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Found 122 results
  1. Content Article
    Medical errors happen all the time. They can be overlooked or they can lead to big lawsuits and settlements. But what they rarely lead to is an apology. However, increasingly, patients, families and healthcare professionals, are calling for a new approach, one that acknowledges the lasting damage that comes from a failure to address medical mistakes. In this report for US media company NPR, a Naomi and Jeff tell their story of losing their daughter Thalia to medical error following planned surgery. They report that concerns they and Thalia raised about their breathing were ignored by healthcare professionals, and Thalia died after her brain was starved of oxygen. The hospital didn't give an explanation or apology for Thalia's death.
  2. Content Article
    The NHS will always need whistleblowers as healthcare is complex, rapidly changing and dangerous. However, whistleblowers continue to be treated very poorly by the health service, as this Private Eye special report highlights. The report looks in detail at several whistleblowing cases and how attempts to cover up mistakes and wrongdoing have resulted in patient deaths and devastated the careers and personal lives of staff who speak up for patient safety.
  3. Content Article
    Lewis Chilcott was 23 years old when he died at Royal Sussex County Hospital in Brighton. In this blog, his father Simon describes what happened to Lewis and how his family was treated by the hospital following Lewis’s death. Simon continues to call for greater transparency in the investigation process and improvements to the way hospitals engage with bereaved families.
  4. Event
    The Duty of Candour, introduced in 2014, requires healthcare professionals to be honest with patients when things go wrong. They must also be open with colleagues, employers, and relevant organisations and participate in reviews and investigations when requested. Our training developed with industry experts - Peter Walsh, the ex-Chief Executive of AvMA, who is well known for his pioneering work on the Duty of Candour, and Carolyn Cleveland, who specialises in training professionals in dealing with difficult emotions and conversations and doing so with empathy, understanding perspectives. The training focuses on empathy and compassion and equips you to navigate the Duty of Candour effectively. The training will cover the following areas: Overview of the Duty of Candour Legislation Requirements and expectations of the Care Quality Commission (CQC) The importance of empathy and compassion in implementing the Duty of Candour Balancing compliance with the human side of the duty Empowering and supporting individuals responsible for the Duty of Candour Understanding the emotional component behind the duty Providing evidence of compliance with the legislation Impact of meaningful interactions on patients, families, and colleagues Avoiding harm when providing an apology Price: £245 + VAT per person Discounted rate for bookings of 3 or more: £220 + VAT per person Event details and booking page Discount Code – Early bird 10% discount code valid until 2 April Hub discount code: DoC-Hub-10 Alternatively, the training can be delivered in-house at your organisation, either in person or online. Please enquire for details by emailing paulas@avma.org.uk
  5. Content Article
    This is my story, as a bereaved mother, about lessons I have learnt following the unexpected death of my previously well 25-year-old daughter Gaia in University College Hospital London (UCLH) in July 2021. I have written 11 patient safety lessons in the hope this helps other families be more assertive if they have a critically sick relative in hospital. Believe me, you must be pushy to be allowed into a hospital ward, even more so ITU. I went to visit my critically sick daughter at around 10am on a Sunday morning, but was not allowed on to the ward. A senior nurse told me to GO HOME using the 'Covid' excuse. I was shut out from the bedside of my critically ill only child. I have set up TruthForGaia.com to share learnings more widely. Please take a look. I hope sharing this may contribute to reducing avoidable deaths from brain conditions which can be only too easily assumed to be intoxication, especially on weekends. I believe raised intracranial pressure (high pressure in the skull) needs more awareness and training. When will UCLH hold a medical grand round on my daughter's case?
  6. News Article
    There was an “unacceptable delay” and “failure to act with candour” in how a trust responded to a serious risk from staff nitrous oxide exposure, an independent investigation has found. Mid and South Essex Foundation Trust found levels of nitrous oxide far above the workplace exposure limit at Basildon Hospital’s maternity unit during routine testing in 2021. However, staff were only notified and a serious incident declared more than a year later. The exposure related to a mixture of nitrous oxide and oxygen, commonly known as gas and air, used during births. While short-term exposure is considered safe, prolonged exposure to nitrous oxide could lead to potential health issues. Chief executive Matthew Hopkins has apologised, after a report by the Good Governance Institute said: “The inquiry found that there was an unacceptable delay in responding to and mitigating a serious risk that had been reported… As a result of this failure to act on a known risk, midwives and staff members on the maternity unit were exposed to unnecessary risk or potential harm from July 6 2021 to October 2022." Read full story (paywalled) HSJ, 14 February 2024
  7. News Article
    Senior leaders are resorting to “ticking the duty of candour box” instead of developing a “just and learning” culture in their organisations because their bandwidth is full, the patient safety commissioner has said. Speaking with HSJ as she begins the second year of her first term in the newly-established role, Henrietta Hughes said the bandwidth of senior leaders is “too full for them to make and maintain the necessary culture change”. She warned the duty of candour — giving patients and families the right to receive open and transparent communication when care goes wrong — gets seen as a “bit of a tick box exercise, ‘doc tick’ as it’s described to me, which is a bit depressing really”. A GP herself, she said individual doctors typically respond to concerns or they are handled by someone who knows the patient. Elsewhere, complaints are often addressed through a chief executive’s office, once all staff have provided written statements, she said. She added: “[In general practice] it feels more compassionate and empathetic… I find it’s often quicker to have a conversation with the patient before it turns into a formal complaint and resolves it quickly.” “What needs to change is that [NHS] trusts are currently held accountable to a very narrow set of criteria — financial and operational performance,” she said. “This is how we will improve safety and experience, transparency, a just and learning culture, and improve morale.” Read full story (paywalled) Source: HSJ, 30 January 2024
  8. Content Article
    Traditionally, recommendations regarding responding to medical errors focused mostly on whether to disclose mistakes to patients. Over time, empirical research, ethical analyses and stakeholder engagement began to inform expectations — which are now embodied in communication and resolution programmes (CRPs) — for how healthcare professionals and organisations should respond not just to errors but any time patients have been harmed by medical care (adverse events). CRPs require several steps: quickly detecting adverse events, communicating openly and empathetically with patients and families about the event, apologising and taking responsibility for errors, analysing events and redesigning processes to prevent recurrences, supporting patients and clinicians, and proactively working with patients toward reconciliation. In this modern ethical paradigm, any time harm occurs, clinicians and health care organisations are accountable for minimising suffering and promoting learning. However, implementing this ethical paradigm is challenging, especially when the harm was due to an error.
  9. Event
    This popular training day covers the must-dos and the grey areas around the statutory Duty of Candour, with a strong emphasis on going beyond mere compliance and delivering the duty of candour in a meaningful way for patients and families and for the staff involved and the organisation. It has been updated to directly support the successful implementation of the PSIRF guidance and the ‘Harmed Patient Pathway’. The training is delivered by Peter Walsh, the ex-Chief Executive of AvMA, who is well known for his pioneering work on the Duty of Candour, and Carolyn Cleveland, who specialises in training professionals in dealing with difficult emotions and conversations and doing so with empathy, understanding perspectives. Prices: £245 (plus vat) per person. Discounted rate for bookings of 3 or more: £220 (plus vat) per person AvMA is offering a 10% discount for delegates referred via the hub. Use code: DoC-Hub-10 Register for the training Training can also be delivered in-house at your organisation, either in person or online. Please enquire for details by emailing paulas@avma.org.uk
  10. News Article
    The Campaign to Save Mental Health Services in Norfolk and Suffolk is calling for a criminal investigation into an apparent scandal that decisively surfaced over the summer, centred on the Norfolk and Suffolk NHS foundation trust (or NSFT), which sees to mental health provision across those two very large English counties. It is centred on the “unexpected” deaths of 8,440 people between April 2019 and October 2022, all of whom were either under the care of the trust, or had been up to six months before they died. The story of the failures that led to that statistic date back at least a decade; the campaign says it amounts to nothing less than “the largest deaths crisis in the history of the NHS”. The figure of 8,440 was the key finding of a report by the accounting and consultancy firm Grant Thornton – commissioned by the trust, ironically enough, to respond to anxious claims by campaigners, disputed by the trust, that there had been 1,000 unexpected deaths over nine years. There are no consistent national statistics for such deaths, and no universal definition of “unexpected”: in Norfolk and Suffolk, a death will be recorded as such if the person concerned was not identified by NHS staff as critically or terminally ill; the term includes deaths from natural causes as well as suicide, homicide, abuse and neglect. The period in question includes the worst of the pandemic, although the trust’s own annual deaths figures did not reach a peak until 2022-23. But the numbers still seem jaw-dropping: they represent an average of about 45 deaths a week. To put that in some kind of perspective, earlier reports about the trust’s deaths record had raised the alarm about a similar number of people dying every month. And the Grant Thornton report included another key revelation: the fact that the trust’s record-keeping was so chaotic that in about three-quarters of cases, it did not know the specifics of how or why the people concerned had died. After its publication, moreover, there were more revelations about the trust, and its culture and practices. Read full story Source: The Guardian, 21 January 2024
  11. Content Article
    In this blog, Scott Ellner, a general surgeon from the US, describes the case of a surgeon colleague who unintentionally harmed a patient, Sarah, during surgery. Sarah ended up in the surgical intensive care unit from septic shock due to a missed bowel injury. Her recovery from what should have been a straightforward procedure was long and complicated. Scott recalls how the surgeon was shocked by the way Sarah's husband responded to him when he explained what had happened—instead of an anger and blame, Sarah's husband expressed compassion for the doctor and reiterated his trust in him. Scott highlights the importance of creating a Just Culture in healthcare systems and outlines challenges to this in the current climate, referring to the case of nurse RaDonda Vaught. He also outlines the impact patient safety incidents and medical errors can have on healthcare professionals, calling on the healthcare community to embrace shared humanity. All of us come with imperfections, vulnerabilities and the capacity for healing and growth.
  12. Content Article
    The review into the statutory duty of candour has been established by the Department of Health and Social Care to consider the design of operation of this requirement, assess its effectiveness and make advisory recommendations. The duty of candour is about people’s right to openness and transparency from their health or care provider. It means that when something goes wrong during the provision of health and care services, patients and families have a right to receive explanations for what happened as soon as possible and a meaningful apology.
  13. Content Article
    Whistleblowing presentation from Peter Duffy to the Association for Perioperative Practice, September 2022. York University.
  14. Content Article
    Would you know what to do if something went wrong with your medical treatment in private/independent healthcare? This guide from PHIN tells what you should understand before choosing where to have your treatment and what to do if everything doesn’t go to plan.
  15. Content Article
    You have the right to make a complaint about any aspect of NHS care, treatment or service The information on this NHS page will guide you through the NHS complaints process, as well as the core requirements for NHS complaints handling.
  16. News Article
    Lessons still have not been learned at a Kent hospital trust which was criticised in a damning report, a mother has said. Dr Bill Kirkup's review found at least 45 babies might have survived with better care at East Kent NHS hospitals. Victoria, whose six-year-old daughter needs 24-hour support, said: "I've had no contact from anyone from the trust." Her case was one of 202 that were examined by Dr Kirkup in his report, which was published exactly a year ago. Victoria, whose daughter is living with the consequences of failings in her care during her birth, said: "Our children have become unwell because of what has happened to them. "I don't feel lessons have been learned whatsoever. "Treatment hadn't been made available as easily as it should have done for children that are still living this experience every day." Read full story Source: BBC News, 19 October 2023
  17. Content Article
    In a recent report, the Professional Standards Authority (PSA) for Health and Social Care sets out its view on the biggest challenges affecting the quality and safety of health and social care. In this blog, Alan Clamp, PSA's chief executive, summarises these challenges and the possible solutions. You can also read Patient Safety Learning's reflections on the PSA report here.
  18. Content Article
    Derek Richford’s grandson Harry died in November 2017 at just a week old. Since Harry’s death, Derek has worked tirelessly to uncover the truth about what happened at East Kent Hospitals University Foundation Trust (EKHUFT) to cause Harry’s death. His efforts resulted in a three-week Article 2 inquest that found that Harry had died from neglect. In addition, the Care Quality Commission (CQC) successfully prosecuted the Trust for unsafe care and treatment and Derek’s work has contributed to a review into maternity and neonatal care services at EKHUFT. In this interview, we speak to Derek about how EKHUFT and other agencies engaged with his family following Harry’s death. As well as outlining how a culture of denial at the Trust affected his family, he talks about individuals and organisations that acted with respect and transparency. He highlights what still needs to be done to make sure bereaved families are treated with openness and dignity when a loved one dies due to avoidable harm.
  19. Content Article
    In this article for Health Services Insight, NHS consultant David Oliver examines why most comments on articles in the Health Services Journal (HSJ) are posted anonymously. He highlights that this tendency towards anonymity from commenters who are clearly in influential, senior NHS posts, indicates that the culture in the NHS management community, from NHS England down, is one that makes most people fearful of saying anything in their own name in case of reprisal. He also points out that a culture where people are afraid to make comments and criticisms in their own name is in conflict with the Nolan Principles of 'selflessness', 'integrity', 'objectivity', 'accountability', 'openness', 'honesty' and 'leadership' that senior NHS managers and officials are supposed to be guided by.
  20. Content Article
    In this letter, Rob Behrens, the Parliamentary and Health Service Ombudsman, calls on the Secretary of State for Health and Social Care, Steve Barclay MP, to prioritise improving patient safety in the wake of the Lucy Letby trial.
  21. News Article
    Hospitals are still covering up serious mistakes in patient care and fobbing off families that raise concerns, the head of the watchdog that investigates complaints against the NHS has warned. Rob Behrens told The Times he had seen cases of medical records being changed after a death and spoken to doctors who were too scared to speak out about failings in their hospitals. He called on ministers to change the law to introduce a “duty of candour” on health and other public service staff to “transform” the system and make it more accountable to patients. He warned: “There is a deep reluctance to explain and give an account of what you do in the health service or the public service for fear of retribution. The things that really get to me are the avoidable deaths of babies in the health service — dying because there’s been poor coordination or they’d been wrongly diagnosed or the parents hadn’t been listened to. That is shocking.” Read full story (paywalled) Source: The Times. 6 March 2023
  22. News Article
    Bereaved families of coronavirus victims feel the Welsh government has not adequately taken part in the Covid public inquiry, their solicitor says. Craig Court, who represents bereaved families, said the Welsh government had not participated "as well as they should have". He claimed the Welsh government failed to deliver crucial paperwork with just days to go before Tuesday's inquiry. The UK-wide inquiry could go on as long as three years, and will predominantly look at the UK government's approach to the pandemic. A Wales-specific inquiry was blocked by Labour members of the Senedd, with First Minster Mark Drakeford saying it should wait until after the UK-wide investigation had been completed. Mr Court told BBC Wales "there is a great concern over the duty of candour" displayed by the Welsh government. Read full story Source: BBC News, 9 June 2023
  23. Content Article
    In December 2022, the All Party Parliamentary (APPG) for Whistleblowing heard evidence on the state of the NHS following the recent report on the avoidable deaths and life changing injuries caused to mothers and babies at the East Kent Trust. The culture at this hospital was described as one where “everyone knew the problems” and where whistleblowers were “thrown to the lions”. A culture attributed to 45 of the 65 baby deaths reviewed.  This blog first appeared on the Whistleblowers UK website in December 2022.
  24. Content Article
    In this blog for Medpage Today, US doctor Diane Solomon talks about the power of apologising to patients. Outlining the tendency of healthcare professionals to defend their practice, she describes how being honest and open with patients about errors demonstrates humanity and compassion. She talks about the importance of being sincere when apologising and outlines how taking responsibility builds trust and can positively change future outcomes.
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