Trust throughout the last two decades, as well as failures from external bodies to effectively monitor the care provided. This final report identifies hundreds of cases where the Trust failed to undertake serious incident investigations, with even cases of death not being examined appropriately. The review found that where investigations did take place they did not meet the expected standards at that time and failed to identify areas for improvement in care. The report contains 64 local actions for learning w
  4. News Article
    The purpose of Care Quality Commission (CQC) ratings has been a hotly contested question since the creation of the four category classifications in the last decade. The original idea was to give the public a sense of how good their local hospital was, as well as providing commissioners, system managers and government with an idea of whether the local, regional or national health services they had responsibility for were getting better or worse. The practicality of the first aim was always questionable given the public’s inability and unwillingness, in most cases, to take their
  5. Event
    This national conference looks at the practicalities of Serious Incident Investigation and Learning. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) a version of which has now been published and which is being tested in early adopter sites. NHS Improvement is working with these early adopters to test implementation, and analysis of this will inform the final version. Local systems and organisations outside of the early adopter areas are free to use the already published version
  6. Content Article
    This document sets out the guiding principles that will allow NHS board members to understand the: Collective role of the board including effective governance in relation to the wider health and social care system. Activities and approaches that are most likely to improve board effectiveness in governing well. Contribution expected of them as individual board members.
  7. Content Article
    Both the 2019/20 CCG and PSS CQUIN schemes comprise indicators, aligned to four key areas, in support of the NHS Long Term Plan. Patient safety Mental health Prevention of ill health Best practice pathways This document sets out the: Overview of quality and safety indicators CCG Scheme Specialised Services Scheme Scheme Eligibility and Value Rules and Guidance - Agreeing and Implementing a CQUIN Scheme
  8. Content Article
    This guidance aims to help the NHS to create an environment to better support staff when things go wrong and to encourage learning from incidents. Key challenges include: fear equity and fairness bullying and harassment.
  9. Content Article
    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
  10. Content Article
    "Several concerns have been raised about the risk of overdose and death from oral morphine sulphate solution over the past few years, but they have gone unheard." In light of coroners reports of deaths related to abuse, or accidental overuse of Oramorph or oral morphine sulphate solution. the author argues for increased regulation. Commenting: "In the absence of any action from ministers, it seems that healthcare professionals are going to have to take the care of vulnerable patients into their own hands." My reflections on this are: Is this a signal for increased regulation or
  11. Content Article
    I believe all clinicians should read this latest report. There is so much to be learned and so many changes in clinical practice that can be made right away. Since 2018, I have been teaching using Oliver's tragic story to promote reflection on best practice in prescribing and in implementing the Mental Capacity Act. I could write a lot here; however, I believe this is a report all clinicians, and especially all prescribers, need to read in full. A summary of how I see this (or indeed how any individual sees it) it will not be adequate.
  12. Content Article
    NICE's role is to improve outcomes for people using the NHS and other public health and social care services. They do this by: Producing evidence-based guidance and advice for health, public health and social care practitioners. Developing quality standards and performance metrics for those providing and commissioning health, public health and social care services. Providing a range of information services for commissioners, practitioners and managers across the spectrum of health and social care. This website will link into all NICE Guidelines.
  13. News Article
    NHS hospitals have been forced to pay millions of pounds to regulators after wrongly claiming their maternity units were among the safest in the country. Seven NHS trusts, including some now at the centre of major care scandals, will have to pay back a total of £8.5m after self-assessments of their maternity services were found to be false. Families whose babies died as a result of avoidable errors at some of the hospitals told The Independent it was further evidence of poor governance and management failings. NHS Resolution, which acts as the health service’s insurer for clinic
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