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Showing results for tags 'Communication problems'.
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Content Article1 million people in the UK are unable to speak English well, or at all. People who speak little or no English are more likely to be in poor health, have a greater likelihood of experiencing adverse events and of developing life-threatening conditions and tend to have poorer access to and experiences of healthcare services than people who don’t have language barriers. They can struggle at all points of their journeys through healthcare. Translation and interpreting services for community languages are inconsistent across the NHS. Support for them by NHS commissioners, national programmes and NHS trusts is variable and the lack of high quality, appropriate and accessible services is stopping people from engaging with the healthcare they need. NHS organisations, including commissioners and trusts, have legal duties to provide accessible and inclusive health communications for patients and the public. This framework is designed to support the provision of consistent, high-quality community language translation and interpreting services by the NHS to people with limited English proficiency. Community languages are defined as languages used by minority groups or communities where a majority language exists (for example, English in the UK). It should be used as a framework for action across the NHS, including by NHS trusts and integrated care boards (ICBs). In primary care, it supplements the existing guidance for commissioners on interpreting and translation services and should be used alongside it.
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News Article
Hospital and manager guilty over patient death
Patient Safety Learning posted a news article in News
A hospital trust and a staff member have been found guilty of health and safety failings over the death of a young woman in a mental health unit. Alice Figueiredo, 22, was being treated at Goodmayes Hospital, east London, when she took her own life in July 2015, having previously made many similar attempts. Following a seven-month trial at the Old Bailey, a jury found that not enough was done by the North East London Foundation NHS Trust (NELFT) or ward manager Benjamin Aninakwa to prevent Alice from killing herself. The trust was cleared of the more serious charge of corporate manslaughter, while Aninakwa, 53, of Grays in Essex, was cleared of gross negligence manslaughter. The jury deliberated for 24 days to reach all the verdicts, setting a joint record in the history of British justice, according to the Crown Prosecution Service (CPS). Both the trust and Aninakwa were convicted under the Health and Safety at Work Act. It was only the second time an NHS trust has faced a corporate manslaughter charge. During the trial, prosecutors said that not only was Alice repeatedly able to self-harm while she was in hospital, but that these incidents were not properly recorded or assessed. The court also heard there were concerns about Benjamin Aninakwa's communication, efficiency, clinical and leadership skills. The trust had previously placed him on a performance improvement plan for three years, which ended in December 2014. In addition, there was a high turnover of agency staff on the ward, the court heard. Mrs Figueiredo says she raised concerns about her daughter's care verbally and in writing on a number of occasions to the hospital and to Mr Aninakwa. After Alice died, she said the family found it very difficult to get answers about what happened. For nearly a decade they gathered evidence and pressed both the police and the CPS to take action. Read full story Source: BBC News, 9 June 2025 -
News Article
I had to beg doctors for help, sepsis patient says
Patient Safety Learning posted a news article in News
A man said he was left "begging for help" from doctors after he suffered life-changing injuries due to sepsis caused by failures at his local hospitals. Paul Robinson, 70, developed recurring sepsis for almost a year after being hospitalised on multiple occasions in Brighton and Worthing. The company director from Goring, in West Sussex, said: "I've lost my freedom, confidence, business, very nearly my family home, and almost my will to live." Mr Robinson was diagnosed with cancer in 2018. He successfully had a lump removed from his lung. But during chemotherapy, he became unwell and was diagnosed with sepsis. He said he went through several relapses with sepsis and was in hospital for 13 days. "I was left for 11 months with recurring, untreated sepsis – despite begging for help," he said. Describing his care at Worthing Hospital and Royal Sussex County Hospital in Brighton, he said there was a breakdown in communication between nurses, doctors and departments. He said there had been "systemic failures" and "ignored warnings" with his care. "We asked for help 47 times, and we were ignored 47 times," he added. "Every day I see NHS campaigns about spotting the signs of sepsis. We knew the signs, we pleaded for help, and nobody listened." Read full story Source: BBC News, 5 June 2025 -
News Article
Cancer patients are dying after choosing fad social media ‘cures’
Patient Safety Learning posted a news article in News
Cancer patients are dying due to misinformation on social media, turning down life-saving treatment in favour of “radical diets” and natural “cures”, oncologists have said. Doctors gathered in Chicago for the American Society for Clinical Oncology (ASCO) general meeting said that some patients are delaying the start of their treatment until their cancer becomes metastatic, or incurable. Some patients are choosing alternative treatments such as diets and essential oils instead of life-saving medicines, the doctors said, with patients falling victim to those who “deliberately push unproven treatments or ideas”. The oncologists said that the field was “losing the battle for communication” in the age of misinformation. England’s chief doctor added that the rates of misinformation around cancer seen by the NHS had become “alarmingly high” recently. Richard Simcock, the chief medical officer at the charity Macmillan Cancer Support, said: “I have recently seen two young women who have declined all proven medical treatments for cancer and are instead pursuing unproven and radical diets promoted on social media. “As a doctor, I want to be able to use the best available therapies to help people with cancer. A person is perfectly entitled to decline that therapy but when they do that on the basis of information which is frankly untrue or badly interpreted it makes me very sad. It’s clear that we have work to do to build back trust in evidence-based medicine.” Read full story (paywalled) Source: The Times, 2 June 2025 -
News Article
Basic errors lay behind trust’s botched IT upgrade, leak reveals
Patient Safety Learning posted a news article in News
A string of basic errors led to a teaching trust botching a pathology lab IT upgrade, causing major disruption to tests, according to an internal review seen by HSJ. The problems with Leeds Teaching Hospitals Trust’s upgrade to the Clinisys WinPath system in December resulted in tens of thousands of blood tests being lost or delayed, with managers admitting patients were potentially put at risk. An internal LTHT review of how “communication and escalation” problems contributed to the disruption, including: Training delivered very late – even on the day of roll out – or not at all. No end-to-end testing of the system took place prior to roll out. There was no engagement with primary care to understand how the update could affect their workflows. Ineffective communication channels for escalation of problems. Lessons from previous NHS WinPath roll outs were not learned. Read full story (paywalled) Source: HSJ, 30 May 2025 -
News Article
One in ten patient safety incidents in hospitals due to poor communication
Patient Safety Learning posted a news article in News
Patients’ lives are being put at risk by poor communication from healthcare professionals in hospitals worldwide, according to new research. The analysis included 46 studies, published between 2013 and 2024, involving over 67,000 patients across Europe, North and South America, Asia and Australia. And the findings are alarming. The authors discovered that poor communication was the sole cause of patient-safety incidents in over one in ten cases and contributed to causing incidents in one in four cases. These aren’t just statistics, they represent real people harmed by preventable errors. In one documented case, a doctor accidentally shut off a patient’s Amiodarone drip (a drug to treat heart arrhythmias) while silencing a beeping pump. The doctor failed to tell the nurse, and the patient’s heart rate spiked dangerously. In another example, a patient died after a nurse failed to tell a surgeon that the patient was experiencing abdominal pains following surgery and had a low red blood cell count – clear indicators of internal bleeding. The patient later died from a haemorrhage that could have been prevented with adequate communication. These findings confirm what many healthcare professionals have long suspected: communication breakdowns directly threaten patient safety. What’s particularly concerning is that these incidents cut across different healthcare systems worldwide. Read full story Source: The Conversation. 28 April 2025 -
News Article
NHS ‘routinely failing’ deaf patients in England, report finds
Patient Safety Learning posted a news article in News
Deaf patients face systemic discrimination when it comes to learning about their own health due to NHS failings, with some not understanding that they might have a terminal illness, according to a damning report. The study by the Royal National Institute for Deaf People (RNID) accuses the NHS of “routinely failing” deaf people. A survey of more than 1,000 people in England who are deaf or have hearing loss found that almost one in 10 had avoided calling an ambulance or attending A&E due to their disability, and a quarter had avoided seeking help for a new health concern. The survey also found that about half of sign language users reported not having understood their diagnosis, or how their treatment worked. NHS staff said a lack of training, time and a poor IT system were major factors in being unable to provide these accessibility requirements for deaf people. The report also highlights instances of deaf people receiving particularly poor NHS care. In one instance, a woman was not provided with an interpreter, which meant she was unaware she had had a miscarriage. Another example was a patient receiving no food or water during a hospital stay as they could not hear staff offering it to them. Sharing her experiences as part of the report, Dr Natasha Wilcock, a deaf doctor who works in palliative care, said she had met patients who had been referred to palliative care services who, due to the lack of communication, did not understand they were dying and no longer receiving cancer treatment. Read full story Source: The Guardian, 24 April 2025 Further reading on the hub: Top picks: 11 resources to support people with hearing loss or deafness -
News ArticleNavigating health systems in a foreign country can add another layer of anxiety to situations that often already stressful. Cultural differences, language barriers and a lack of confidence can all present obstacles to getting the right medical care. A new app has been designed to help immigrant women deal with these challenges by providing them with AI-powered support they can use during health appointments. It aims to make medical treatment more accessible and “empower women to manage their health with confidence”. And as well as offering help on understanding their health insurance, it also includes an online community where women can share experiences and support. The WE app concept was created by QIMU Design in the US and recently won a UX Design Award. The award judges said: “Enabling healthcare access for everyone should be a goal for both society and healthcare providers. “WE tackled this challenge with an app, reducing barriers for non-native speaking women to access healthcare. Its simple, user-friendly design suits its target audience, enabling effective navigation through complex healthcare systems. A wide range of functions including translation, insurance guidance, articles, chat and advice offer holistic support. The relevance and thoughtful design make WE a compelling and impactful concept.” Read full story Source: CIEHF, 20 March 2025
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News ArticleStruggling to contain a raging measles epidemic in West Texas, public health officials increasingly worry that residents are relying on unproven remedies endorsed by Robert F. Kennedy Jr., the health secretary, and postponing doctor visits until the illness has worsened. Hospitals and officials sounded an alarm this week, issuing a notice explaining which measles symptoms warranted immediate medical attention and stressing the importance of timely treatment. “I’m worried we have kids and parents that are taking all of these other medications and then delaying care,” said Katherine Wells, director of public health in Lubbock, Texas, where many of the sickest children in this outbreak have been hospitalized. Some seriously ill children had been given alternative remedies like cod liver oil, she added. “If they’re so, so sick and have low oxygen levels, they should have been in the hospital a day or two earlier,” she said. In his first public statements about the outbreak, Mr. Kennedy faced intense backlash for minimizing the situation, saying it was “not unusual” and falsely claiming that many people hospitalized were there “mainly for quarantine.” In the following weeks, Mr. Kennedy altered his approach, offering a muted recommendation of vaccines for people in West Texas while also promoting unproven treatments like cod liver oil, which has vitamin A, and touting “almost miraculous and instantaneous” recoveries with steroids or antibiotics. Read full story (paywalled) Source: New York Times, 15 March 2025
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News Article
USA: The appointment of Robert F Kennedy has horrified public health experts
Patient Safety Learning posted a news article in News
The announcement that Donald Trump has appointed Robert F Kennedy as the US secretary of health and human services has sent shock waves through the health and scientific community. The main goal Kennedy has trumpeted recently is to “Make America healthy again”. At face value, it’s a noble aim. That’s the essence of public health: how to reduce risk factors for disease and mortality at a population level and improve the quality of health and wellbeing. But behind this slogan comes a darker, conspiracy-laden agenda. Kennedy is well known as a prominent anti-vaxxer. He has claimed that vaccines can cause autism, and also said that “there’s no vaccine that is safe and effective”. He called the Covid-19 vaccine the “deadliest vaccine ever made”. None of these claims are true: repeat studies have shown that the MMR vaccine does not cause autism, we have numerous safe and effective vaccines against childhood killers such as whooping cough and measles, and the Covid-19 vaccines have saved millions of lives globally. Similarly, he has tweeted about the benefits of raw milk. Raw milk consumption is a risk factor for a number of dangerous illnesses from E coli to salmonella, but is even more worrying with the widespread infection of dairy herds in the US. While pasteurisation has been shown to kill the H5N1 virus in milk and prevent its ability to infect, raw milk retains its pathogens. Raw milk demand in the US has gone up, with some vendors claiming that “customers [are] asking for H5N1 milk because they want immunity from it”. How do you try to engage with those who believe things that are simply not true? It’s hard: a recent Nature study found that the more time you spend on the internet trying to validate what is true and not true, you more you go down the rabbit hole of false information. Those who believe outlandish theories are generally people who think of themselves as more intelligent than the average person, have a lot of time to do their own research on the internet, and are convinced that everyone else is being duped. Read full story Source: The Guardian,17 November 2024 -
News ArticleThe National Academies of Science, Engineering, and Medicine is scrubbing pending reports of words such as “health equity,” “marginalized populations,” and “restorative justice” and replacing them with vaguer terms in an effort to appease the Trump administration, according to a letter protesting the actions sent to the organisation’s leaders and obtained by STAT. The National Academies, or NASEM, are widely seen as the nation’s leading science organisation and to many, its conscience. The organisation has been responsible, over the past two decades, for creating and publishing some of the nation’s most seminal reports on health disparities, such as the 2003 report Unequal Treatment which unequivocally stated that racism within healthcare was one driver of the nation’s health disparities. The letter, signed by 100 of the academy’s members, said those signing the letter were “deeply disturbed” by the accommodations and said they understood the academy was “taking unilateral action to remove specific words or concepts from pending reports” and such “excessive anticipatory censoring” impacted the scientific rigor and integrity of the reports. Many NASEM reports are a year or more in the making and require the time and expertise of academy members, who are considered leaders in their fields. The letter specifically cited an upcoming report, “Blueprint for a National Prevention Infrastructure for Behavioral Health Disorders” that was scheduled to be released in early February but has not been released and said that authors had learned that staff have been instructed to replace words in the report including the term “health equity.” That replacement of certain words, the letter states, appears “designed to appease the current administration.” Removing the term equity was particularly upsetting to the letter’s authors. “Equity is a core part of NAM’s mission. Our understanding is that staff are being told that these terms are being deleted because equity is not a matter of science. Yet that term alludes to a core value to which we in medicine and public health are deeply committed,” the letter read. Stripping the term, the letter said, “goes against our values as members, the published principles of NAM/NASEM, and decades of scientific work on health inequities,” it continued. Read full story Source: STAT, 20 February 2025
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News ArticleSome researchers who have published on a government patient safety website are refusing to alter their reports to comply with Trump administration executive orders around language, leaving them offline. Gordon Schiff, MD, of Brigham and Women's Hospital and Harvard Medical School in Boston, is the author of a 2022 case report and commentary on suicide risk assessment that includes a line noting several groups at high risk of suicide, including the LGBTQ community. Rather than remove the line, the piece remains off the Patient Safety Network, which is part of the Agency for Healthcare Research and Quality (AHRQ). "I think as a matter of principle, it's not a good idea to give into this," Schiff told MedPage Today. "We could find alternate ways of publishing it, I guess," he said. "And I think we don't want to legitimize this process of what's happened. I think it would be a mistake. It would be a disservice, actually, to cave in. I think people do need to stand up and say, this is not okay." Patrick Romano, MD, MPH, of the University of California Davis and co-editor-in-chief of the Patient Safety Network, told MedPage Today that five full-length, peer-reviewed cases and commentaries, at least one perspective interview, and about 15 short summaries of other published papers, remain offline. (However, they can still be accessed via the Internet Archive.) Removal of these resources occurred in the wake of a Trump administration Office of Personnel Management (OPM) memorandum, "Initial Guidance Regarding President Trump's Executive Order Defending Women." Each of the removed resources had a term, such as "transgender," "gender identity," "non-gender-conforming," "LGBTQ," or "LGBTQIA," that violated OPM guidance, according to Romano. Though Romano told MedPage Today that the authors of the resources have been given the opportunity to revise their work to have it republished on the site, all of them have declined to accept the required changes. Ultimately, concern has extended beyond the recently removed resources. There has been "some worry," with regard to the word "equity," Romano said. For instance, "when we talk about equity on [the Patient Safety Network site] we're talking about treating patients equitably," he said. "We're talking about making sure that patients get diagnosed in an equitable manner, and that, for example, people who live in rural communities don't suffer because of the lack of accessibility to sub-specialty providers." So, "it's different from talking about equity in the occupational context, or in the context of recruitment or admission to elite universities, and so forth," he said, adding that, "as these words are targeted, I think a lot of us are concerned about all the different ways in which those words are used, and the importance of the underlying concept that is really essential as we try to take better care of patients and communities." Read full story Source: MedPage Today, 20 February 2025
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Content Article
The challenges of navigating the healthcare system: Margaret's story
Anonymous posted an article in By patients and public
We hear time and time again on the hub about the lack of joined up care and communication within and across organisations. Patients and their families and carers not knowing who to contact to chase up a referral, systems not joined up, lack of communication, having to repeat the patient’s history and medications to every new healthcare professional they see because the notes haven’t been shared or clinicians "don’t have time to read them all". These issues are widespread and urgently need to be addressed if we are to prevent people falling through the gaps and suffering worse health outcomes. In this blog, *Margaret shares her and family's experiences of trying to coordinate their elderly father's upcoming surgery. Interoperability issues My father has dementia and has a complex set of health issues, as a lot of elderly people do. He has a number of comorbidities, including vascular, heart, and cognition and memory problems, that has meant coordinating his care between the care home, his GP, the local hospital and a specialist hospital has been quite complex. There have been multiple issues but there were two that stood out. The first issue was at the diagnostic stage. My father has severe vascular problems and he needed fairly urgent and necessary surgery. In order to assess whether he was suitable for surgery, given his heart condition, he needed a scan. We have had problems in the past in getting access to scans on his heart so the GP said in order to move things on quicker it would be good to get the scan done privately. As the surgery was urgent, we paid to get the scan done at a private diagnostic centre. However, when it came to getting the information from the private diagnostic centre to the tertiary hospital where he was being treated we encountered problems. The hospital couldn’t access the scans from the private hospital because they were two different systems which meant there was an interoperability issue as the two systems ‘didn’t talk to each other’. One of the suggestions I was given was that I could drive to the private diagnostic centre, which was about a 40 mile drive from my house, with a CD, and then they would download the scans onto the CD and I could then drive back to the hospital, which was about another 35 mile drive. There were multiple calls and this was really quite distressing for our family because we knew my father needed access to the scans urgently. In the end they said they’d do another scan in the hospital. Although I don't think there were any kind of safety issues with my father having another scan, it did mean that not only did it cause delays and stress for my father and the family, it was also a cost to the NHS, which could have been avoided. Communication problems between departments Then around the same time, the hospital wanted to do another scan on my father to prepare for the surgery. Again, as it was urgent, I kept ringing the hospital asking if he had his scan yet but because my father was under the vascular and cardiac departments it was often difficult to know who to speak to because one department needed information from the other and they hadn't received it. So I’d get through to one department who then told me to phone another department, or I would be put on hold by someone from admin who didn’t know the answer and would say they’d ring back but didn’t because they were very busy. As a carer/relative you don’t know what’s happening and you become worried that your loved one is lost in the system. I persisted in phoning but, coincidentally, at the same time my sister visited my father’s house to pick up some bits for him. She saw there was a letter from the hospital so she opened it and it was a letter inviting my father in to have an outpatient appointment scan in the hospital he was an inpatient in! I ended up going to PALS. The lady I spoke to was understanding, sympathetic, kind and highly efficient. But she told me this happened all the time as the radiology department doesn't have access to the hospital's IT system, so they wouldn't know my father was an inpatient and would have just invited him in in a timely way but they would have done that as if he was an outpatient. I coordinated between the different departments and we finally got the scan for my father, he had the surgery and survived. However, these delays could have compromised his health because the surgery was urgent and if he had deteriorated whilst waiting that may have killed him. As a family we were very conscious that time was of the essence and we had to push continuously. Lack of information given to families These are just two examples from a multiple of occasions where we as a family were trying to get information. My father was elderly and wouldn’t have questioned the doctor. And because of his cognition issues due to his dementia, and also because he was on high doses of pain medication, he becomes confused and we couldn’t always rely on what he told us. However, often the healthcare professionals wouldn’t tell us things, despite me being next of kin and with documented power of attorney, and told us to speak to my father. So as a carer or relative you are trying to join the dots and work within a health system that isn’t coordinated. What I want to see change On the face of it they may seem like quite small examples, but when they build up, they are significant in terms of risk. My father was a high-risk patient and if it wasn’t for our diligence and persistence he would have fallen through the cracks, to a significant detriment to his health. I didn’t want there to be avoidable harm, an investigation and ‘lessons learned.’ I want us to be working in a coordinated and proactive manner to recognise the risks and void any harm. And for that insight to be used to ensure systems and processes are improved for the benefit of other patients and families. Also, I want opportunities to share my experience, not as a formal complaint but for genuine interest in our family’s customer experience. Again, for learning and future preventative action not for blame. *The names in this blog have been changed to ensure anonymity. Are you a patient, relative or carer frustrated with navigating the healthcare system? Or is your GP practice or Trust doing something innovative to make it easier for patients? We would love to hear your stories. Please add to our community forum (you will need to register with the hub, it's free and easy to sign up) or email us at [email protected]. Related reading The challenges of navigating the healthcare system: David's story The challenges of navigating the healthcare system: Sue's story Navigating the healthcare system as a university student: My personal experience Lost in the system? NHS referrals "I love the NHS, BUT..." Preventing needless harms caused by poor communication in the NHS (DEMOS, November 2023) Robust collaborative practice must become the bedrock of modern healthcare Robbie: A homeless patient’s struggles with the system Digital-only prescription requests: An elderly woman sent round the houses Lost in the system: the need for better admin Digital-only prescription requests: An elderly woman sent round the houses -
Content Article
The challenges of navigating the healthcare system: David's story
Anonymous posted an article in By patients and public
We hear time and time again on the hub about the lack of joined up care and communication within and across organisations. Patients and their families and carers not knowing who to contact to chase up a referral, having to travel miles for appointments, miscommunication, diagnostic errors, or having to repeat the patient’s history and medications to every new healthcare professional they see because the notes haven’t been shared or clinicians "don’t have time to read them all". These issues are widespread and urgently need to be addressed if we are to prevent people falling through the gaps and suffering worse health outcomes. In this blog, David* shares his story about his elderly sister and a mix up with an urgent referral which led to a near miss. Background My sister has cancer and she's got a diagnosis of dementia too. The cancer is very aggressive and it causes her a lot of pain. Her care team are managing her pain very well. Due to her age and frailty, chemotherapy was out of the question but she had surgery and it seemed to go well. She was having routine check ups post-op to monitor her. An urgent referral A few months later unfortunately the cancer came back and we got an urgent referral from her GP for her to see her consultant. So when within a couple of weeks we got an invite to the hospital for an appointment we assumed it was for her urgent cancer referral. When we got to the appointment, neither the consultant or her advanced nurse practitioner team, who were all familiar with her diagnosis and history, were there. Instead there was a junior doctor on his own. He asked my sister how she had been since her surgery and was she doing well. When my sister said, well no, the tumour had grown significantly and we think the cancer had come back, he went white and rushed out of the room saying he needed to speak to someone else. Communication issues He came back and said my sister would need 20 days of successive radiotherapy in the hospital (which is at least a two-hour round trip). We had many questions we wanted to ask but he wasn’t able to answer them, and I was very concerned whether this was the right course of treatment for her. There were a number of issues—I had questions about how aggressive the cancer was, whether the cancer had spread elsewhere, whether this was palliative or curative treatment, what impact this would have on my sister’s health. Radiotherapy is harsh and my sister was physically very frail. In the end, because I phoned the advanced nurse practitioner and explained what had happened and my concerns, we were invited back for another appointment, and a few days later we saw the consultant. On the advice given, my sister was told about the significant risks and unsuitability of radiotherapy because of her co-morbidities and she decided not to go ahead with the radiotherapy. This was a relief as I didn’t want her to have unnecessary treatment, especially treatment that would not address her cancer and make her remaining months painful and distressing. The consultant was wonderful, and I’ve written him a lovely letter thanking him, but there has been a big communication issue here which could have led to a different outcome altogether. A 'near miss' The issues here, as I see them, are that the urgent referral got mixed up with the routine post-op appointment, which led to a doctor in training being placed in a situation for which he was untrained and unprepared in making significant treatment decisions. The advice he received and acted upon was from an unnamed consultant who didn’t even speak with or examine my sister. There is also the fact that they didn’t have a conversation with my sister about her options and they just told her she needed the radiotherapy. This is not informed consent! If we hadn't been there with her and questioned it, would she have had that course of treatment, accepted the radiotherapy, even though it was completely unnecessary, which would have led to avoidable harm? This really is a big ‘near miss’. What would have happened if she hadn’t had anyone there to intervene and advocate for her. She has absolute confidence in the health system but, for her family trying to navigate the system, this was incredibly stressful. What happens to the patients who haven’t got a family around to support and advocate for them? We need to look at the whole care pathway and try to design it from the patient and family’s perspective. *The names in this blog have been changed to ensure anonymity. Are you a patient, relative or carer frustrated with navigating the healthcare system? Or is your GP practice or Trust doing something innovative to make it easier for patients? We would love to hear your stories. Please add to our community forum (you will need to register with the hub, it's free and easy to sign up) or email us at [email protected]. Related reading The challenges of navigating the healthcare system: Margaret's story The challenges of navigating the healthcare system: Sue's story Navigating the healthcare system as a university student: My personal experience Lost in the system? NHS referrals "I love the NHS, BUT..." Preventing needless harms caused by poor communication in the NHS (DEMOS, November 2023) Robust collaborative practice must become the bedrock of modern healthcare Robbie: A homeless patient’s struggles with the system Digital-only prescription requests: An elderly woman sent round the houses Lost in the system: the need for better admin Digital-only prescription requests: An elderly woman sent round the houses -
Content Article
The challenges of navigating the healthcare system
Patient_Safety_Learning posted an article in Care pathways
Navigating the healthcare system in the UK can be complex and frustrating for patients, families and carers. We hear time and time again on the hub about the lack of joined up care and communication within and across organisations. Failing to share the right information at the right time can create significant patient safety risks. Poor communications, both with patients and between healthcare professionals, can result in misunderstandings and mistakes resulting in poor outcomes and potentially patient harm. In a new series of blogs on the hub, patients and their relatives describe the challenges and barriers they have faced when trying to navigate the healthcare system. Although every experience of navigating the healthcare system is different, the blogs in this series highlight some clear themes: Confusing communications and correspondence. Information not accessible across departments. Disjointed electronic systems, often not talking to each other. Concerns around the impact of delays to treatment and diagnostic tests. Near misses managed by patients and family members. Concerns for more vulnerable patients and those without advocates. The negative impact on mental health and stress levels. Not knowing who to contact to chase referrals, appointments or results. Read Sue’s story Sue’s husband Neil has a very rare chronic condition and is under the care of many different specialties. In this blog, Sue shares her and Neil’s experiences of trying to coordinate the healthcare system and highlights the challenges and frustrations they continuously face. Read David’s story In this blog, David shares his story about his elderly sister who has dementia, and a mix up with an urgent referral which led to a near miss. Read Margaret’s story Margaret’s father has dementia and a complex set of health issues. In this blog, Margaret shares her experience of trying to coordinate their elderly father's upcoming surgery. Read a university student’s story Moving to university is a big transition for many. In this anonymous blog, a student describes how persistent health issues led to a frustrating journey through the healthcare system. These stories illustrate how disjointed systems can affect patient and carer experiences and have a negative impact on health outcomes. Commenting on the issues highlighted in the series, Chief Executive of Patient Safety Learning, Helen Hughes says: “Poorly coordinated care is not only confusing and frustrating for patients but also creates safety risks that can result in serious avoidable harm. We hear many examples, such those covered in this blog series, of patients and their families facing a complex and fragmented healthcare environment. When they raise concerns about care and treatment, in too many cases they encounter an unresponsive system where they are left to ‘join the dots for patient safety’. The needs of patients should be central to improving health and care services, actively listening and acting on their experiences and insights when things go wrong for safety improvement.” Share your story What has been your experience of navigating the healthcare system? What is and isn’t working? How does it feel as a patient or carer when you hit barriers? Has your health been affected? Share your story in our community forum or contact our editorial team at [email protected]. Related reading Lost in the system? NHS referrals "I love the NHS, BUT..." Preventing needless harms caused by poor communication in the NHS (DEMOS, November 2023) Robust collaborative practice must become the bedrock of modern healthcare Robbie: A homeless patient’s struggles with the system Digital-only prescription requests: An elderly woman sent round the houses Lost in the system: the need for better admin Digital-only prescription requests: An elderly woman sent round the houses -
Community Post
The challenges of navigating the healthcare system
Patient Safety Learning posted a topic in Improving patient safety
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In a new series of blogs on the hub, patients and their relatives describe the challenges and barriers they have faced when trying to navigate the healthcare system. What has been your experience of navigating the healthcare system? What is and isn’t working? How does it feel as a patient or carer when you hit barriers? Has your health been affected? Or perhaps you're a healthcare professional who has insights to share? Is your work affected by disjointed systems? Have you been involved in implementing systems to help care coordination? Please comment below (sign up first for free) or you can email us at [email protected]. -
News ArticleA consultant paediatrician warned medical colleagues treating her son that they had failed to give him life-saving antibiotics hours before he died from sepsis, an inquest has heard. William Hewes, 22, a history and politics student, died on 21 January 2023 of meningococcal septicaemia at east London’s Homerton hospital, where his mother, Dr Deborah Burns, worked. Burns brought her “very ill” son into the A&E at the hospital just after midnight and told her colleagues he was seriously ill and needed treating for meningitis, the inquest into his death heard on Thursday. A doctor prescribed 2 grams of the antibiotic ceftriaxone within minutes of Hewes’s arrival and the medical team knew the drug had to be given as soon as possible. But due to a communication mix-up between the duty emergency registrar, Dr Rebecca McMillan, and nurses, the “life-saving” drug was not administered within the vital first hour of treatment, the inquest heard. Burns said her son only got the antibiotics after she warned Dr Luke Lake, the acting medical registrar on duty at the time, about the failure to administer the drug. In written evidence read to the court, she said: “I told him I didn’t think William had the antibiotics. Luke reassured me, that they had been written up earlier. I replied: ‘Yes, but they have not been given.’” Earlier, Dr McMillan recounted her distress when she realised at about 1.17am that the drug had not been administered by nurses as she requested. She said: “I do recall standing outside the resus room with [nurse Marianela Balatico] where she asked if I was OK and said that I looked really upset when I realised that antibiotics had not been given. “We had a conversation along the lines of we didn’t understand how this had happened. We were both upset when we realised that this hadn’t happened.” Fighting back tears, McMillan said one of the “learning points” from Hewes’s death was the need “to be clearer who I’m giving instruction to”. She added: “I obviously thought that my instructions had been clear enough. I have thought about that moment over and over.” Read full story Source: The Guardian, 13 February 2025
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Content ArticleMedical misinformation can have a profound impact on perioperative patient safety. With users numbering in the billions, platforms such as Facebook, Instagram, TikTok, X (formerly Twitter), Snapchat, Pinterest, Reddit, Messenger and YouTube command an ever-increasing share of the public’s time, attention, and dependence. Consequently, they have also become primary sources of information for politics, sports, general knowledge, and news for the general public. Statistics published by Pew Research in 2022 show that adults under the age of 30 actually trust information from social media almost as much as national news outlets, and in 2023, half of US adults get news at least some of the time from social media. The relationship between medical care and information on the internet has been fraught since the early days of the internet, predating the more recent increase of medical misinformation. According to the United States Office of the Surgeon General, medical misinformation is “information that is false, inaccurate, or misleading according to the best available evidence at the time. Misinformation can affect understanding of public health concerns, as was seen in the recent Covid pandemic when concerns were expressed regarding social distancing, mask mandates, and vaccination. Perioperative medicine is no less affected, as highlighted in this blog in the Anaesthesia Patient Safety Foundation (APSF) newsletter.
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News ArticleA coroner has ordered an integrated care board to fill gaps in its services and address mental health bed shortages following the death of a 29-year-old with autism and ADHD who spent 26 days in A&E. Matthew “Matty” Sheldrick (they/them), who identified as non-binary, died from self-ligature outside Royal Sussex County Hospital after returning to A&E one month on from the 26-day stay. Matty had struggled to access community services for support with their mental health, autism, and ADHD. Confusion about and delays to appointments during their time in hospital and the community contributed to a sense of hopelessness, according to Matty’s mother, Shelagh Sheldrick. In two prevention of future death reports published last month, senior area coroner Penelope Schofield said Matty received “no meaningful therapeutic input” during their prolonged first stay in an A&E short-stay ward and that the environment “contributed to the deterioration of their mental health difficulties”. In a report addressed to Sussex Integrated Care Board, Ms Schofield raised concerns over a lack of funding for private mental health beds for autism patients, and the fact that oversubscribed public providers “very often” rejected referrals for autism patients because of “additional risks”. Read full story (paywalled) Source: HSJ, 28 January 2025
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Content ArticleMatthew Zak Sheldrick (Matty) had struggled with their mental health throughout their adult life, but it wasn’t until 2019 that Matty was finally diagnosed with Autism. ADHD and Autistic Spectrum Disorder. However, they had never been sectioned under the Mental Health Act or had spent time as a voluntary patient in a mental health hospital. Matty had moved to Brighton from Surrey in November 2021 having wanted to live independently. They were drawn to Brighton as they wished to be involved in the trans/non-binary community. Matty’s mental health deteriorated during the summer of 2022 due to accommodation issues that they had been facing and issues with an online relationship. By 3rd September they were in crisis. On 5 September 2022 Matty was admitted to A&E at the Royal County Hospital, Brighton. They remained within A&E, short stay ward, for 26 days awaiting a psychiatric bed. During this time no bed was found, and they were eventually discharged back home with support from the Crisis Home Treatment Team. Matty’s mental health had been affected by the unsuitability of the environment within A&E for someone awaiting an inpatient mental health bed. Less than 5 weeks later Matty was again admitted to the A&E department at the Royal Sussex County Hospital on 3rd November 2022 in crisis. Their presentation fluctuated and this led to them being assessed under the Mental Health Act. However, they were not found to be detainable. They left the hospital shortly after the assessment and were sadly found hanging in the grounds of the hospital. Matters of concern The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health who are awaiting beds. In Matty’s case a bed was not found for them within a 26-day period. There being a shortage of beds for Autistic patients (both informal and detained) within the private sector that are being funded by the ICB. Evidence was heard that those providing beds within the public sector very often refused to accept autistic patients due to their additional risks. There being a shortage of beds for transgender patients who are in need of a mixed ward. In Matty’s case it appears there was a lack of appreciation by the ICB of his extensive length of stay in A&E. It appears that this information (and others who had lengthy stays) was not at that time being collected, monitored and acted on by the ICB. The unsuitability of the environment of A&E as a holding place for those in need of a mental health bed. The evidence was that the environment in A&E as a holding place is not conducive for those suffering with Autism and/or who are neurodiverse. The environment in A&E can exacerbate and cause further deterioration in their mental health. There is a gap in services for those who are not ill enough to be detained but who are too high risk to be sent home. There is a significant wait time for referral to the Assessment and Treatment Service. Therefore, any therapeutic input is delayed, and this results in repetitive attendances at A&E when in crisis. Current gaps in service around psychosocial support for transgender, non-binary and intersex adults have been provided by third party charitable organisations. It is understood that much of their funding has recently been withdrawn by the ICB. This is of particular concern as Brighton is recognised as having one of the largest trans communities in the Country.
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News Article
Vapes '95% safer' than cigarettes messaging backfired
Patient Safety Learning posted a news article in News
The message that vaping is 95% safer than smoking has backfired, encouraging some children to vape, says a top health expert. Dr Mike McKean treats children with lung conditions and is vice-president for policy at the Royal College of Paediatrics and Child Health. He says the 2015 public messaging should have been clearer - vapes are only for adults addicted to cigarettes. Evidence on the possible health risks of vaping is still being gathered. In an exclusive interview with the BBC, Dr McKean said: "Vaping is not for children and young people. In fact it could be very bad for you," although he stresses that it is not making lots of children very sick, and serious complications are rare. "Vaping is only a tool for adults who are addicted to cigarettes." He says the 95% safe messaging was "a very unwise thing to have done and it's opened the door to significant chaos". "There are many children, young people who have taken up vaping who never intended to smoke and are now likely addicted to vaping. And I think it's absolutely shocking that we've allowed that to happen." Read full story Source: BBC News, 26 September 2023- Posted
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Content ArticleThe plan to introduce league tables is a simplistic, retrograde gimmick that will demoralise NHS staff – and sideline their incredible work, writes Rachel Clarke, a palliative care doctor, in this opinion piece for the The Guardian. Naming and shaming, complete with inflammatory language that’s designed to scapegoat staff, such as the bad managers branded as the NHS’s “guilty secret”, is not constructive.
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Content ArticleThe Prime Minister and the Health Secretary have sparked debate by repeatedly stating that the NHS is broken. One poll by YouGov found that nearly two-thirds of the public agree with this description, but what do NHS staff think? The King's Fund have explored the views of staff that they work with as well as those who have spoken publicly on the issue to consider what impact this language might have on the system and its workers.
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Community Post
Can the NHS learn from healthcare systems overseas?
Steve Turner posted a topic in Organisational
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Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS an attractive place to work again, providing the NHS Constitution for England is at the heart of changes and is kept up to date. In my experience, having worked in healthcare for the private sector and the NHS, and lived and worked in other countries, we need to open our eyes. At present it could be argued that we have the worst of both worlds in England. A partially privatised health system and a fully privatised social care system. All strung together by poor commissioning and artificial and toxic barriers, such as the need for continuing care assessments. In my view a change, for example to a German-style system, could improve patient safety through empowering the great managers and leaders we have in the NHS. These key people are held back by the current hierarchical crony-ridden system, and we are at risk of losing them. In England we have a system which all too often punishes those who speak out for patients and hides failings behind a web of denial, obfuscation and secrecy, and in doing this fails to learn. Vast swathes of unnecessary bureaucracy and duplication could be eliminated, gaps more easily identified, and greater focus given to deeply involving patients in the delivery of their own care. This is a contentious subject as people have such reverence for the NHS. I respect the values of the NHS and want to keep them; to do this effectively we need much more open discussion on how it is organised and funded. What are people's views? -
Content ArticleA casually centred proposal identifying how Fire and Rescue Services can improve pre-hospital care and quality of life outcomes for burn survivors. David Wales and Kristina Stiles have released this report looking at the burn survivor experience in the pre-hospital environment. The work makes ten operational recommendations and also two 'lessons learned' recommendations exploring strategic partnership working and the resulting fragmented services.
