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Found 29 results
  1. Content Article
    Summary of recommendations The following recommendations are made to support the delivery of a new regional policy/procedure for reporting, investigating and learning from adverse events. The Department of Health should work collaboratively with patient and carer representatives, senior representatives of Trusts, the Strategic Performance and Planning Group, Public Health Agency and Regulation and Quality Improvement Authority to co-design a new regional procedure based on the concept of critical success factors. Central to this must be a focus on the involvement of patients and f
  2. Content Article
    Everyone who works in health and social care should listen to this podcast in full. I've followed Will's search for justice and I am proud to know Will. A man of great integrity who is campaigning for an individual #dutyofcandour in #healthcare, for the benefit of us all. I remain shocked, when I teach on this, how few know Robbie's story. There has been so much lost learning, a failure of accountability, and a failure to deliver an effective statutory duty of candour. For me, this appalling story of failure and cover up highlights clearly why we have to recognise the value of w
  3. Content Article
    A 75-year-old patient suffered a stroke in the early hours of the morning. He had woken feeling unwell (two hours after going to bed) and waited to see if his symptoms would improve. They didn’t improve and nearly three hours later, his wife called an ambulance. Before they set off with the patient, one of the paramedics contacted the emergency department (ED) at the first hospital (Trust A) to ‘pre-alert’ them of his arrival. The ED advised that they could not accept the patient as their stroke service was closed between 11pm and 8am, and that the paramedics should contact a neighbouring
  4. Content Article
    Sharps injuries pose a significant global risk to staff and patient safety, and many of these injuries are caused by incorrect disposal. The Royal College of Nursing (RCN) estimates that there are 100,000 sharps injuries in healthcare in the UK every year,[1] and research by both the RCN and The European Biosafety Network highlights that the situation has worsened under the pressure of the Covid-19 pandemic.[2][3] There is also evidence that sharps injuries are underreported, meaning the number of incidents could be much higher.[2] The Safer Healthcare and Biosafety Network recently launched a
  5. Content Article
    One of the three areas of patient harm investigated by the Independent Medicines and Medical Devices Safety (IMMDS) Review (also known as the Cumberlege Review) related to implanted pelvic mesh. Complications with mesh implants can have a life-changing impact, resulting in severe and chronic pain, infections, reduced mobility, sexual difficulties, autoimmune issues and psychological strain. The Review made a number of recommendations in regard to the shocking scale of avoidable harm experienced by mesh-injured patients, including the establishment of a network of specialist centres that c
  6. Content Article
    The report provides information on the patient involved and background to the adverse incident, analyses the reasons for the incident and provides recommendations for the administration of intrathecal chemotherapy to prevent a similar incident occurring in the future: Recommendations include: changes to operational practices in pharmacy and ward settings changes to protocols in pharmacy and ward settings the provision of separate prescri0ption charts for intrathecal drugs formal, appropriate training on practical chemotherapy administration for senior house offi
  7. Content Article
  8. News Article
    A whistleblower at the centre of a bullying scandal at West Suffolk hospital says she will “never be the same again” after being “pursued” by NHS managers when she raised concerns about a doctor injecting himself with drugs while on duty. Dr Patricia Mills was exonerated last week in an independent NHS review that was highly critical of the way she was ignored and then subjected to disciplinary investigation that verged on “victimisation”. The review, by Christine Outram, chair of the Christie NHS foundation trust, said Mills’s concerns about the self-injecting doctor were “well foun
  9. Content Article
    The Independent Inquiry into the Issues raised by Paterson was prompted by the case of Ian Paterson, a breast surgeon who was convicted of wounding with intent some of the 11,000 patients he treated and jailed for 20 years in 2017. More than 200 patients and family members gave evidence as part of the Inquiry and it is estimated that he could have harmed more than 1000 patients. Its findings and recommendations were set out in a report published on the 4 February 2020. Summary of the Government response to each of the recommendations Recommendation 1 – We recommend that there sho
  10. Content Article
    "Many voices are not heard in British mental health care (and beyond), significant flaws are overlooked. If you are not satisfied with the status quo or just curious, follow us!" Here's a sample of some of the podcasts: Episode 33 - Basaglia's International Legacy: From Asylum to Community... review Episode 8 - Lived experience in Trieste, a mental health system without psychiatric hospitals, with Marilena and Arturo Episode 25 - Clinical Psychology vs Psychotherapy in Italy and the UK Episode 18 - The Trieste model cannot be exported to the UK because... let's un
  11. News Article
    Dozens of hospital trusts have failed to act on alerts warning that patients could be harmed on its wards, The Independent newspaper has revealed. Almost 50 NHS hospitals have missed key deadlines to make changes to keep patients safe – and now could face legal action. One hospital, Birmingham Women’s and Children’s Foundation Trust, has an alert that is more than five years past its deadline date and has still not been resolved. Now the Care Quality Commission (CQC) has warned it will be inspecting hospitals for their compliance with safety alerts and could take action against hospi
  12. Content Article
    Social normalisation of deviance means that people within the organisation become so much accustomed to a deviant behaviour that they don’t consider it as deviant, despite the fact they exceed their own rules for the elementary safety. People grow more accustomed to the deviant behaviour the more it occurs . To people outside of the organisation, the activities seem deviant; however, people within the organisation do not recognise the deviance because it is seen as a normal occurrence. In hindsight, people within the organisation realise that their seemingly normal behaviour was deviant.
  13. Community Post
    I've been posting advice to patients advising them to personally follow up on referrals. Good advice I believe, which could save lives. I'm interested in people's views on this. This is the message I'm sharing: **Important message for patients relating to clinical referrals in England** We need a specific effort to ensure ALL referrals are followed up. Some are getting 'lost'. I urge all patients to check your referral has been received, ensure your GP and the clinical team you have been referred to have the referral. Make sure you have a copy yourself too. Things
  14. Content Article
    In Spring 2021, I was due to meet a senior NHS official, along with a group of pelvic mesh campaigners, to ask for consistent training of all surgeons performing mesh removal procedures. That meeting was cancelled, and I’m calling for it to be reinstated, and fast. We desperately need action to sort out the inadequate, piecemeal approach the NHS has taken to redress the harm caused by surgical mesh. I manage a Facebook support group of over 9,200 women, most of whom are still living with debilitating pain and side effects caused by pelvic mesh. Each experience tells of harm added to
  15. Content Article
    To access this video you will need to sign in to BBC iPlayer and be in the possession of a TV licence.
  16. News Article
    Early warning scores are used in the NHS to identify patients in acute care whose health is deteriorating, but medics say it could actually be putting people in danger. The rollout of an early warning system used in hospitals to identify patients at the greatest risk of dying is based on flawed evidence, according to a study published in the BMJ which suggests that much of the research supporting the rollout of NEWS was biased and overly reliant on scores that could put patients at greater risk.. Medical researchers said problems with NHS England's National Early Warning Scores (NEWS
  17. Content Article
    In her report, the coroner highlights two matters of concern in this case: Initial delay in seeing a doctor Mr Collinson was not seen by a Doctor until eight hours after he arrived at hospital. The reason given for this was that the department was highly pressured on this date, and although a junior doctor had assigned the case to them by "clicking", that doctor had not in fact been able to see Mr Collinson. He did not "unclick" the patient and therefore other doctors who may have had capacity were not aware that Mr Collinson had not been seen. The coroner expressed concerns that
  18. News Article
    In a report published today, AvMA, the charity Action Against Medical Accidents, reveals serious delays in NHS trusts implementing patient safety alerts, which are one of the main ways in which the NHS seeks to prevent known patient safety risks harming or killing patients. The report, authored by Dr David Cousins, former head of safe medication practice at the National Patient Safety Agency, NHS England and NHS Improvement, identifies serious problems with the system of issuing patient safety alerts and monitoring compliance with them. Compliance with alerts issued under the now abolishe
  19. Content Article
  20. Content Article
    “After he died, the little plastic ID band that was around his tiny wrist should have been slipped onto mine. There was nothing more that could have been done for him, but there was plenty that needed to be done for me. I needed an infusion of truth and compassion. And the nurses and doctors who took care of him, they needed it too." Leilani Schweitzer[1] When someone is hurt, it is reasonable to expect the healthcare system to provide care to alleviate symptoms or to cure. It is also reasonable to expect those providing the care to be adequately
  21. Content Article
  22. Content Article
    Recommendations from the report There should be a single repository of the whole practice of consultants across England, setting out their practising privileges and other critical consultant performance data, for example, how many times a consultant has performed a particular procedure and how recently. This should be accessible and understandable to the public. It should be mandated for use by managers and healthcare professionals in both the NHS and independent sector It should be standard practice that consultants in both the NHS and the independent sector should write to patient
  23. Content Article
    'Dr Lucy Johnstone, one of the lead authors of the Power Threat Meaning Framework, said: "The Power Threat Meaning Framework can be used as a way of helping people to create more hopeful narratives or stories about their lives and the difficulties they have faced or are still facing, instead of seeing themselves as blameworthy, weak, deficient or ‘mentally ill’. It highlights and clarifies the links between wider social factors such as poverty, discrimination and inequality, along with traumas such as abuse and violence, and the resulting emotional distress or troubled behaviour, whet
  24. Content Article
  25. Content Article
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