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Found 219 results
  1. News Article
    Trust chiefs have collectively called for the Care Quality Commission (CQC) to review its use of single-word inspection ratings, following MPs’ calls for an overhaul of Ofsted ratings for schools. In a report containing a series of recommendations for CQC reform, shared with HSJ, NHS Providers urges the regulator to re-evaluate the success of its single-word ratings, asking it to consider adding a narrative verdict as part of its new provider assessment reports. The recommendation is made “in the context of the Ofsted inquiry findings” following the death of headteacher Ruth Perry by suicide, which a coroner ruled was contributed to by an Ofsted inspection. It prompted MPs on the Commons’ education committee to call for a ban on single-word Ofsted ratings. The NHSP report said the inquiry’s concerns around inspectors’ behaviour, the complaints process, and single ratings can also be applied to CQC. The report adds: “While we recognise the differences between the two regulators’ approaches, we believe now is the right time to take stock… for example, CQC may need to consider the value of its single-word ratings, modelled upon Ofsted’s rating system. “As suggested by the Nuffield Trust and many trust leaders, a single-word rating will inevitably oversimplify what happens in a very complex organisation". Read full story (paywalled) Source: HSJ, 21 March 2024
  2. News Article
    Many popular AI chatbots, including ChatGPT and Google’s Gemini, lack adequate safeguards to prevent the creation of health disinformation when prompted, according to a new study. Research by a team of experts from around the world, led by researchers from Flinders University in Adelaide, Australia, and published in the BMJ found that the large language models (LLMs) used to power publicly accessible chatbots failed to block attempts to create realistic-looking disinformation on health topics. As part of the study, researchers asked a range of chatbots to create a short blog post with an attention-grabbing title and containing realistic-looking journal references and patient and doctor testimonials on two health disinformation topics: that sunscreen causes skin cancer and that the alkaline diet is a cure for cancer. The researchers said that several high-profile, publicly available AI tools and chatbots, including OpenAI’s ChatGPT, Google’s Gemini and a chatbot powered by Meta’s Llama 2 LLM, consistently generated blog posts containing health disinformation when asked – including three months after the initial test and being reported to developers when researchers wanted to assess if safeguards had improved. In response to the findings, the researchers have called for “enhanced regulation, transparency, and routine auditing” of LLMs to help prevent the “mass generation of health disinformation”. Read full story Source: The Independent, 20 March 2024
  3. News Article
    Doctors made do-not-resuscitate orders for elderly and disabled patients during the pandemic without the knowledge of their families, breaching their human rights, a parliamentary watchdog has said. In a new report on breaches of the orders during the pandemic, the Parliamentary Health Service Ombudsman (PHSO) found failings from at least 13 patient complaints. The research, carried out with the charity Dignity in Dying, found “unacceptable” failures in how end-of-life care conversations are held, and in particular with elderly and disabled patients. Following a review of complaints in 2019 and 2020 the PHSO found evidence in some cases that doctors did not even inform the patient or their family that a notice had been made and so breached their human rights. The report calls for health services in Britain to improve the approach by medics in talking about death and end-of-life care. In examples of cases reviewed, the PHSO revealed the story of 58-year-old Sonia Deleon who had schizophrenia and learning disabilities and a notice which was wrongly applied during the pandemic. In 2020, she was admitted to Southend University Hospital after contracting Covid-19 at age 58. On three occasions a notice was made but her family were never informed. Following Sonia’s death her family found out the reasons given by doctors for the DNAR which “included frailty, having a learning disability, poor physiological reserve, schizophrenia and being dependent for daily activities.” Sonia’s sister Sally-Rose Cyrille said: “I was devastated, shocked and angry. The fact that multiple notices had been placed in Sone’s file without consultation with us, without our knowledge, it was like being hit with a sledgehammer. Read full story Source: The Independent, 14 March 2024
  4. News Article
    A mental health trust linked to thousands of unexpected patient deaths repeatedly failed to act on coroners' safety warnings, campaigners say. BBC News has been given exclusive access to new evidence from coroners' reports gathered by a campaign group. It wants a criminal investigation into why so many patients died at Norfolk and Suffolk NHS Foundation Trust - and has sent police the evidence. Campaigners, including patients and bereaved families, claim it is failing to make vital safety improvements despite promising to do so. Last summer, a report found more than 8,000 mental-health patients had died unexpectedly in Norfolk and Suffolk between 2019 and 2022. This is defined as the death of a patient who has not been identified as critically ill or whose death is not expected by the clinical team. The new evidence, based on 38 coroners' prevention of future death (PFD) reports since 2013, suggests there were repeated warnings more patients could die unless safety issues were addressed, including: dangerously poor record-keeping and communication family concerns being ignored unsafe levels of staffing at the trust. And campaigners say the trust's failure to improve safety has led to more deaths. Read full story Source: BBC News, 12 March 2024
  5. Content Article
    Healthwatch and national organisations representing patients and NHS leaders express concerns over Royal Mail plans to delay bulk mail of NHS appointment letters from two days to three days. 
  6. News Article
    It is still unclear how unauthorised metal parts came to be implanted in a number of the 19 children with spina bifida who suffered significant complications after spinal surgery. But it has emerged that one child died and 18 others suffered a range of complications after surgery at Temple Street Children’s Hospital – with several needing further surgery, including the removal of metal parts which were not authorised for use. Parents of the children undergoing complex surgery were left distraught by the disclosures that emerged yesterday, after campaigning for years while the young patients in need of operations deteriorated on waiting lists. Gerry Maguire, of Spina Bifida Hydrocephalus Ireland, said “absolute horror is being visited on parents and their advocates”. He condemned as disturbing the information which is “being drip-fed to his group and “more alarmingly the families concerned”. One mother expressed concern about further delays in surgery and said children are too complex to be taken for care abroad. Read full story Source: Irish Independent, 19 September 2023
  7. Content Article
    Demos is Britain's leading cross-party think tank, working on different policy areas, from improving public services to building a more collaborative democracy. In this blog, Miriam Levin, Director of Participatory Programmes at Demos, tells us about their recent report, “I love the NHS but…”: Preventing needless harms caused by poor communication in the NHS. She argues there is an urgent need to improve NHS communications for patients and staff if we are to prevent people falling through the gaps and suffering worse health outcomes. Miriam highlights key issues with NHS referrals, disjointed computer systems and gaps in patient information, and offers some potential solutions. 
  8. News Article
    Doctors tore down posters offering patients a secondary care review if they were worried about their condition in hospital, the mother of a teenager who died of sepsis claimed. Merope Mills, who has campaigned for a similar policy called “Martha’s Rule” named after her 13-year-old daughter, claimed a small minority of “bad actors” in hospitals risked slowing down the initiative. It comes as NHS England announced 100 hospitals with critical care units will be invited to sign up for the policy, which will be rolled out from April this year. Martha died from sepsis in 2021 after staff at King’s College Hospital failed to move her to intensive care despite her family warning them her condition had deteriorated. “When something similar to Martha’s Rule was introduced to Royal Berkshire Hospital, doctors actually pulled down the posters advertising the service to patients because they hated the idea of giving patients this kind of power,” Mrs Mills told the Today Programme. “A small minority of bad actors whose arrogance, complacency or pride stops them listening and doing the right thing and that is what we are trying to challenge with Martha’s Rule. There are pockets of damaging cultures in hospitals around the country. Sometimes it is not a whole hospital, sometimes it is just a ward in a hospital, sometimes it is just a particular individual on a ward in a hospital.” Read full story Source: The Independent, 21 February 2024
  9. Content Article
    Join Alan Lindemann, an obstetrics-gynecology physician, who shares his insights and real-life experiences, shedding light on the issues surrounding patient care, medical decision-making, and the role of institutions and personal connections in shaping health care outcomes. Discover how the pursuit of quality care can sometimes be obstructed by self-interest and the need to protect reputations. Alan also proposes innovative ideas to enhance transparency and public involvement in health care quality assurance.
  10. Content Article
    Rob Behrens reflects on the work the Parliamentary and Health Service Ombudsman (PHSO) has done over the last year to drive improvements in patient safety.
  11. News Article
    Many people are deeply confused about the growing number of “physician associates” in the NHS and wrongly assume they are doctors, research suggests. Around 4,000 physician associates work in the NHS in England. Ministers and health chiefs plan to increase the figure to 10,000 to help plug widespread gaps in the NHS workforce. However, there is widespread confusion among the public about their role and relationship with fully trained medics, according to a survey commissioned by the British Medical Association (BMA). A quarter of the representative sample of 2,009 people erroneously believed that a physician associate was a doctor, while a fifth made the same mistake about “physician assistants”. Many respondents thought that a physician associate was more senior than a junior doctor, even though only the latter have a medical degree. The expansion of physician associates has prompted a backlash by grassroots medics. They fear patients will be misled into thinking they have seen a doctor despite physician associates not having the same skills and training. The government has moved to try to quell criticism of physician associates by legislating to ensure they are regulated by the General Medical Council (GMC). Read full story Source: The Guardian, 13 December 2023
  12. News Article
    Campaigners have written to the chief constables of Norfolk and Suffolk to request an investigation into thousands of mental health deaths in those areas. They say coroners are raising safety issues but no improvements are being made. A report by independent auditors found as many as 8,440 patients had died unexpectedly over three years. Norfolk and Suffolk NHS Foundation Trust said it had started a review of patient deaths. Coroners worried about the risk of future deaths highlight unsafe practices in prevention of future deaths reports (PFDs). And authorities are required by law to respond with an action plan within 56 days. The Norfolk and Suffolk trust said it had responded to all PFDs and was working to ensure recommendations and actions were implemented. But Mark Harrison, from the Campaign to Save Mental Health Services in Norfolk and Suffolk, said: "There's a criminal case to answer. And we want the police to investigate, where the same mistakes have been repeated time and time again." He said coroners were repeatedly warning of risks such as delays to treatment, lack of patient follow-ups, chaotic record keeping and disorganised communication between teams. Mr Harrison said: "The mental health trust always responds saying they've learned lessons, they are changing policy and practices. "But then what we're seeing in analysing the orders from the coroner are repeat circumstances where other people have died in similar circumstances to a previous prevention-of-future-deaths notice." Read full story Source: BBC News, 12 December 2023
  13. Content Article
    In a multicultural society, individuals from diverse linguistic backgrounds may face language barriers when seeking healthcare. Effective communication is essential to ensure that patients can accurately express their symptoms, concerns and medical history, and understand the information given to them by healthcare providers. In this blog, Kathryn Alevizos discusses some of the common language barriers non-native English speaking patients can experience, and offers practical advice on how we can all improve our intercultural communication skills.
  14. News Article
    A North Wales coroner has concluded there was a ‘gross failure’ in the case of a coeliac patient, who tragically died in Wrexham Maelor hospital. Mrs Hazel Pearson, 79, had coeliac disease and a number of other medical conditions and died from aspiration pneumonia four days after being given Weetabix for breakfast while at the hospital. Whilst her coeliac disease was noted on her admission records, there was no sign above her bed and staff were unaware of her dietary needs and as a result Mrs Pearson had been fed gluten containing food on multiple occasions. Tristan Humphreys, Head of Advocacy for Coeliac UK said: “We are deeply saddened and concerned by this verdict and our thoughts go out to Mrs Pearson’s loved ones at this very difficult time. Her death reflects a clear failure of care and it is patently unacceptable that this was allowed to happen. Coeliac disease is a serious autoimmune condition for which the only treatment is a medically prescribed gluten free diet. It is critical that people with coeliac disease can access the gluten free food they need to be healthy. This is all the more important when someone is unwell and, as in Mrs Pearson’s tragic case, unable to advocate for themselves. Wales has mandatory food standards which make very clear the level of care that should be provided yet these have not been met. As a charity, we are empowering patients, family members, carers and working with hospital caterers by providing advice and guidance to support safe provision of gluten free food. However, it’s high time the health service consistently delivered the care people with coeliac disease deserve.” Read full story Source: Coeliac UK, 24 November 2023
  15. News Article
    Chaotic communication by the NHS in England is causing harmful delays to treatment and endangering patient health, according to research. Widespread communication problems that leave patients and staff scrambling to find their referrals, missing appointments, or receiving late diagnoses have been uncovered in a study by the Demos thinktank, the Patients Association, and the PMA, a professional membership body for healthcare workers. In a poll of 2,000 members of the public and NHS staff across England in October, more than half said they had experienced poor communication from the health service in the past five years, with one in 10 saying their care had been affected as a result. The research also found that over the last year, 18% had their care, or the care of an immediate family member, delayed or affected because they were referred to the wrong service, while 26% said they or a close family member had been inconvenienced because they were given the date and time of an appointment without enough notice. Miriam Levin, the director of participatory programmes at Demos, said that despite the great esteem and pride in the NHS, patients found navigating the system frustrating and stressful. “We heard countless stories of critical appointments missed, diagnoses not shared or shared too late, and referrals for treatment that went missing. This leads to real harm,” she said. Read full story Source: The Guardian, 27 November 2023
  16. News Article
    Calls are being made to improve NHS interpreting services, with staff resorting to online translation tools to deliver serious news to non-English speaking patients. The National Register of Public Service Interpreters said "poorly managed" language services are "leading to abuse, misdiagnosis and in the worst cases, deaths of patients". The BBC's File on 4 programme has found interpreting problems were a contributing factor in at least 80 babies dying or suffering serious brain injuries in England between 2018 and 2022. NHS England says it is conducting a review to identify if and how it can support improvements in the commissioning and delivery of services. Rana Abdelkarim and her husband Modar Mohammednour arrived in England after fleeing conflict in Sudan, both speaking little English. It was supposed to be a fresh start but they soon suffered a devastating experience after Ms Abdelkarim was called to attend a maternity unit for what she thought was a check-up. In fact, she was going to be induced, something Mr Mohammednour said he was completely unaware of. "I heard this 'induce', but I don't know what it means. I don't understand exactly," he said. His wife suffered a catastrophic bleed which doctors were unable to stem and she died after giving birth to her daughter at Gloucestershire Royal Hospital in March 2021. He said better interpreting services would have helped him and his wife understand what was happening. "It would have helped me and her to take the right decision for how she's going to deliver the baby and she can know what is going to happen to her," he added. The Healthcare Safety Investigation Branch (HSIB) found there were delays in calling for specialist help, there was no effective communication with Ms Abdelkarim, and the incident had traumatised staff. Gloucestershire Royal Hospitals NHS Foundation Trust has apologised and said it had acted on the coroner's recommendations to ensure lessons have been learned to prevent similar tragedies. Read full story Source: BBC News, 21 November 2023
  17. News Article
    Patients are being left feeling “confused and neglected” by not being told who to contact about their future care when they are discharged from hospital, an NHS watchdog has said. Research by Healthwatch England has found that 51% of people are not being given details when they leave of which services they can turn to for help and advice while they are recovering. The NHS was risking patients having to be readmitted as medical emergencies and hospital beds becoming even more scarce by failing to adhere to its own guidelines on discharge, it said. “While our findings show some positive examples, it’s alarming that guidance on safe discharge from the hospital is routinely not being followed,” said Louise Ansari, the patient champion’s chief executive. Healthwatch asked 583 people and their carers how their discharge had gone. Read full story Source: The Guardian, 19 November 2023
  18. Content Article
    New research from Healthwatch reveals worrying problems with hospital discharge arrangements. Many people told us they are not given the right support or information when being discharged from hospital. Read on about their experiences and Health Watch's calls to action.
  19. Content Article
    Stephen Shorrock looks at how we use deficit-based taxonomies when describing incidents in healthcare and why neutralised taxonomies may be more flexible and useful.
  20. Content Article
    This blog calls for action on the careful review of established pain medication when a patient is admitted to hospital. Richard describes the experience of two elderly patients who suffered pain due to their long term medication being stopped when they were admitted to hospital. Pain control needs must not be ignored or undermined, there needs to be carer and patient involvement and their consent, and alternative pain control must be considered.
  21. News Article
    Almost two-thirds of maternity units provide dangerously substandard care that puts women and babies at risk, the NHS watchdog has said in a damning report. The Care Quality Commission (CQC) has rated 65% of maternity services in England as either “inadequate” or “requires improvement” for the safety of care – up from 54% last year. Services are beset by a host of problems, including serious staff shortages and internal tensions, which mean that too many mothers and their babies receive care that is not good enough, it said. Women too often face delays in accessing care, do not receive the one-to-one care from a midwife to which they are entitled or experience communication problems with staff looking after them, including being shouted at by midwives. The CQC judged overall quality of care to be inadequate or require improvement at 85 maternity units, almost as many at which it rated it to be either good or outstanding – 87. The number of units offering substandard care has soared by 30 in the last year, from 55 to 85. It said that, having inspected 73% of all maternity units, “the overarching picture is one of a service and staff under huge pressure. People have described staff going above and beyond for women and other people using maternity services and their families in the face of this pressure. “However, many are still not receiving the safe, high-quality care that they deserve.” Read full story Source: The Guardian, 20 October 2023
  22. News Article
    An ambulance trust has apologised after a patient who was declared "dead" later woke up in hospital. As first reported by The Northern Echo, the individual was taken by paramedics to Darlington Memorial Hospital on Friday. The newspaper reported they had been declared dead following an incident earlier that day. The North East Ambulance Service (NEAS) apologised to the patient's family and said an inquiry had begun. The patient has not been identified or their current condition revealed. NEAS director of paramedicine Andrew Hodge said: "As soon as we were made aware of this incident, we opened an investigation and contacted the patient's family. "We are deeply sorry for the distress that this has caused them. "A full review of this incident is being undertaken and we are unable to comment any further at this stage. "The colleagues involved are being supported appropriately and we will not be commenting further about any individuals at this point." Read full story Source: BBC News, 17 October 2023
  23. News Article
    The NHS has launched an investigation after it sent “priority” letters to people who died years ago, in some cases decades, urging them to book flu and Covid-19 jabs to reduce their risk of serious illness. The health service is asking eligible patients to arrange appointments for both vaccines to avoid a potential “twindemic” of flu and coronavirus this winter, which would pile further pressure on hospitals and GP surgeries. “You are a priority for seasonal flu and Covid-19 vaccinations,” the two-page letter tells recipients. “This is because you are aged 65 or over (by 31 March 2024). However, some of the letters, which contain personal information such as NHS numbers, have been sent to people who died years ago. Others have been sent to people who are not eligible for the vaccines, with no connection to the addressee. In a statement, NHS England told the Guardian it was investigating. It declined to answer questions about when the error was first discovered, what had caused it and how many people had been affected. “We have been made aware of some letters sent in error and appreciate this may have been upsetting for those who received it – we are working as quickly as possible to investigate this,” a spokesperson for NHS England said. Read full story Source: The Guardian, 24 October 2023
  24. News Article
    The BMA’s GP Committee (GPC) has demanded an investigation into the Government and NHS England’s ‘mismanagement’ of this year’s vaccination programmes. A motion was passed at the GPC England meeting today which called for a review of the ‘circumstances which led to muddled and mismanaged communications’ and for reflection on how to ‘prevent a repeat occurrence’. Last month, there was confusion over the start date for the adult flu and Covid vaccination programmes, which usually start in September. NHS England said the programmes would start in October this year – a move which the BMA said would cause ‘serious disruption’. But the Government then announced that vaccination will begin on 11 September, in what the BMA has called a ‘u-turn’, following the identification of a new Covid variant. GPs were asked to vaccinate ‘as many people as possible’ by the end of October. The GPC has said today that these ‘conflicting instructions’ led to confusion among GPs while also impacting on patient safety. Read full story Source: Pulse, 21 September 2023
  25. News Article
    An NHS hospital trust in Nottingham failed to send more than 400,000 digital letters and documents to GPs and patients, BBC News can reveal. A former employee has told of "a lack of responsibility" over a new computer system. Patient body Healthwatch said it was "deeply concerned" by the scale of the incident and the impact on care. The trust says a full investigation took place in 2017 and found no significant harm to patients. But it has now said it will carry out a review of that investigation and take any further action needed. The healthcare regulator the Care Quality Commission (CQC) said it was not aware of the incident and would be following up with the trust. This is the second major incident in England involving unsent NHS letters uncovered by the BBC recently. Read full story Source: BBC News, 30 September 2023
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