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Found 203 results
  1. Content Article
    This paper identifies some of issues around transitions of care when a patient leaves an intensive care unit (ICU) for ‘a general medical ward (or other de-escalated care settings, such as a step-down unit) for observation, treatment, and discharge planning.’ The authors describe a checklist to support safe ICU transfers of patients to medical wards or step-down units.  The proposed 7-step checklist has the mnemonic SIMPLER: Stable vital signs Intact aeration Medications reviewed Prepared psychology Lingering catheters Extreme laboratory findings, and Return plans. The authors state: "The first 3 steps are prerequisites in a medical ward and denote the importance of stable vitals signs, intact aeration, and a diligent medication check. The next 3 steps are priorities in the ICU and involve determining patient expectations, managing catheters or other devices, and reviewing laboratory results. The final step concerns contingency plans for unforeseen deteriorations and goals of care."
  2. Content Article
    This report sets out how the NHS will resuscitate urgent and emergency care, with a focus on getting patients out of corridors, keeping more ambulances on the road, and enable those ready to leave hospital to do so as soon as possible. Summary of actions and impact for patients and carers Focus as a whole system on achieving improvements that will have the biggest impact on urgent and emergency care services this winter By the year-end, with improvement over winter, we expect to: Reduce ambulance wait times for Category 2 patients – such as those with a stroke, heart attack, sepsis or major trauma – by over 14% (from 35 to 30 minutes). Eradicate last winter’s lengthy ambulance handover delays by meeting the maximum 45-minute ambulance handover time standard, helping get 550,000 more ambulances back on the road for patients. Ensure a minimum of 78% of patients who attend A&E (up from the current 75%) are admitted, transferred or discharged within 4 hours, meaning over 800,000 people a year will receive more timely care. Reduce the number of patients waiting over 12 hours for admission or discharge from an emergency department compared to 2024/25, so this occurs less than 10% of the time. This will improve patient safety for the 1.7 million attendances a year that currently exceed this timeframe. Tackle the delays in patients waiting to be discharged – starting with the nearly 30,000 patients a year staying 21 days over their discharge-ready-date, saving up to half a million bed days annually. Increase the number of children seen within 4 hours, resulting in thousands of children every month receiving more timely care than in 2024/25. Develop and test winter plans, making sure they achieve a significant increase in urgent care services provided outside hospital compared to last winter Improve vaccination rates for frontline staff towards the pre-pandemic uptake level of 2018/19. This means that in 2025/26, we aim to improve uptake by at least 5 percentage points. Increase the number of patients receiving urgent care in primary, community and mental health settings, including the number of people seen by Urgent Community Response teams and cared for in virtual wards. Meet the maximum 45-minute ambulance handover time standard. Improve flow through hospitals, with a particular focus on reducing patients waiting over 12 hours, and making progress on eliminating corridor care. Set local performance targets by pathway to improve patient discharge times, and eliminate internal discharge delays of more than 48 hours in all settings. Reduce length of stay for patients who need an overnight emergency admission. This is currently nearly a day longer than in 2019 (0.9 days) and needs to be reduced by at least 0.4 days . Reduce the number of patients who remain in an emergency department for over 24 hours while awaiting a mental health admission. This will provide faster care for thousands of people in crisis every month. National improvement resource and additional capital investment is simplified and aligned to supporting systems where it can make the biggest difference Allocating over £370 million of capital investment to support: Around 40 new same day emergency care centres and urgent treatment centres. Mental health crisis assessment centres and additional mental health inpatient capacity to reduce the number of mental health patients having to seek treatment in emergency departments. Expansion of the Connected Care Records for ambulance services, giving paramedics access to the patient summary (including recent treatment history) from different NHS services, enabling better patient care and avoiding unnecessary admissions.
  3. Content Article
    The transition of older adults from the emergency department (ED) to home remains a potential area of preventable harm. Through a human-centred design process, the authors developed a patient-centred intervention aimed at improving communication and coordination between ED staff and patients. The intervention included a new electronic health record (EHR)-based template for physicians to enter discharge instructions, a redesigned after-visit-summary (AVS), enhanced nurse training for patient teach-back, and EHR-embedded tips for nurses at the time of follow-up call. The research objective was to evaluate this patient-centred ED discharge process redesign from multiple perspectives. The authors used A SEIPS 3.0 model to evaluate the intervention, in particular work system barriers and facilitators in the three subprocesses of the redesigned ED discharge process: physician writing discharge instructions, nurse/patient communication at discharge, and nurse/patient communication at follow-up call. The authors used multiple methods to collect quantitative and qualitative data from the perspectives of patients, and ED physicians and nurses. Overall, the redesigned patient-centred discharge process was perceived positively by ED physicians and advanced practice providers, ED nurses, and patients. All three groups identified work system facilitators regarding the intervention, in particular the usability of the AVS. Work system barriers pointed to areas for future improvement of the intervention, such as adding prepopulated information to the AVS. Using a human-centred design process, the authors improved ED discharge for older adults. The SEIPS-based research and evaluation fit with the learning health system concept as it provides input for future work system and patient safety improvement.
  4. News Article
    A leading health think tank says urgent and emergency care in England is performing "far worse" than before the pandemic. The Health Foundation argues that the NHS was "in distress" this winter with A&E waiting times reaching a record high. The group says it would be wrong just to blame relatively high levels of flu. The government is due to publish an urgent and emergency care plan soon. The Department for Health and Social Care said that hospitals were "feeling the strain" but that it was taking "decisive action" to prevent winter crises. The Health Foundation report on the recent winter says that the number of people waiting 12 hours or more in A&E after a decision to admit to a ward was the highest since modern records began. It topped 60,000 in January, or 11% of emergency admissions. The report says that a familiar problem remains as acute as ever – delays discharging patients from hospital who are fit to leave. This, it says, made bottlenecks worse in A&E and for ambulances trying to hand over patients and that delays for those handovers were worse than in previous winters. Read full story Source: BBC News, 28 April 2025
  5. Content Article
    The health service in England has endured a punishing winter. Stark warnings about a potential ‘quad-demic’, the ‘busiest year on record’ for A&E and ambulance services, and ’jampacked’ hospitals prompted comparisons with the COVID-19 pandemic.  But how bad was winter 2024/25? The Health Foundation present analysis of routinely collected and publicly available data on health service performance and the possible contributing factors.  Key points: This winter saw the NHS in distress. Only 73% of A&E patients were treated within 4 hours, similar to the last two winters, and far below the 95% constitutional standard. The number of people experiencing 12-hour waits before admission reached a new record high. Numbers of A&E diverts and ambulance handover delays were worse than over previous winters. Looking at operational performance, winter pressures and other factors, the analysis explores the extent to which disruptions to urgent and emergency care were caused by higher than usual levels of winter illnesses and/or systemic weaknesses within the NHS. Levels of flu and diarrhoea and vomiting were higher than usual. Hospital admissions for flu reached a similar peak to winter 2022/23 but took longer to fall, leading to a 50% higher total number of flu bed days. However, hospital admissions for RSV were similar to previous winters, while admissions for COVID-19 remained low. Winter A&E attendances have risen steadily each year. However, slightly fewer patients attended major A&E departments in winter 2024/25 than in 2023/24, and emergency hospital admissions fell slightly. This suggests the NHS struggled to cope with a small increase in demand from patients needing emergency hospitalisation, while also expanding elective activity in line with government commitments to improve elective performance. Bed occupancy during winter has been rising for the last 15 years, exceeding the NHS 92% threshold for the first time in winter 2017/18, highlighting a system at its limits. Since COVID-19, a substantial increase in delayed discharges is likely to have obstructed the flow of patients out of hospitals, worsening bottlenecks upstream in the care pathway from A&E into wards and from ambulances into A&E. Overall, the conditions this winter, while severe, were similar to those in recent years and not far above what the NHS can normally expect. Attributing operational problems to external factors such as winter illnesses and higher demand risks offering false comfort about the resilience of the health service. The shows the health service performing far worse than before the pandemic and reporting record or near-record levels of operational problems across urgent and emergency care. Ahead of the government’s forthcoming Urgent and Emergency Care Plan, this raises key questions about what might be behind some of the underlying issues contributing to what has now become an annual winter crisis.
  6. News Article
    An “immobile” patient was found dead after a trust discharged him home with no support and no means of calling for help, a coroner has found. Samuel Brookes, who lived alone, was taken home from Russells Hall Hospital, run by The Dudley Group Foundation Trust, and left in his bed without access to his alarm or mobile phone. John Ellery, the coroner for Shropshire, Telford and Wrekin, said in a Prevention of Future Deaths report sent to the hospital: “Mr Brookes was left unattended for two weeks until on the 22 April 2024 his grandson attended and found him unresponsive, wedged between his bed and the bedroom wall… When Mr. Brookes got into difficulty he could not raise the alarm or call for help.” The coroner found the hospital had sent Mr Brookes home “without rearranging his required care” and there was “no record or documentation or process to show or demonstrate that the care had been rearranged”. Read full story (paywalled) Source: HSJ, 28 April 2025
  7. Content Article
    Samuel Brookes was discharged home from Russells Hall Hospital, Dudley, on the 8 April 2024 where he had been admitted following a fall and long lie at home. The hospital arranged his transportation without rearranging his required care of two carers, four times a day. Mr Brookes, who was immobile and lived alone, was transported to his bed where he could not reach his pendant alarm nor his mobile phone, which was in another room. Mr Brookes was left unattended for two weeks, until on the 22 April 2024 his grandson attended and found him unresponsive, wedged between his bed and the bedroom wall. An ambulance was called, sadly on arrival paramedics confirmed that Mr Brookes was deceased and his death was declared at 11:37 hours. The Coroner in his report highlighted the following matters of concern: The hospital arranged for Mr Brookes transportation home without rearranging the required care. There was no record or documentation or process to show or demonstrate that the care had been rearranged. The transport company were responsible for transportation only and were not required to notify either the hospital, or if known, the care company of Mr Brookes’ safe return. It proceeded on the basis or assumption that care would have restarted within 4 hours or sooner. Mr Brookes did not have his alarm pendant around his neck and nor was his mobile phone available (it was in another room). Accordingly when Mr Brookes got into difficulty he could not raise the alarm or call for help.
  8. News Article
    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
  9. Content Article
    On 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).
  10. News Article
    The rate of patients dying by suicide shortly after discharge from mental health units has increased in recent years, with researchers calling for better post-discharge support. According to the National Confidential Inquiry into Suicide and Safety in Mental Health annual report – an audit published by the Health Quality Improvement Partnership – the number and rate of deaths after discharge from a ward have been gradually increasing since 2017, after falling from 2013-17. The rate in 2022, the most recent figures reported, was 14.1 per 10,000 discharges. Isabelle Hunt, senior research fellow at the Manchester University and report co-author, told HSJ the most recent figures should be “treated with caution”, but added that the rise in post-discharge suicides could be attributed to the case mix of patients. A “reduction in inpatient beds” could mean “a higher-risk group of patients are being managed by services” and being discharged when more unwell. Dr Hunt said the increases could also be associated with changes in the circumstances patients are being discharged to. “Around a quarter of patients who died by suicide within three months of discharge were known to have been discharged to housing, financial or employment problems and a fifth were discharged to poor social support,” Dr Hunt said. “Awareness of the stressors patients may face after leaving hospital is a key element when judging the appropriateness of discharge, and greater involvement of families and carers is likely to provide a clearer picture of the circumstances a patient is returning to.” Read full story (paywalled) Source: HSJ, 12 March 2025
  11. Content Article
    In early 2022, following his wishes, my husband was discharged from hospital for end of life care at home to be provided by his family (his wife, three adult children and son-in-law) and nurses from our local hospice. We were completely unprepared for the challenges and disruption that lay ahead for us all.  Challenges during discharge The first challenge we encountered was receiving conflicting, confusing information from different staff members regarding my husband’s prognosis and future treatment and care. His consultant and their team were optimistic, speaking of further tests and a possible response to treatment in 3 weeks’ time. It was in that meeting, and on that basis, that we supported discharge and discussed arrangements. But the senior specialist nurse caring for him was alarmed by what we had been told. Immediately after the meeting they took us aside to tell us that, in their view, my husband had only days left to live. Although unsettled by this conflicting information, we preferred to believe in the more optimistic prognosis. On that understanding, we began to make preparations. At this point we knew: My husband would be taken home by ambulance the next day. A hospital bed and other equipment would be delivered to our home the next morning. We would receive a supply of medication on leaving the hospital. Hospice nurses would visit us twice a day to assist, starting the next day. Apart from needing a family member to wait at home in the morning to receive the bed, we thought we would be able to spend his last day in hospital quietly by his bedside. What actually happened couldn’t have been more disorderly or more disturbing. In practice, in addition to receiving the conflicting prognoses, this is what we experienced before discharge: My husband’s discharge was delayed by more than 48 hours, as hospital staff had great difficulty coordinating everything required for his move home. There were significant requirements we had not been told about, such as the need for an oxygen supply at home, which had to be located at a distance from a gas supply. The coordination difficulties meant that one of us waited alone at home for two full days, to receive the hospital bed and other equipment. This family member was therefore unable to be with my husband for an extended period at a critical time. On the second day of the delay, in direct contradiction of their advice the previous day, the ward sister advised us to take an immediate patient transport appointment even though it would mean going home before the hospital bed had arrived, and without any confirmation of when, or if, one would arrive. As the day went on, this nurse’s exhortations to leave without a bed in place at home were repeated and increasingly aggressive, and included the threat that there would, as a result, be no guarantee that hospice nurses could support us when we did eventually get home. We experienced this as bullying, coercive behaviour that greatly confused and disturbed us at a time when we most needed clarity, consistency and sensitivity. Delivery of the hospital bed was not straightforward. Access had not been checked beforehand, and when the bed arrived it was found that the layout of the house made it impossible to move it into a bedroom. With some difficulty, it was placed in the living room. The other equipment included an oxygen supply. This was not straightforward either. The bed had been placed near a gas fire. It had to be moved to a safe distance from the gas supply, which required taking furniture out of the room, difficult for the one family member at home handling this situation. Ward staff had contacted our local hospice on our behalf. We asked to have direct contact with the hospice ourselves so we could confirm arrangements. The ward sister (the one whose behaviour we had experienced as coercive) advised us not to contact them. We complied with this and so we left the hospital with no information about what the hospice nurses knew of my husband’s condition and no direct confirmation of their visits. This felt very insecure and contributed to our stress. We felt thrust into the unknown when we were at our most vulnerable by a system that didn’t want us. While we worked our way through all the problems, my husband’s condition was deteriorating, and he was suffering. He had a high temperature, great pain and nausea. But once the discharge decision was taken, nursing staff stopped taking his observations, stopped providing him with any medication to relieve symptoms and stopped washing him and providing meals. We had to insist that he be provided with some ongoing care and medication, and although he did receive the latter we had to overcome considerable resistance. These problems compounded one another and created chaotic, confusing circumstances. All family members at the hospital were spending their time running around, trying to get assistance and accurate information about what was happening and when from the various departments involved in the discharge of a patient in palliative care, all the while trying to be present for my husband and trying to ensure his comfort. We’d been very wrong indeed to have thought that we could spend the period before discharge gathered round his bedside, gently reminiscing. Challenges at home Once home, we faced further difficulties: There was a great deal to learn: how to operate the hospital bed; how to store and use the oxygen supply safely; how and when to administer the medication supply; how to turn my husband, and deal with incontinence; and how and when to try to feed him or give fluids. We all (including the hospice nurses) struggled to understand the medication which had been provided. We’d received 15 different drugs. They were to be administered according to widely varying schedules and had different means of administration (subcutaneous, injection, oral rinse, sublingual, oral). The explanations provided were delivered rapidly while we were standing in a congested corridor inches from my husband who was being removed by the ambulance staff, when he needed me and was calling to me. We had no opportunity to confirm our understanding of the different medications or to check the contents of the bag before we left the hospital. At home, we found several errors to the medication supply. There was a supply of chemotherapy medication that wasn’t prescribed. There was no supply of other medication that was prescribed. Most critically, we hadn’t received any pain relief medication in a form that we could administer, as my husband’s condition had deteriorated significantly during the delay to his discharge and he became unable to swallow. As a result, just a few hours before he died, at the advice of the hospice nurses who were waiting to receive a syringe driver for intravenous morphine administration, I was compelled to drive from pharmacy to pharmacy searching for pain relief medication that we could administer. I deeply regret that time away from my husband’s bedside. The hospice nurses arrived at our home a few hours after we did. We spent a significant period of time briefing them on their first visit. They needed details of my husband’s medical history, condition, and medication. This also took time away from his bedside. We found there were errors to the information recorded in the discharge summary we’d received on his departure from hospital. One was to his condition, which was assessed and recorded as ‘moderately frail’ (it had been erroneously auto-populated with admission data and should have been ‘terminally ill’). This information bewildered and misled us (causing some family members to delay visiting him, believing he was fitter than he was, for example) and created difficulties for the hospice nurses. They had prepared to assist someone ‘moderately frail’ and it took them time to adjust and get the necessary equipment and pain relief. Consequently my husband didn’t receive intravenous morphine until one hour before he died. As a result of these and many other issues, 34 hours after arriving home, my husband died having endured terrible pain and distress in chaotic and undignified conditions, which was devastating for his family to witness. Learning from experience If we had been aware of what we were undertaking, seeing how quickly my husband was deteriorating during the delay and understanding how little time we had left, we would have encouraged him to remain in hospital and explained to him why going home wasn’t a good idea. We wouldn’t have supported the decision to discharge him home. The delayed discharge and the short time that remained to us meant that all the problems we experienced were concentrated, and much harder to deal with as a result. This detracted from the very precious few hours that we had left together. Even the period immediately after his death was affected. We’d had no time to find out what happens once someone has died, and were devastated to learn, at 1 am, that we needed to identify undertakers as a matter of some urgency. Given the delay to my husband’s discharge and his deterioration, we should have asked for his suitability for discharge to be reassessed. As part of that reassessment, we should also have insisted on a review of his medication, particularly his pain relief medication. He left with a supply of medication that was based on an assessment of his condition made three days before his discharge. But even when everything goes smoothly and there are none of the problems described above, taking someone home for end of life care is still a major undertaking. The following could be useful for anyone preparing to do that. Key things needed to help families prepare to take someone home for end of life care 1. A handbook, providing: A checklist of what should happen and in what order, once the decision to discharge a patient has been made. Contact information for all hospital departments involved in discharging a patient for end of life care at home, including an indication of who’s responsible for what. The advice to find, if possible, a more distant relative, a friend or a neighbour willing to be at your home to receive the hospital bed and other items on your behalf. Instructions for use of all of the equipment provided, e.g. the hospital bed and the safe storage and use of the oxygen supply. Instructions for how to care for a bed bound patient in palliative care, e.g. how to turn them, wash them, deal with incontinence, how to feed them and provide liquids, and the best position for them to be in to facilitate breathing and their general comfort. Contact information and details of available support in the community, including, for example, pharmacy opening hours. A checklist of what items are needed to make the patient as comfortable as possible once home. Instructions for what needs to be done in the hours following death. 2. Contact with the hospice before discharge A meeting or phone call in which the patient’s medical history, condition and medication is shared. Information about what to expect e.g. visit frequency, timing and length; what the nurses will do/not do; how to manage in between visits and what support is available then, especially at night or otherwise out of hours. The hospice contact details, including emergency numbers. 3. A private meeting, in the hours prior to discharge, between the primary caregiver and a nurse familiar with the patient’s care and condition, enabling: A discussion of the patient’s ongoing care. An explanation of the discharge summary (and checking accuracy). A review of, and instructions for, the medication supply, including which medication should be prioritised in the event that not all can be administered. Confirmation that pain relief medication is provided in a form that can be administered as a patient in palliative care is likely to become unable to swallow. All of the above needs time. With time, the transition home is more likely to be successful. But if time is short, and particularly if problems arise, there can be concentrated chaos and confusion, likely to detract from the patient’s last hours and interfere with their care, as we found. For these reasons, in our experience, it isn’t viable or advisable to take a patient home from hospital for end of life care when they are deteriorating and it seems likely that only hours or days remain. If my husband had remained in hospital he would have received undisrupted care and medication (albeit in our case only with our insistence). All members of his family would have been able to be at his bedside throughout. He would have died in less pain, in more comfort and security, and with his dignity intact. And his family would have been much less traumatised by the experience. We live with enduring shame and sorrow for his suffering. What makes it worse is that much of it could have been avoided. Motivated by a desire to reduce the possibility of others suffering as we had done, in 2022 we submitted 20 complaints to the hospital concerned. Following a largely unsatisfactory response, we made a submission to the Parliamentary and Health Service Ombudsman. Our efforts over 16 months to bring about improvement are documented here. Related reading on the hub: HSIB: Variations in the delivery of palliative care services to adults Patients who experience harm provide stories, but who will really engage with their insights and opinions? Top picks: Eight resources about hospice and palliative care
  12. News Article
    NHS England has for the first time put a figure on the potential impact on A&E performance of eliminating discharge delays for patients going into adult social care packages. Amanda Pritchard told MPs NHSE’s analysis suggested eliminating discharge delays for patients who receive adult social care (ASC) packages when they leave hospital could “theoretically” improve the A&E four-hour target by 6 per cent points. She said the figures suggest “around two-thirds of bed days lost to delayed discharges are associated with individuals accessing adult social care, community care and/or care home services on discharge. A third of these delays – around a fifth overall - are for individuals accessing adult social care packages on discharge.” The outgoing NHSE CEO added: “Eliminating the lost bed days for just the third of delays for individuals accessing adult social care packages on discharge… if all other things were equal, including the rate of admissions and rate of flow through hospitals, theoretically… could potentially improve performance by up to 6 per cent.” Read full story (paywalled) Source: HSJ, 5 March 2025
  13. News Article
    "I feel very angry, upset, worthless, and like my mental health and my life does not matter," says Jessie, propped up in a hospital bed. She is recording this in a video diary. Blue NHS curtains are drawn around the bed and all her possessions are stacked up in the tiny chaotic space this creates. Among the piles of boxes and bags sit the dolls she holds to keep her calm. Thirty-five-year-old Jessie spent 550 days in Northampton General Hospital. For nearly all that time, she was medically fit to leave but finding her a suitable place to go to was difficult. The BBC has followed her story for more than five months as the NHS trust took costly High Court action against her, to have her evicted from the hospital bed she was occupying. Jessie was eventually arrested and taken to a care home where she says she feels anxious. Her story is an extreme example, but it demonstrates the acute pressures faced by a care system coping with more complex cases, the knock-on effect to the NHS, and how the person at the heart of it can feel lost. North Northamptonshire Council, which is responsible for her housing and care, says it cannot comment because of an ongoing police investigation into Jessie's behaviour. The hospital says it "is not the best environment for patients who are not in need of acute medical care". The Department of Health and Social Care has told the BBC: "This is a troubling case which shows how our broken NHS discharge system is failing vulnerable people." Read full story Source: BBC News, 8 February 2025
  14. News Article
    A new report from the Health Services Safety Investigations Body (HSSIB) has shed light on significant systemic issues within mental health services, highlighting a persistent culture of fear and blame, and a lack of patient and family involvement, which obstruct effective learning from inpatient deaths. The HSSIB report scrutinises how mental health providers learn from deaths occurring in inpatient units and within 30 days post-discharge. The investigation reveals multiple processes involved in learning from deaths, including the Learning from Deaths Framework, coroner's inquests, and investigations following patient safety events. The report indicates that there are substantial challenges in maintaining safety, conducting effective investigations, and ensuring system-wide learning. It identifies that investigations and patient safety event analyses, although intended to promote transparency and learning, often suffer from variable quality. Local investigations frequently lack comprehensive information and fail to observe clinical work practices in real-time, hindering a complete understanding of care delivery. A critical revelation of the investigation is the prevalent culture of blame within mental health services. Patients, families, and organisations often fear safety investigation processes, which are perceived as punitive rather than educational. The report underscores that patient safety investigations rarely account for the emotional distress experienced by those involved, leading to compounded harm. Read full story Source: National Health Executive, 30 January 2025
  15. Content Article
    Every winter, the NHS faces immense pressure, with poor standards of care becoming an expected part of the "winter crisis." The Patients Association, the Royal College of Emergency Medicine, the Royal College of General Practitioners, the College of Paramedics, the National Association of Primary Care, and the Association of Ambulance Chief Executives have joined together to propose practical solutions for meaningful, long-term improvement. The joint statement identifies four core issues at the heart of the crisis: Primary care does not have the capacity to meet its patient demand. We are not pro-actively looking after patients who are currently the most frequent users of urgent and emergency care to stop them getting so unwell. The urgent and emergency ‘system’ in the NHS remains fragmented and disjointed, making it hard to navigate patients to the right place to get their care. Emergency departments (EDs) have become hugely congested because of lack of flow into and out of hospital beds. Proposals to address these issues 1) Increasing primary care capacity by: In 2025/26 ensuring the uplift in funding promised by the government does translate into the ability of practices to employ more GPs. In subsequent years increase the share of NHS funding for general practice to match the increased workload involved in the planned shift of care from hospitals to the community. Freeing up GP time, so they have more time to spend with the patients who most need continuity by cutting bureaucratic red tape, supporting practices to improve triage systems to help navigate patients to the right part of primary care and the wider NHS. This could also contribute to freeing up capacity in 111. Introducing a national alert system to flag unsafe levels of workload and allow GP practices to access additional support. Every Integrated Care System (ICS) should be required to establish alert systems for general practice, similar to the ‘operational pressures escalation levels framework’ in hospitals. Beginning the implementation of integrated neighbourhood working by aligning community services to each primary care network so we can better use existing resources across the primary and community care sector to focus on prevention and keeping people well in their communities. Making the best use of the paramedic workforce to support primary care with home visiting and face to face services. 2) Improving care for the patient groups who are currently using urgent and emergency care the most by: Resource is needed to enable every older person in a high risk group to have a full health ‘MOT’ every year, including consideration of loneliness and isolation risks, a known driver of ill-health. These should be conducted by integrated neighbourhood health teams with multi-disciplinary team input particularly from primary, community and mental health colleagues. The resulting care plans should be readily accessible to all healthcare professionals with whom they come into contact. All people in residential and nursing homes should have the NHS delivered to them. This should be led by GP and community teams with the expectation that care is provided to them in their place of residence and the first point of contact for most urgent care episodes is those teams and not 999. All patients known to be on a palliative care pathway should have a care plan, accessible to clinicians across the emergency care pathway that is explicit about where the patient would like to die so that we can honour their last wishes. Identifying the highest users of urgent and emergency care in each ICS footprint, in order to agree a care plan for these individuals and to reduce their use of ED. Providing more support to patients in deprived communities by reviewing all funding streams (including primary care) to channel more spending to areas of greatest need. Identifying patients who are at high risk of emergency admissions (supported by AI) with a particular focus on adults with chronic breathing and cardiac conditions to create bespoke care plans (including using wearable devices) with pro-active monitoring to minimise the spikes in demand we see every winter. Consider making the flu vaccination available, subject to JCVI approval, to a much broader group than currently defined, and then making sure we maximise both the uptake and speed of vaccination. 3) Joining the urgent and emergency system back together by: Creating a single 24/7 service for each ED catchment area that is focused on caring for people in their normal place of residence that brings together the current urgent community response teams, virtual ward teams and ED teams into a single multi-disciplinary team. Supporting the development of the principle of senior clinical decision making in community as well as the ED environment. Making it an expectation that community-based clinicians and hospital staff routinely discuss their patients to ensure they get the right care, blurring the boundaries between hospital and community / primary care. Integrating urgent mental health services into ambulance, ED and 111 delivery and training many more clinicians with mental health skills for managing patients in mental health crisis. Allowing the ambulance service the time to do a fuller clinical assessment for all patients who call 999 who do not obviously need conveying to an ED. Having a patient’s medical record that is accessible by all providers who can read and update it and that patients can see themselves. Re-wiring the NHS financial flows to incentivise the system to work together and to reward providers who deliver the interventions in this paper. Creating a workforce strategy for the urgent and emergency care system looking at capacity needed for in and out of hours GP services, community nursing, mental health and paramedics, aligning training and careers together. Create an improvement culture in urgent and emergency care by routinely evaluating, learning and adapting initiatives. 4) Improving the flow through emergency departments: We have to improve flow in hospitals by beginning to resolve the bottlenecks that delayed discharges create, primarily because of insufficient bed capacity and lack of social care funding. Rather than rehearse the arguments that have been made in recent weeks, we endorse all the feedback being voiced by many, that the solutions for social care cannot wait until 2028 and we must begin to increase social care capacity before next winter. Implementing many of the recommendations from the Cavendish review from 2022 would be a good place to start. We also need to maximise opportunities to prevent deconditioning of our frail or elderly patients when they are inpatients through improved therapy and dietetic support.
  16. News Article
    Patients who spent more than 12 hours in A&E were twice as likely to die within 30 days as those treated, transferred or discharged within two hours, a landmark study has found. From April to December this year there have been over 1.2 million instances of patients spending 12 hours or longer in A&E – a 19% rise on the same period the year before. Twelve-hour waits from arrival were relatively rare until recent years, and data was not previously published by NHSE. The study revealed that, for patients who spent 12 hours or more in the department, the risk of post-discharge death was 2.1 times higher than those who spent two hours or less. Mortality was 1.9 times higher for those who spent nine hours in A&E, 1.6 times for those who spent six hours, and 1.1 times for three hour stays, the ONS found. The study also discovered the risk of death after 12 hours stays was greatest for older patients, those in the North East of England, those who presented with airway and breathing difficulties, and those who were admitted to inpatient care. Read full story (paywalled) Source: HSJ, 17 January 2025
  17. Content Article
    Report from the National Office for Statistics (ONS) showing the relationship between time spent in A&E and the odds of 30-day, post-discharge, all-cause mortality, controlling for other factors. Main points Of people who attended an accident and emergency (A&E) department in England between 21 March 2021 and 30 April 2022 and did not die during their A&E attendance, 1.3% died within 30 days of leaving A&E to return home or be admitted to inpatient care; this analysis covers patients who required non-immediate care in an emergency department. At two hours of total time spent in A&E from arrival to discharge for non-immediate care, 0.02% of patients aged 20 years died post-discharge, increasing to 0.1% for patients aged 40 years, 0.3% for patients aged 60 years and 0.8% for patients aged 80 years; this was after adjusting for a range of other socio-demographic and clinical factors related to post-discharge death. The adjusted risk of post-discharge death increased with total time spent in A&E after approximately two hours for patients requiring non-immediate care. Compared with patients requiring non-immediate care who spent two hours in A&E, the odds of post-discharge death were: 1.1 times higher for those who spent three hours in A&E; 1.6 times higher for those who spent six hours in A&E; 1.9 times higher for those who spent nine hours in A&E; and 2.1 times higher for those who spent 12 hours in A&E. The relationship between total time spent in A&E and post-discharge death among patients requiring non-immediate care varied by age, region, chief complaint and admission status. The relative difference in the risk of post-discharge death after 12 hours in A&E compared with two hours in A&E was greatest for: younger patients (for example, the odds at 12 hours were 4.6 times higher than at two hours for patients aged 20 years), those in London (2.7 times higher), those who attended A&E for reasons to do with their eyes (7.9 times higher), and those who were not admitted to hospital for inpatient care after visiting A&E (2.8 times higher).
  18. News Article
    As The Times reports on how the failure to act on coroners’ recommendations costs lives, Lottie Hayton says many are not issuing Prevention of Future Deaths reports in the first place. Lottie's mum, Carrie, was sectioned on September 16, 2022. When Carrie took her own life two months later, the inquest into her death criticised the care she received and her “rapid discharge”. But, owing to significant flaws in the inquest system in England and Wales, lessons from her care and death will not be learnt. Four days after Carrie’s admission, on September 20, when the duty doctor came back from bank holiday leave, he “introduced” himself. The brief introductory meeting amounted, according to the medical notes, to an assessment of mum’s mental state. Thirteen minutes after he recorded the introduction, mum was discharged. The discharge notes read: “Mrs Hayton utilised her leave well and did not present with any suicidal thoughts. It was felt the inpatient environment would be detrimental to her grieving process and her risks could be managed with home treatment and community team support.” That the risks were not able to be managed with home treatment is obvious by the fatal outcome. The review recommends a clear solution: “Acute Inpatient Operational Policy must take place to ensure clear provision for what should happen when a rapid discharge occurs.” In Carrie’s case, there was no evidence of a policy or process being followed. At the conclusion of an inquest a coroner can issue a Regulation 28 Prevention of Future Deaths report, or PFD, to an organisation or individual, outlining actions which could be taken by them to prevent future similar deaths. An average of 500 PFD reports are issued every year but it is ultimately up to an individual coroner to decide whether they issue one. The facts of Carrie’s case and the serious incident investigator’s submission, would, you might assume, lead to the coroner thinking that a PFD should and could be issued with simple recommendations. But the coroner overseeing the inquest in Dorset, chose not to issue a PFD. Read full story (paywalled) Source: The Times, 15 January 2025
  19. News Article
    Two elderly patients have been in the emergency department (ED) of the Royal Victoria Hospital (RVH) in Belfast for more than five days, BBC News NI can reveal. This comes after more than 500 patients were unable to be discharged from Northern Ireland's hospitals on Sunday night, despite being medically fit. With no suitable care for them in the community, it meant they remained in beds preventing other sick people from being admitted to hospital wards. Lead nurse Claire Wilmont said that staff in the RVH were "treating the most vulnerable elderly sick patients in an intolerable environment". At 17:00 GMT on Monday, 1,052 people were in Northern Ireland's nine EDs, up from 797 on Sunday night. There were 349 people who had waited more than 12 hours. The Department of Health said longer-term solutions required sustained investment and reform. Read full story Source: BBC News, 6 January 2025
  20. News Article
    The drive to cut NHS waiting lists is being hampered by bed-blockers who now cost taxpayers more than £2billion a year, a study reveals. More than 12,000 hospital beds every day are occupied by patients who no longer have a medical need to remain but are unable to leave. The huge scale of the crisis - equivalent to closing 26 entire hospitals - is forcing managers to cancel operations and fuelling ambulance delays as there are so few beds for new admissions. A total of 15.7million bed days have been lost to bed-blocking over the past three-and-a-half years, according to new analysis of NHS figures. This averages 12,008 beds per day over the study period but the problem has significantly worsened during this time - soaring 59% from an average of 8,039 per day in April 2021 to 12,772 in April 2024. Many of those stuck on wards are waiting for a place in a care home or for a package of care to be arranged in their own home. Charities warn the longer elderly people remain in hospital the more they deteriorate and the greater they risk they will never regain independence. Read full story Source: The Daily Mail, 31 December 2024
  21. News Article
    A patient transport company which is taking over contracts worth hundreds of millions of pounds is grappling with concerns about service performance and risk to patients. EMED has been delivering the non-emergency patient transport service in the Surrey Heartlands area since April. HSJ has learned that several trusts have repeatedly highlighted problems with missed and late appointments, including those for renal patients attending for dialysis. One trust – Ashford and St Peter’s – said in a board paper the contract “continues to generate significant patient safety and patient experience concerns across the whole system”. The Royal Surrey County Hospital Foundation Trust’s board papers said challenges had “a knock-on effect with patient experience, particularly in end of life care transfers, and longer waits for patients being discharged”. Read full story (paywalled) Source: HSJ, 13 December 2024
  22. News Article
    Health and social care secretary Wes Streeting has said he is “shocked” by his lack of oversight of adult social care and said he is “determined to improve this” in a call with local leaders this morning. Addressing a webinar on winter pressures with NHS and care leaders, Mr Streeting said he was “shocked by poor levers and line of sight [from DHSC] into the social care system” compared with the NHS, and said this contrast was “day and night, and I’m determined to improve this”, according to sources present. Mr Streeting also stressed the importance of reform and a “plan” for social care on the call, alongside NHS England chief executive Amanda Pritchard this morning. The health secretary also told trust leaders to “prioritise patient safety” by focussing on improving emergency ambulance response times, addressing handover delays and tackling the longest waits in accident and emergency. He said he did not want trusts to prioritise patients who can be seen and discharged more quickly — and therefore would help meet the four-hour A&E target — above those with the greatest clinical need. Trusts were pressured to do this last winter amid efforts to meet the flagship target. In a press statement, Mr Streeting said: “We inherited a broken NHS that saw annual winter crisis as the norm. This year, we’re seeing record pressures on services as we move into December. “This winter I want to see patient safety prioritised as we brace ourselves for the coming months. I’m asking trusts to focus on ambulance delays, handovers and the longest A&E waits.” Read full story (paywalled) Source: HSJ, 9 December 2024
  23. Content Article
    The Scottish Government needs a delivery plan that clearly explains to the public how it will reform the NHS and address the pressures on services. Despite increasing funding and staffing, the NHS in Scotland is still seeing fewer patients than before the Covid-19 pandemic. Auditors found that: commitments to reducing waiting lists and times have not been met the number of people remaining in hospital because their discharge has been delayed is the highest on record and NHS initiatives to improve productivity and patient outcomes have yet to have an impact and lack clear progress reporting.
  24. News Article
    Mental health patients in England are being harmed by the rise in psychiatric unit placements far from their homes and families, a report indicates. Some patients had experienced anxiety and post-traumatic stress disorder (PTSD), while others had died by suicide as a result of their distant placements, according to a Health Services Safety Investigations Body (HSSIB) report, which drew on interviews with patients and their families. The participants said their experiences had resulted in anger, frustration and a loss of trust in the mental health system. Neil Alexander, a senior safety investigator, said “urgent improvements” were needed to reduce harm to patients. “The reality is patients need to be treated and sometimes it is seen as safer to admit them to an inpatient ward or unit,” he said. “However, as our investigation sadly showed, the harm caused to patients when moved far from home or moved back and forth between settings can be distressing, for them and for their families. “The investigation emphasised that inappropriate out-of-area placements are a symptom of wider issues within health and social care: financial and resources pressures, long waiting lists for social housing and a lack of true integration between the two.” Read full story Source: The Guardian, 21 November 2024
  25. Content Article
    This is one of a series of Health Services and Safety Investigations Body (HSSIB) and on the theme of patient safety in mental health inpatient settings. This investigation explored the issue of out of area placements (OAPs) – that is, scenarios where a patient is placed in a mental health inpatient setting that is a long way from their home or usual place of residence. This report examines the reasons for OAPs, the harms caused by them and how patients can be kept safe if an OAP is necessary. In particular it focuses on inappropriate OAPs. These are where a patient is unable to be cared for in their local NHS mental health acute inpatient setting and has to be sent to another, normally independent, mental health provider for ongoing treatment and care. These OAPs can be significant distances from a person’s residence. The investigation recognises that other OAPs exist for specialised commissioned services such as those for patients with eating disorders, but these were not considered in this investigation. The investigation has been informed by work carried out in the other investigations in the series, in particular ‘Creating conditions for learning from deaths and near misses in inpatient and community mental health services’. Findings Relating to patient, family and carer experiences The investigation found that harm (including dying by suicide, physical, psychological, distress and anxiety) was happening to patients, families and carers because of OAPs and the impact of being far away from their normal support network. There was also significant anger, frustration and loss of trust in the mental health system as a result of their experiences. Patients, families and carers rarely want an OAP and their choice and opinions are not always taken into consideration when decisions about sending someone to an OAP are made. The investigation found that OAPs can increase patients’ length of stay in hospital and therefore contribute to harm to patients. Patient, family and carers’ wishes and preferences, as required in the Mental Health Act 1983: Code of Practice, are not documented by health and care staff or routinely monitored during Care Quality Commission inspections. This leaves patient, families and carers feeling they are not listened to and increases anxiety, frustration and anger, leading to harm for people and creating distrust in the system. Advocacy services are vital for a patient to be able to put forward their views for consideration in decision making about their care, but advocacy is not always offered to patients. Relating to conditions in the health and care There is a national drive to reduce OAPs, but there continues to be an increasing trend in their use. OAPs may be the only option for patients if they are acutely unwell and need admission to inpatient services and there are no beds available in their local NHS mental health hospital. If OAPs are not utilised in this situation, people will remain unwell in the community and potentially present a high risk of harm to themselves or others. The rules, governance and legal framework within which health and social care organisations work differ. This can create friction in the system, preventing integration and pooling of funds across organisations, slowing down discharge and patient flow, and is a significant factor in the use of OAPs. It is impossible to look at the mental health inpatient system in isolation; consideration must be given to other health and care services such as community mental health services, social care and social housing provision by local authorities. When patients are sent to OAPs, the sending hospitals do not maintain responsibility for the welfare or clinical oversight of those patients. Limited patient flow through mental health and other services reduces trusts’ ability to discharge patients from hospital, which can increase the use of OAPs. NHS mental health trusts do not always have local authority social workers embedded in their organisations, as used to be the case under previous working arrangements. Embedding social workers within trusts was viewed by social workers and healthcare staff as a benefit to patients and improved patient flow and discharge planning. Some NHS trusts are undertaking some of the functions of local authorities relating to social housing, in order to enable patients to be discharged and reduce the need for OAPs. Beds and patients are managed in an impersonal way without seeing patients as having individual requirements. They are both treated as “commodities” when deciding on the need for an OAP because of the pressure on services and need for acute mental health beds. Crisis resolution and home treatment teams can have a significant influence in the early discharge of patients, that then creates a bed for the most mentally unwell patients in the community. Hospitals that send patients out of area sometimes rely on Care Quality Commission rating to base OAP decisions on, but many of these ratings are out of date and may not reflect the current situation. Many acute mental health patients have neurodevelopmental conditions and would benefit from early testing when they are in contact with community and acute mental health settings. Early assessment makes sure people are placed on the right pathway and may reduce admissions to acute mental health settings and the need for OAP. HSSIB makes the following safety recommendations HSSIB recommends that the Department of Health and Social Care includes the documenting of patient, family and carers’ wishes and preferences within the Mental Health Bill. This will ensure all patient, family and carer voices are considered in decisions relating to where the patient identifies they would like to be close to, for example the patient’s home or a family member, specifically when an out of area placement is needed. HSSIB recommends that the Department of Health and Social Care works across government to review the statutory instruments, business processes and regulations that govern mental health services, social care and housing services impacting on mental health out of area placements and creates a proposal for the future accountability and integration of health and social care. This is to ensure that they are operating to consistent statutory, financial and regulatory frameworks. By addressing system integration and nd local authorities will define accountability and reduce or prevent out of area placements. HSSIB makes the following safety observations NHS organisations can improve patient safety by maintaining clinical and welfare oversight and responsibility for patients being treated in an out of area placement. This can ensure harm is minimised and that patients are returned to their sending hospital as soon as possible. Mental health inpatient services can improve patient safety by offering advocacy to all mental health inpatients at the point of admission, and ensuring that the patient’s decision about whether or not to have an advocate is continually reviewed as their treatment continues and needs may change. This can ensure that patients’ needs and views are taken into account by health and social care staff when decisions about their care are being made, particularly when in an out of area placement. Crisis resolution and home treatment teams can improve patient safety by joining quality networks for crisis resolution and home treatment teams and could consider using continuous clinical reviews of mental health acute inpatients. This can ensure that appropriate patients are discharged early and could maximise acute care bed availability for patients in the community who are at high risk because of their mental health problem, and reduce the need for out of area placements. Health and social care organisations can improve patient safety by working together and embedding mental health social workers from the local authority in mental health acute hospitals. This can ensure that patients’ holistic health and social care needs are considered throughout their acute mental health admission and on into the community, and improve efficiency of working, patient flow and discharge and reduce the use of out of area placements. Mental health services can improve patient safety by reviewing their community mental health services to see if they meet the needs of their population with the aim of keeping as many people as possible out of inpatient services and thus preventing the use of out of area placements. Healthcare services can improve patient safety by conducting assessments for neurodevelopmental conditions such as autism and attention deficit hyperactivity disorder, where it is safe and clinically indicated, at the earliest opportunity when a person is in contact with community and acute mental health services. This can ensure that patients are put on the appropriate pathway early. This can prevent harm that may be caused by receiving inappropriate treatment and reduce admissions to mental health inpatient settings, thus reducing the need to use out of area placements.
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