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Found 51 results
  1. Content Article
    In the early days of my career, I worked with clinical teams while managing a hospital and later a network of hospitals. I must say, the experience I gathered in these different roles shaped me into what I am today. I can fit into healthcare conversations easily because of these early relationships and interactions with clinical experts. When I look back to my experience as a hospital administrator, a particular incident keeps coming back to mind; I sometimes link this to my later involvement in patient safety but most times I feel it is my conscience speaking to me. There was a patient we were trying to give a surgical intervention to; although he was already in a bad condition, he stood a chance to survive yet he died. We had an antenatal case we had managed from conception and the lady had opted for an elective caesarean section (CS). When she was term, we brought her in and prepared her for the theatre. At the time set of the surgery, our anaesthetist was not available; he was assisting another surgery in another facility, but he gave us a name of his anaesthetist colleague we could use for this patient. We brought this new anaesthetist in to assist in the patient’s CS. While we stretchered in the lady for her elective CS, a severe emergency case was rushed in needing an urgent surgical intervention. This case obviously had to override the elective CS in order of triage. We returned the lady to her ward while we rushed to the emergency case. The medical team that was going to operate on the CS patient was now needed for this new case. About 20 minutes into the surgery, our lead surgeon came out of the theatre with an upset look on his face. I sensed something was wrong and I immediately led him into my office which was near to the theatre and locked the door. I asked him what happened? He told me that there had been an anaesthesia accident. The new anaesthetist we brought in to assist with the surgery had not understood our anaesthetic machine as he had never used it before. He had used the machine incorrectly and had given the patient an overdose of gas and the patient’s heart packed up. The lead surgeon was very upset. I was thinking, this could have been my Dad, my Mum or any of my family members; it was a totally life-changing experience for me. The relatives of the patient were notified that the patient had died; there was wailing and shouting in the hospital. I locked myself inside my office and cried because I knew this patient should not have died from an error of one man. I imagined the pain we had caused the family; the grief and the vacuum we created by our error. It was all too much horror for my fragile heart to deal with at that time. But the greatest mistake we made was that the error was never discussed among the team for us all to learn from and we were also not honest enough to own up to the patient’s relatives. This incident led me into researching and reading materials on medical safety and this was how I got into patient safety advocacy. But when I look back at the incident today, was it the anaesthetist’s fault? No not at all; it was the fault of the system. The anaesthetist should not have been allowed access to that machine in the first place as he had not been trained to use that machine. This was where we should have trapped the risk before it got to the patient. In safety, when you change or replace a machine or a piece of equipment your policy must be reviewed to capture the new equipment and users must be trained on the new machine in its specifications and peculiarities. This is what happens in aviation. A pilot cannot fly an aircraft which he has not been simulated to fly and this is one of the reasons why aviation is still one of the safest sectors in the world today.[1] Having established that it was a system error, we should have also been professional and honest enough to let the relatives of the patient know what had actually happened. When we are honest it shows clear transparency, but when we try to sweep things under the carpet it is mostly misunderstood that our actions could have been deliberate. As I am writing this article, I am sure the relatives of the patient, many years down the line, still don’t know what actually happened. Following the Communication and Optimal Resolution (CANDOR) processes,[2] we should have made an early and honest disclosure of the adverse event known to the patient’s relatives, offered them an apology, refunded their payment and let them know how much this mattered to us and what we were going to do to improve our system. Our actions totally contravened all required amicable and fair resolution for the patient’s family. Owing to the fact that every man is fallible – this is why we are mere mortals in the first place – there may be errors but losing the opportunity to learn from those errors is deliberately creating new levels of errors. We never discussed what happened to our patient. I was the only one who got to know about this incident outside the clinical team who were in the theatre when this happened. The Medical Director may not have even known, so the case was never discussed and we could never all learn from it. When I think of this, I feel we need more openness and information sharing in healthcare, allow teams to discuss and share experiences, give room for reporting without blame, design a system that encourages patient safety conversation and liberalise communication processes. Each time this incident crosses my mind, I think of the lady who we had originally booked for elective CS. This clinical team was put together for her CS before the sudden emergency that came to take her place. She never knew what happened. The evening of that same day her CS was done and she had her baby boy who should be a grown man now. This brings to mind the bible verse Isaiah 43.4 “…I will give people in exchange for you, nations in exchange for your life”. Could this have been what happened? No, the system is what killed the patient and I think we should all own up to this. References Kai-Jorg S. Pilot training: What can surgeons learn from it? Arab Journal of Urology 2014;1: 32-35. Agency for Healthcare Research and Quality (AHRQ). Communication and Optimal Resolution (CANDOR).
  2. News Article
    Great Ormond Street Hospital may have broken the law by failing to share information with parents that showed its errors had contributed to their son’s death, The Independent understands. The care watchdog is speaking to Great Ormond Street about its handling of an expert report into five-year-old Walif Yafi in 2017. It showed that the hospital’s failure to share results that showed a deadly infection had played a role in Walif’s death. But the boy’s parents were only told about the findings after inquiries by The Independent – months after settling a lawsuit with Great Ormond Street in which the trust denied responsibility. The Care Quality Commission is looking at concerns relating to duty of candour regulations, which require hospitals to be open and honest with families about mistakes made that result in serious harm to patients. Breaching the regulations is a criminal offence and can lead to prosecution. Read full story Source: The Independent, 7 December 2020
  3. News Article
    A major acute trust has confirmed the health service inspectorate has begun a criminal investigation into three incidents at its hospitals. University Hospitals Birmingham FT told HSJ the Care Quality Commission (CQC) has started a criminal investigation into incidents involving potential errors around the provision of anti-coagulant medication. The trust received a letter from the CQC this month informing it that the regulator has begun the investigation under regulation 22 of the Health and Social Care Act 2008 (regulated activities) regulations 2014. The incidents happened at Queen Elizabeth Hospital in Birmingham and Good Hope Hospital — the trust’s two main sites. Regulation 22 says: “In order to safeguard the health, safety and welfare of service users, the registered person must take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced persons employed for the purposes of carrying on the regulated activity.” The CQC launched a prosecution into East Kent Hospitals University FT this month for failing to meet fundamental standards of care. The regulator also successfully prosecuted University Hospitals Plymouth Trust in September after it pleaded guilty to breaching the duty of candour. Read full story (paywalled) Source: HSJ, 23 October 2020
  4. News Article
    A hospital trust has been fined for failing to be open and transparent with the bereaved family of a 91-year-old woman in the first prosecution of its kind. Elsie Woodfield died at Derriford hospital in Plymouth after suffering a perforated oesophagus during an endoscopy. The Care Quality Commission (CQC) took University Hospitals Plymouth NHS trust to court under duty of candour regulations, accusing it of not being open with Woodfield’s family about her death and not apologising in a timely way. Judge Joanna Matson was told Woodfield’s daughter Anna Davidson eventually received a letter apologising over her mother’s death, which happened in December 2017, but she felt it lacked remorse. Davidson said she still had many unanswered questions and found it “impossible to grieve”. The judge said: “This offence is a very good example of why these regulatory offences are very important. Not only have [the family] had to come to terms with their tragic death, but their loss has been compounded by the trust’s lack of candour.” Speaking afterwards, Nigel Acheson, the CQC’s deputy chief inspector of hospitals, said: “All care providers have a duty to be open and transparent with patients and their loved ones, particularly when something goes wrong, and this case sends a clear message that we will not hesitate to take action when that does not happen." Lenny Byrne, the trust’s chief nurse, issued a “wholehearted apology” to Woodfield’s family. “We pleaded guilty to failure to comply with the duty of candour and fully accept the court’s decision. We have made significant changes in our processes.” Read full story Source: The Guardian, 23 September 2020
  5. News Article
    An NHS trust is to appear in court today charged with breaking the law on being open and transparent after a woman’s death in the first ever court case of its kind. The Care Quality Commission (CQC) has brought a criminal prosecution against University Hospitals Plymouth Trust which will appear at Plymouth Magistrates Court tomorrow morning. The trust is charged with breaching the duty of candour regulations under the Health and Social Care Act 2008 which require hospitals to be honest with families and patients after a safety incident or error in their care. Hospitals are legally required to notify patients or families and investigate what has happened and communicate the findings to families and offer an apology. The case relates to how the Plymouth trust communicated with a woman’s family after her death which happened after she underwent an endoscopy procedure at Derriford Hospital in December 2017. The trust was required by law to communicate in an open and transparent way. The CQC has accused the trust of failing to do this. Read full story Source: The Independent, 22 September 2020
  6. Content Article
    I have included this poignant video as a matter of public interest. This is an issue which goes beyond party politics. I use Robbie's story in all of my teaching on ethics and clinical governance.
  7. Event
    This masterclass will provide participants with an in-depth knowledge of what needs to be done to comply with the duty of candour; clarify ‘grey areas’ and provide guidance on dealing with difficult situations which may arise. It will provide participants with an understanding of good practice in implementing the duty and, in particular doing so in a meaningful way with empathy, to not only comply, but to work with patients and loved ones in a way that puts the emotional experience at the heart of communication. Anyone with responsibility for implementing the duty of candour should attend, whether as a health or social care professional or at an organisational level, be it in the NHS, private healthcare or social care. Health and social care professionals; staff with responsibility for quality, safety, clinical governance, safety investigations, complaints or CQC compliance, patient experience and executive teams would benefit from attending. Further information and registration
  8. Event
    This masterclass will provide participants with an in-depth knowledge of what needs to be done to comply with the duty of candour; clarify ‘grey areas’ and provide guidance on dealing with difficult situations which may arise. It will provide participants with an understanding of good practice in implementing the duty and, in particular doing so in a meaningful way with empathy, to not only comply, but to work with patients and loved ones in a way that puts the emotional experience at the heart of communication. Anyone with responsibility for implementing the duty of candour should attend, whether as a health or social care professional or at an organisational level, be it in the NHS, private healthcare or social care. Health and social care professionals; staff with responsibility for quality, safety, clinical governance, safety investigations, complaints or CQC compliance, patient experience and executive teams would benefit from attending. Further information and registration
  9. Content Article
    This edited collection can be seen to facilitate global learning. This book will, hopefully, form a bridge for those countries seeking to enhance their patient safety policies. Contributors to this book challenge many supposed generalisations about human societies, including consideration of how medical care is mediated within those societies and how patient safety is assured or compromised. By introducing major theories from the developing world in the book, readers are encouraged to reflect on their impact on the patient safety and the health quality debate. The development of practical patient safety policies for wider use is also encouraged. The volume presents a ground-breaking perspective by exploring fundamental issues relating to patient safety through different academic disciplines. It develops the possibility of a new patient safety and health quality synthesis and discourse relevant to all concerned with patient safety and health quality in a global context.
  10. Content Article
    Guidance for NHS trust and NHS foundation trust boards on Freedom to Speak Up Freedom to Speak Up supplementary information Freedom to Speak Up self-review tool
  11. Content Article
    Every healthcare professional must be open and honest with patients when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress. This means that healthcare professionals must: tell the patient (or, where appropriate, the patient’s advocate, carer or family) when something has gone wrong apologise to the patient (or, where appropriate, the patient’s advocate, carer or family) offer an appropriate remedy or support to put matters right (if possible) explain fully to the patient (or, where appropriate, the patient’s advocate, carer or family) the short and long term effects of what has happened. Healthcare professionals must also be open and honest with their colleagues, employers and relevant organisations, and take part in reviews and investigations when requested. They must also be open and honest with their regulators, raising concerns where appropriate. They must support and encourage each other to be open and honest, and not stop someone from raising concerns
  12. Content Article
    This guidance aims to help the NHS to create an environment to better support staff when things go wrong and to encourage learning from incidents. Key challenges include: fear equity and fairness bullying and harassment.
  13. Content Article
    Attached is a presentation (December 2019) by Andrew Pepper-Parsons, Head of Policy at Protect. The presentation outlines Protect's Better Regulators Campaign. The objectives of the campaign are to: start to create a more consistent approach in how whistleblowers are interacted with set and shape the standards expected from internal whistleblowing processes start a dialogue between the regulators themselves and with Protect.
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