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In this article, Professor Paul Bowie, Programme Director for Safety & Improvement at NHS Education for Scotland (NES), outlines an NES research project which aimed to critically review the safety-related content, language and assumptions of a small but diverse range of health and care safety learning reports, policies, databases and curricula. The following information sources, which were in the public domain or volunteered by care organisations, were selected for review: NHS Board Adverse Event Learning Summaries Ombudsman Reports on Complaints Data from incident reporting and learning systems National and organisational management of adverse events policies Organisational incident investigation reports National and international patient safety curricula The study identified the following issues in the information reviewed: Omitting the ‘systems approach’ Using the language of blame and human failure Overlooking the ‘local rationality’ principle Engaging in counterfactual reasoning Misunderstanding key concepts Related reading: HSIB: Learning Response Review and Improvement tool- Posted
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Hindsight bias (colloquially known as ‘the retrospectoscope’) is the tendency to perceive past events as more predictable than they actually were. It has been shown to play a significant role in the evaluation of an past event, and has been demonstrated in both medical and judicial settings. This study in Clinical Medicine aimed to determine whether hindsight bias impacts on retrospective case note review, through an internet survey completed by doctors of different grades. The authors found that in some cases, doctors are markedly more critical of identical healthcare when a patient dies compared to when a patient survives. Hindsight bias while reviewing care when a patient survives might prevent identification of learning arising from errors. They also suggest that hindsight bias combined with a legal duty of candour will cause families to be informed that patients died because of healthcare error when this is not a fact.- Posted
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In this blog, Steve Turner reflects on why genuine patient safety whistleblowers are so frequently ignored, side-lined or victimised. Why staff don't speak out, why measures to change this have not worked and, in some cases, have exacerbated the problems. Steve concludes with optimism that new legislation going through Parliament offers a way forward from which everyone will benefit. The scale of the problem The hidden costs of stigmatisation of healthcare whistleblowers are immense. System-wide problems in this area of healthcare are reinforced by a lack of transparency and the failure of accountability. The consequences of this failure have been investigated many times over the years. A seminal case was that of the Bristol heart surgery scandal in the 1990s. This was brought to light by the anaesthetist Steve Bolsin and led to the implementation of a system of clinical governance.[1] This advance in measures to deliver quality, consistent and safe care remains as relevant today as it ever was. More recently, the investigation into the failings at mid Staffordshire[2] highlighted how a ‘good news’ only culture, where reputation management was placed above patient safety, is failing patients. Critically for me the shocking fact is that where staff who blow the whistle can't, or don't, speak out, are ignored or silenced, the onus to expose wrongdoing falls on patients and their relatives. This involves great personal cost. The onus to expose wrongdoing falls on patients and their relatives. This involves great personal cost. This shameful thread of patient-led whistleblowing goes back a long way and has not stopped. Examples where patients, carers or relatives have had to take the lead and blow the whistle include the death of Robbie Powell,[3] Elizabeth Dixon,[4] Oliver McGowan,[5] Claire Roberts and those who died in the Belfast Hyponatraemia scandal,[6] the Gosport War Memorial Hospital scandal,[7] and the investigation into maternity services in East Kent.[8] These patient safety scandals show no sign of abating despite the report on the failings at mid Staffordshire[2] and Sir Robert Francis’ major review into whistleblowing in the NHS.[9] This is reinforced by the 2023 Bewick Review,[10] which is the first of three planned reviews into University Hospitals Birmingham NHS Foundation Trust. This review was commissioned following repeated serious concerns relating to patient safety, leadership, culture and governance, which were initially downplayed or ignored. The full story behind these failings and their significance has yet to fully come to light. Patients have to blow the whistle on unsafe care A stream of healthcare scandals (too many to mention all of them here) have been exposed by members of the public. Key examples include the case of Robbie Powell who died of untreated Addison's disease in 1990.[3] Thanks to the tenacity of Robbie’s father (Will Powell) this led to the clarification of the absence of an individual legal Duty of Candour for healthcare professionals.[11] Despite numerous reports and failed investigations, including one of which put forward 35 suggested criminal charges, the Robbie Powell case remains open with the Crown Prosecution Service (CPS). In addition, the former Welsh Ombudsman and the English Ombudsman are both calling for a public inquiry into the case.[12] Another case concerns those who died at Gosport War Memorial Hospital in the 1990s who were prescribed opioid medicines that were not indicated for their condition. This led to an Independent Review Panel,[7] which took four years and cost £14 million. The Panel found that 456 deaths in the 1990s had "followed inappropriate administration of opioid drugs". In 2019, Assistant Chief Constable Nick Downing, head of the Serious Crime Directorate for Kent and Essex Police, announced that a new criminal investigation into the deaths was to take place and the campaign for justice continues. Other serious issues include premature deaths of people with learning disabilities and autism,[13] which led to the implementation of the learning from deaths programme. On average, the life expectancy of women with a learning disability is 18 years shorter than for women in the general population. The life expectancy of men with a learning disability is 14 years shorter than for men in the general population.[14] There are numerous individual cases that support this finding, many of which were first highlighted by parents, informal carers or relatives. In 2014, the Department of Health and Social Care published a report that found that almost two-fifths of people with learning disabilities died from causes "amenable to good quality healthcare."[15] In 2022, a report by Dr Bill Kirkup into deaths in East Kent NHS maternity services[8] confirmed that the "onus was on patients to raise concerns" because the culture of fear prevented whistleblowers from speaking out. “In every case staff were aware of serious mistakes or wrongdoing but they were unaware of how to raise concerns because those who tried were subjected to peer pressure to be silent and everyone was afraid of the [personal] consequences.” These consequences were exemplified by the experience of the nursing director who was told that speaking up would harm her career. Another significant report is that into the life and death of Elizabeth Dixon,[4] which contains recommendations that apply across the board: "…6. Clinical error, openly disclosed, investigated and learned from, must not be subject to blame. Conversely, there should be zero tolerance of cover up, deception and fabrication in any health care setting, not least in the aftermath of error. (NHSE, GMC, NMC, MoJ) 7. There should be a clear mechanism to hold individuals to account for giving false information or concealing information relating to public services, and for failing to assist investigations. The Public Authority (Accountability) Bill drawn up in the aftermath of the Hillsborough Independent Panel and Inquests sets out a commendable framework to put this in legislation… It should be re-examined. (MoJ) 8. The existing haphazard system of generating clinical expert witnesses is not fit for purpose. It should be reviewed, taking onto account the clear need for transparent, formalised systems and clinical governance. (DHSC, MoJ)…" The amount of evidence and the number of reports that were initiated thanks to the tenacity and courage of patients, relatives, carers and parents, is truly shocking. How can we change this? How many more reports do we need? The only thing we can say with confidence is that lessons have not been learned. Why don’t staff speak out? I was recently asked ‘why don't staff speak out?’ There's very little rigorous research on whistleblowing in health and social care, so I can only offer my personal views on this apparent absence of ethical behaviour. I believe this quote from Margaret Heffernan (Professor of Practice at the University of Bath School of Management) goes some way to explaining this: “I have never encountered an organisation as vicious in its treatment of whistleblowers as the NHS".[16] If anyone has any doubts there are a string of high-profile cases to support it, including the cases of Steve Bolsin, Raj Mattu, Kim Holt, Peter Duffy and Chris Day. When I was asked why staff stay silent my first thought was to say that those who would speak out have all left. Of course, this can't be the full story. So, what are the other reasons? One possible reason is that people who are promoted to highly paid jobs attain these positions because they ‘toe the line’. Organisational psychologists talk about the role of enablers and ‘flying monkeys’ in maintaining this culture. A flying monkey is a psychology term that refers to an enabler of a narcissistic person, a henchman so to speak. Many staff keep their heads down and don't look too hard at what's going on around them. Some commentators see this as a behaviour that is supported by the promotion of toxic positivity. What I mean by this is a culture of talking-up successes, however small, completely ignoring failure, and therefore missing the learning that comes from failure. The widely used phrase ‘rock the boat but stay in it'[17] springs to mind here, especially the empty references to ‘radicals’ and ‘change agents’. This forms part of learning materials that are often accompanied by reams of management jargon and pseudo-science. This leads to a morally bankrupt approach where ‘all is well’ (‘nothing to see here’) and toxic positivity prevails. The belief that no matter how bad a situation is, people should maintain a positive mindset, move on and not mention it, is a way of working that is directly contradicted in these wise words by the late Professor Aidan Halligan: "Run toward problems, especially on a bad day." My views may sound very harsh, especially coming from someone like me who left direct employment with the NHS in 2008. It's important to point out that I believe the vast majority of NHS staff, at all levels from clerical staff and porters to senior managers and chief executives, do their best to work around the bullying and toxicity to deliver safe care for patients. Doing their best despite the prevailing culture rather than being supported by it. Sometimes biding their time and subtly subverting directives that are not in patients’ best interests. For clinicians, the threat of being referred inappropriately to a professional body is ever present,[18] and an environment where the pressure of work is extreme, exhausting and unstainable are also major factors. For many, the prevailing culture also means that the careers of highly skilled accountable, ethical and caring staff are held back through denial of learning opportunities and promotion, and informal blacklisting which is commonplace. There's an army of people ready for change, a huge informal network of highly motivated caring people, which is why I'm optimistic about the future. Why have ‘speaking up’ reforms failed? These are my personal views based on my experience and that of my colleagues. Since Sir Robert Francis’ whistleblowing report[9] there have been several changes designed to improve the situation. These include Freedom to Speak up Guardians (FTSU), the introduction of an institutional Duty of Candour, the ‘Fit and Proper Persons Test'[14] for Board members and the NHS Whistleblower Support Scheme. In addition, the Health and Safety Investigation Branch (HSIB) was set up in 2017 and a National Patient Safety Commissioner was appointed in 2022. Given all the above, why has there not been a reduction in high-profile healthcare failings? In my view there are several reasons. Many believe, as I do, that the approach of the Care Quality Commission (CQC) to whistleblowing is part of the problem. We often learn from investigation reports that the CQC (and other regulators) had been listing problems in their reports for years and yet no meaningful action has been taken. ‘Regulatory capture’ is a serious problem, which is when regulators are adversely influenced by the people they are inspecting. This is often linked to the revolving door of staff who move from health and care employment to the regulators, and informal links which amount to cronyism. This behaviour is something that commentators have noted and which I have experienced myself.[20]. Patients suffer as a result. The introduction of the National Guardian Office and Freedom to Speak Up Guardians in each NHS trust is also problematic. This initiative has an inbuilt conflict of interest, as the Guardians are employed by the trusts themselves. The All-Party Parliamentary Group on Whistleblowing (APPG) has heard from whistleblowers who have been failed by local Guardians, sharing their experiences that have included the disclosure of their identity to hospital management and boards, which resulted in retaliation. The APPG has also heard from local Guardians who were not supported and themselves the target of retaliation after supporting whistleblowers.[21] In addition, something which I find shocking is that the National Guardian Office appears to studiously avoid the word ‘whistleblowing’ in its material and outputs wherever possible. This adds to the stigma around healthcare whistleblowers and is inexcusable. Another lesser-known initiative is the NHS Speaking Up Support Scheme[22] (originally titled the Whistleblower Support Scheme). There is not much information available on this scheme in the public domain. I became aware of the scheme when I was asked if I wanted to apply. Later I signposted several people to the scheme. I learned that although the scheme has benefited some people, for others it appears to have made their situation worse. Through a freedom of information request, and thanks to the intervention of my MP, I have managed to obtain a redacted copy of the evaluation of the pilot scheme which supports the view of mixed results.[23] Having read this report, it is unclear to me why it hasn’t been published and why it was redacted. Particularly as I think (I can’t be sure of course) that one of the redactions is a comment I made. A comment I wanted to be shared. As for the other post-Francis review initiatives, the Kark Review in 2018 on the Fit and Proper Person Test (FPPT) is unequivocal in its findings: "Essentially it [FPPT] does not ensure directors are fit and proper for the post they hold, and it does not stop the unfit or misbehaved from moving around the system."[24] In addition, the statutory current Duty of Candour[25] seems, at times, to be little more than a tick box, with the responsibility for talking to patients often left to the most junior staff. A Duty of Candour is about simply telling the truth and is everyone’s responsibility, not a task to be delegated. The need for a legal duty of candour on individuals has been highlighted by Robbie Powell’s father Will Powell and links to proposals for a Hillsborough Law. The HSIB and the National Patient Safety Commissioner initiatives have some built in limitations to what can be achieved. The HSIB’s remit does not include investigation of systemic problems. This limits the areas that they can cover. As for the National Patient Safety Commissioner, this is a new role which is very promising. Unfortunately, the scope of this role is limited, with the remit covering only medicines and medical devices. This means that these two initiatives are not able to tackle the systemic organisational cultural issues that are at the root of major patient safety failings. One thing that stands out here is that none of the above measures specifically tackle the stigma around whistleblowing in healthcare. In fact, some reinforce the stigma. A way forward Much has been written about healthcare whistleblowing and measures that have been implemented to promote positive change. Despite these, the victimisation of healthcare whistleblowers and the stigmatisation around whistleblowing in health and in social care has not abated. The measures introduced have so far achieved very little. In some instances, I believe, they have made the problem worse. The Protection for Whistleblowing Bill,[26] which passed its second reading in December 2022, proposes the repeal of the current Public Interest Disclosure Act,[27] replacing it with an Office of the Whistleblower. This would prevent concerns of genuine healthcare whistleblowers becoming buried under an employment issue, and their original patient safety concerns being side-lined. The Public Interest Disclosure Act is expensive, limited in scope and beyond the reach of most whistleblowers. It is also overly complex, with cases currently waiting for over 2 years to be heard. Employers game the system to run whistleblowers out of funds. Fewer than 12% of cases that go to the Employment Tribunal win. It does not protect patients and is not accessible to members of the public who blow the whistle. Currently there is no statutory provision to investigate or address the wrongdoing highlighted by whistleblowers. Many whistleblowers have been denied any protection because they are not workers. An Office of the Whistleblower would change this and help us identify the root causes of systemic patient safety failings.[26] I urge everyone with an interest in this subject to read the bill and watch the video of Baroness Kramer introducing the second reading of the Bill.[28] For the first time in years, I am optimistic. References Department of Health. The report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984-1995: learning from Bristol (Cm5207(II)); 2001. Department of Health. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry; 2013. Hartles S. Robbie Powell: Time for Truth, Justice and Accountability. Open University Harm & Evidence Research Collaborative; 2021. Kirkup B. Independent report. The life and death of Elizabeth Dixon: a catalyst for change; 2020. Ritchie F. Independent Review into Thomas Oliver McGowan’s LeDeR Process Phase two; 2020. Department of Health, Northern Ireland. Report of the inquiry into hyponatraemia related deaths; 2018. Gosport Independent Review Panel Report. The Panel Report - 20th June 2018. Dr Kirkup B. Reading the signals: maternity and neonatal services in East Kent – the report of the independent investigation; 2022. Francis R. Report on the Freedom to Speak Up review; 2015. Bewick M, et al. University Hospitals Birmingham NHS FT (UHB) Phase 1 Review by I4QU. Clinical Safety. iQ4U Consultants; 2023. Action against Medical Accidents. Robbie’s Law. The European Court Ruling in full: https://hudoc.echr.coe.int/fre#{%22itemid%22:[%22002-6998%22]}. Parliamentary and Health Service Ombudsman. Radio Ombudsman: Will Powell’s 32-year quest for justice for son Robbie; 2022. NHS England. About LeDeR; 2023. NHS Digital. Health and Care of People with Learning Disabilities, Experimental Statistics: 2018 to 2019 [PAS]; 2020. Department of Health and Social care. Premature Deaths of People with Learning Disabilities: Progress Update; 2014. Heffernan M. I have never encountered an organisation as vicious in its treatment of whistleblowers as the NHS. BMJ Talk Medicine Podcast; 2020. Bevan H. Rocking the boat and staying in it: how to be a great change agent. Slide set; 2016. Grossman D, Clare S. Birmingham hospital culture worrying - health secretary. BBC Newsnight; 2023. Care Quality Commission. Fit and proper persons: directors; 2022. Clegg A. How cronyism corrodes workplace relations and trust. Financial Times; 2022. WhistleblowersUK, Meeting with Dr Bill Kirkup CBE and the APPG for Whistleblowing: blog; 2022. NHS England. Speaking up support scheme; 2022. Greenop D. NHSI Whistleblowers Support Scheme pilot. Final Evaluation (redacted); 2019. Obtained in 2022 following a Freedom of Information Request. Kark K, Russel J. A review of the Fit and Proper Person Test. Commissioned by the Minister of State for Health; 2018. Care Quality Commission. Regulation 20. Duty of Candour; 2023. UK Parliament. Protection for Whistleblowing Bill [HL]; 2023. UK Government. The Public Interest Disclosure Act 1998 [PIDA]. Baroness Kramer. Protection for Whistleblowing Bill, 2nd Reading, Baroness Kramer 2022. Video recording of the House of Lords introduction.- Posted
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This blog by Dr Georgia Richards looks at the system of learning from preventable deaths in the UK. She highlights that following the publication of a Prevention of Future Deaths report (PFD), there is no system in place to ensure responses are received and actions are taken. She then describes how the Preventable Deaths Tracker collects information from PFDs to screen and analyse preventable deaths, so that lessons can be learnt- Posted
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Diabetes tech: Do national aspirations and local practice align?
Anonymous posted an article in Diabetes
In this anonymous blog, a person with type 1 diabetes describes their recent experience upgrading their insulin pump, a medical device used to continuously deliver insulin instead of taking multiple daily injections. They describe how communication issues and gaps in staff knowledge led to a significant delay in accessing the pump, which caused them significant stress. They also ask whether recent announcements about increased access to diabetes technology over the next few years will match up to the reality experienced by people with diabetes accessing care at local healthcare organisations. In December 2023, NICE approved the roll out of hybrid closed loop systems to all patients with type 1 diabetes, which will make a big difference to both life-impact and clinical outcomes for thousands of adults and children in England. The announcement was a big deal, making mainstream news and lighting up social media. Looking behind the headlines, it will take up to five years to see technology reach everyone who is eligible, as NICE has stated. However, I’m dubious as to whether that target is achievable, because with all the will—and even all the funding—in the world, we need to have enough staff with the right training to make it happen. Diabetes teams need clinical training related to each system, but they also need to know how to run the process of getting this tech from factory to patient, with all the right forms signed and permissions given. They will be dealing with much larger volumes of requests, authorisations and administrative tasks on a daily basis. I recently had a brush with the administrative burden of upgrading my tech, and it somewhat highlighted this gap between the promise and the reality. I’ve been fortunate enough to be on an insulin pump for over a decade. Last December, with my current pump coming to the end of its life, I had the opportunity to choose a new one that I could use alongside my current continuous glucose monitor (CGM) to make a hybrid closed loop system. It felt like a weight had been lifted—in a few weeks, I would have access to a system that promised to make life a bit easier. Fast forward six months, and there’s a different story to tell. I was finally trained and ‘plugged in’ to my new pump last week. Unfortunately, I found myself in a marathon effort to try and access the new device. There were extended delays in getting approval, ordering the pump and booking a training session. My old pump crept out of warranty and became increasingly unreliable, and my stress levels crept up as I tried to figure out why things weren’t progressing. I left so many voice messages and emails to try and establish what was going on, but I often received no reply or call back. I’m still not fully clear on why it all took so long, but I have picked up that the delay was due to a combination of staffing issues, missed emails and lack of familiarity with the tech company's systems. At the beginning of the process, I had been told it would take a few weeks. I don’t want to lay all the blame on the team that runs the service, where I know there are capacity issues. But the experience revealed holes in the system that prevent patients accessing support and treatment that has been agreed. I was bolshy and desperate enough to push things through, and ended up contacting the company directly to see if they could help, which they did. It was me, as the patient, who pieced together where communication had gone wrong and highlighted what needed to happen. I know the health system pretty well and will keep asking until I find the person who can answer my question. My fear is that many people don’t know where to start, or where to go next when they meet a wall of silence. Friends sometimes forward me articles about how people with diabetes will soon all have access to the latest tech, but the headlines usually fail to convey the reality. ‘Soon’ and ‘all’ are subjective terms, depending on the systems that exist within your local organisation. While I believe the national team is putting significant effort into addressing access inequalities and postcode lotteries, there is still so much to do to ensure that patients receive the care they are entitled to and maintain their trust in their healthcare team. I hope that the promise will become a reality sooner rather than later, and that people with diabetes don’t face an uphill struggle to access the help they have been told to expect. The commitment from NHS England to the goal of universal access to closed-loop technology should rightly be celebrated. But the missing link between national policy, local practice and, vitally, how these are communicated to patients, needs some attention. As it stands, it is a recipe for frustration and anxiety.- Posted
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NHS whistleblower in West Suffolk will ‘never be the same again’
Patient Safety Learning posted a news article in News
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 founded” and yet, instead of acting on them, managers subjected her to an investigation that lacked “fairness, balance and compassion”. It included what Outram called the “incendiary” and “extremely ill-judged” demand to Mills and other doctors for fingerprint samples as part of a management hunt for an anonymous letter-writer who had tipped off a grieving family about a potentially botched operation. “I do feel vindicated,” Mills, a 53-year-old anaesthetist, told the Guardian, but she said the 21-month investigation into her conduct, which was only formally dropped in September, has had a lasting impact. “I will never be the same again. To be absolutely pursued like that by your employer inevitably has long-term consequences in terms of psychological wellbeing. It was an orchestrated campaign that really floored me.” Read full story Source: The Guardian, 17 December 2021- Posted
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This is a joint blog by Patient Safety Learning and Sling the Mesh, highlighting key areas of concern included in their recent response to the Royal College of Obstetricians and Gynaecologists consultation on a new Mesh Complications Management Training Pathway. 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 could provide treatment, care and advice for mesh-injured patients. It also recommended that: “Professional bodies should lead on ensuring surgeons only operate within their capabilities. They must provide guidance for their members and ensure that surgeons are appropriately trained, and this should be assured through the appraisal process.”[1] Mesh Complications Training Pathway In the context of this, at the start of this year the Royal College of Obstetricians and Gynaecologists (RCOG) published a consultation on a new Mesh Complications Training Pathway. It states that this has been: “… developed to equip doctors in commissioned regional specialised centres with the clinical skills needed to manage patients presenting with a wide range of mesh implant complications originally inserted for urinary incontinence (UI), pelvic organ prolapse (POP) and rectal prolapse”.[2] This Training Pathway is a much-needed piece of work and should be an important tool in providing patients with confidence in the training and standard of care offered by specialists dealing with mesh complications. However, we have identified a number of key patient safety concerns that we believe need addressing. In this blog, Patient Safety Learning and Sling the Mesh highlight some of the key issues included in our joint response to this consultation. You can find a link to our full consultation response at the end of this blog. Importance of patient engagement One key area of concern was the approach taken to the consultation process. This was held over a fairly short period (initially 3 weeks, subsequently extended to 4) and in our view not publicised enough with mesh-injured patients and groups. While the development of the Training Pathway did involve a focus group comprised of six women with mesh related issues, we believe that RCOG have missed an opportunity to engage much more widely. Patient engagement is key to improving patient safety, even more so when there has been a significant loss of trust for patients in healthcare professionals, such as in the case of surgical mesh. We believe it is vital that RCOG, further to its focus group, should be engaging directly with patient groups to hear their concerns and experiences and to genuinely co-produce this type of guidance. Patient groups with large membership bases are often well placed to provide insights, evidence, and expertise on specific areas of care. For example, in the case of this consultation, Sling the Mesh were able to highlight specific issues relating to the removal of rectopexy and sacrocolpopexy patients, which may not have been captured by a more limited focus group approach to engagement. If effectively engaged with, patient groups can provide a vast repository of patient experience to draw on in improving patient safety and services. Absence of Patient Reported Outcome Measures (PROMs) To fully understand the effectiveness of mesh removal procedures, and identify any emerging patient safety concerns, it is essential that they are accompanied by universal outcome measures for capturing and monitoring patient outcomes. We are concerned that the Training Pathway currently makes no reference to this. In our view it is vital that such information is gathered and that those working in Mesh Centres are proficient at using databases to capture this evidence. This can be used to compare outcomes from procedures at different sites and subsequently feed into requirements which can inform the development of this Training Pathway. Requirements for Mesh Centres In our consultation response we highlighted that the specific training requirements for Specialist Mesh Centres were not included in the Training Pathway. We expressed concerns that in the absence of this, there is a risk that service provision may be variable and that, without appropriate oversight, women may be at risk of inadequate services provision and an increase in avoidable harm. We also highlighted the specific points concerning Mesh Centres: It is important that for a Mesh Centre to be accredited or credentialed it must demonstrate the surgical competency to perform total/complete/entire removal of the mesh device. Significant concerns among patients that some mesh removal centres are run by surgeons who have previously implanted mesh and told the women involved that mesh is not a concern for them. In some cases, women are having to return to the surgeon who initially implanted their mesh, which they are describing as extremely traumatising. Many members of Sling the Mesh have found that they have to first go through a range of other treatments, such as psychiatric treatment and pain management, before they are subsequently given the opportunity to discuss mesh removal with a consultant. Concerns raised by patients that currently some Mesh Centres do not have the skills and experience required for the removal of rectopexy mesh, which requires skilled colorectal and urogynaecology teams working in unison. The need to ensure aftercare is in place, particularly in cases of rectopexy mesh, with patients who have had this major surgery raising concerns with Sling the Mesh about the lack of support for patients in this respect. This procedure can often result ongoing health issues and in some cases require additional surgery. We have heard concerning accounts where patients have needed to attend Accident and Emergency after having been previously discharged following this procedure. Surgical procedural requirements The Training Pathway lists a number of surgical procedural requirements for healthcare professionals working in Mesh Centres. A specific area of concern relates to several procedures listed as ‘Mandatory’ requirements in the Pathway which involve a partial removal of vaginal prolapse mesh, taking out the vaginal section only and leaving in the arms embedded deep in the pelvis. Sling the Mesh have members who have undergone this procedure in the UK and subsequently experienced significant disability and pain resulting from a partial removal of this type. We expressed concerns in our response about the potential for the guidance as written resulting in this becoming the default treatment option for women with vaginal prolapse mesh. We also highlighted a specific concern relating to two procedures listed in the Training Pathway as ‘Optional’ that involve the full removal of vaginal prolapse mesh. These involve the removal the implant in its totality, including the arms embedded in the tissue of the pelvis. We set out concerns that this was misleading as in practice the UK does not currently have any surgeons who are able to perform this type of total removals of vaginal prolapse mesh, and as such is not in practice a viable option for patients. Misleading language Another area of concern highlighted in our consultation response related to the language used in parts of the Training Pathway. Certain procedures that relate to partial removals of mesh are described as removing ‘the entirety of the mesh’. However, in these cases by ‘entirety’ they refer to all the mesh only in relation to a specific part of the body. We are concerned this could easily misunderstood as a full mesh removal when this is not what the procedure entails. Considering cases where complications may arise following surgery, where women may experience pain or disability, it would be concerning if their formal medical records referred to mesh removal in ‘entirety’ when in practice implanted mesh remains. To ensure clarity for patients and surgeons, we have suggested that the terms such as ‘total’ or ‘complete’ should be reserved to describe only the surgical procedures where the mesh device is removed in its entirety. Any other type of removal surgery should include the word ‘partial’. Further engagement needed In establishing and providing the care, treatment, and advice for mesh-injured patients, we believe it is vital that a patient-centred approach is taken. When it comes to mesh removal surgery, patients also need confidence that their experiences and concerns are being listened to and acted upon. We believe that RCOG has a key part to play in this and await to see how they will respond to the issues we have highlighted. References The IMMDS Review, First Do No Harm, 8 July 2020. RCOG, Mesh Complications Management Training Pathway, Last Accessed 9 February 2022. Related reading First Do No Harm APPG public meeting on redress: Speech from Kath Sansom (26 January 2022). Kath Sansom, ‘Mesh removal surgery is a postcode lottery’ – patients harmed by surgical mesh need accessible, consistent treatment (2 December 2021). McFadden et al, The long-term impact of vaginal surgical mesh devices in UK primary care: a cohort study in the CPRD (4 August 2021). Sharon Hartles, Mesh: Denial, half-truths and the harms (23 March 2021). Patient Safety Learning, A year on from the Cumberlege Review: Initial reflections on the Government’s response (23 July 2021).- Posted
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This report describes an adverse incident at Queen's Medical Centre in Nottingham in 2001, when a male patient being treated for leukaemia died after being mistakenly given the chemotherapy drug Vincristine intrathecally (into the spine). Vincristine should be administered intravenously, and accidental intrathecal administration of Vincristine is almost always fatal. 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 officers and specialist registrars enhanced checking procedures, involving the patient and family as well as medical staff agreed limits on the involvement of staff under supervision or shadowing a targeted communications campaign about the dangers of incorrect administration of Vincristine distinctive and clear labelling for intrathecal drugs the development of a new spinal needle with a different connection, to avoid accidental introduction of intravenous drugs. Related reading Safe administration of intrathecal chemotherapy (2003)- Posted
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- Cancer
- Adminstering medication
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Content Article
This blog by the Institute for Safe Medication Practices identifies ten medication safety concerns in the US from 2021 that still need to be addressed. These concerns are: Mix-ups between the paediatric and adult formulations of the Pfizer-BioNTech COVID-19 vaccines Mix-ups between the COVID-19 vaccines or boosters and the 2021-2022 influenza (flu) vaccines EPINEPHrine administered instead of the COVID-19 vaccine Preparation errors with the Pfizer-BioNTech purple cap or grey cap COVID-19 vaccines Errors and delays with hypertonic sodium chloride Errors with discontinued or paused infusions Infection transmission with shared glucometers, fingerstick devices, and insulin pens Adverse glycaemic event errors Every organisation needs a medication safety officer Increasing error reporting- Posted
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- Medication
- Vaccination
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Content Article
This report from the Department of Health and Social Care sets out the Government’s response to the Independent Inquiry into the Issues raised by Paterson. 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 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 the independent sector. Government response – accept in principle. Significant progress has been made on the collection of consultant performance data in the independent sector and the NHS. In 2018, the Acute Data Alignment Programme (ADAPt) was launched to move towards a common set of standards for data collection, performance measure methodologies and reporting systems across the NHS and the independent sector, with potential to be fully implemented by 2022 to 2023. This data will be made available for managers and healthcare professionals across the system to help support learning and identify outliers. Over the next 12 months, we commit to reaching a decision with key stakeholders on what information can be published and whether further government action will be needed to achieve this. Recommendation 2 – We recommend that it should be standard practice that consultants in both the NHS and the independent sector should write to patients, outlining their condition and treatment, in simple language, and copy this letter to the patient’s GP, rather than writing to the GP and sending a copy to the patient. Government response – accept. Recommendation 3 - We recommend that the differences between how the care of patients in the independent sector is organised and the care of patients in the NHS is organised is explained clearly to patients who choose to be treated privately, or whose treatment is provided in the independent sector but funded by the NHS. This should include clarification of how consultants are engaged at the private hospital, including the use of practising privileges and indemnity, and the arrangements for emergency provision and intensive care. Government response – accept. Recommendation 4 – We recommend that there should be a short period introduced into the process of patients giving consent for surgical procedures to allow them time to reflect on their diagnosis and treatment options. We recommend that the General Medical Council monitors this as part of Good medical practice. Government response – accept in principle. Many key organisations, including the General Medical Council (GMC), have taken steps to update their guidance and to confirm that doctors should give patients sufficient time to consider their options before making a decision about their treatment and care. During annual appraisals, doctors must provide supporting information to demonstrate that they are continuing to meet the principles and values set out in ‘Good medical practice’. The Care Quality Commission (CQC) takes all GMC guidance into account during its assessments. Recommendation 5 – We recommend that CQC, as a matter of urgency, should assure itself that all hospital providers are complying effectively with up-to-date national guidance on MDT (multidisciplinary team) meetings, including in breast cancer care, and that patients are not at risk of harm due to non-compliance in this area. Government response – accept. Recommendation 6a - We recommend that information about the means to escalate a complaint to an independent body is communicated more effectively in both the NHS and the independent sector. Government response – accept. Recommendation 6b – We recommend that all private patients should have the right to mandatory independent resolution of their complaint. Government response – accept in principle. CQC will strengthen its guidance to make clearer that it expects to see arrangements in place for patients to access independent resolution of their complaints regarding independent sector providers. We will review uptake across the independent sector in the next year, and if uptake is not widespread, we will explore whether current legislation needs to be amended to ensure that all providers make provision for independent adjudication. Recommendation 7 – We recommend that the University Hospitals Birmingham NHS Foundation Trust board should check that all patients of Paterson have been recalled, and to communicate with any who have not been seen. Government response – accept. Recommendation 8 – We recommend that Spire should check that all patients of Ian Paterson have been recalled, and to communicate with any who have not been seen, and that they should check that they have been given an ongoing treatment plan in the same way that has been provided for patients in the NHS. Government response – accept. Recommendation 9 – We recommend that a national framework or protocol, with guidance, is developed about how recall of patients should be managed and communicated. This framework or protocol should specify that the process is centred around the patient’s needs, provide advice on how recall decisions are made, and advise what resource is required and how this might be provided. This should apply to both the independent sector and the NHS. Government response – accept. Recommendation 10 – We recommend that the government should, as a matter of urgency, reform the current regulation of indemnity products for healthcare professionals in light of the serious shortcomings identified by the inquiry and introduce a nationwide safety net to ensure patients are not disadvantaged. Government response – pending. In 2018, the government launched a consultation on appropriate clinical negligence cover for regulated healthcare professionals. This sought views on whether to change legislation to ensure that all regulated healthcare professionals in the UK not covered by state indemnity hold regulated insurance, rather than discretionary indemnity. The government has now extended this programme to consider the issues raised by the inquiry and is committed to bringing forward proposals for reform in 2022. Recommendation 11 – We recommend that the government should ensure that the current system of regulation and the collaboration of the regulators serves patient safety as the top priority, given the ineffectiveness of the system identified in this inquiry. Government response – accept. Recommendation 12a – We recommend that if, when a hospital investigates a healthcare professional’s behaviour, including the use of an HR process, any perceived risk to patient safety should result in the suspension of that healthcare professional. Government response – do not accept. We agree that exclusions and restriction of practice can be necessary, and in some cases immediate exclusion is an appropriate response while an investigation is ongoing. However, we do not believe it would be fair or proportionate to impose a blanket rule to exclude practitioners in such cases. Such a step may inadvertently cause a chilling effect, dissuading healthcare professionals from raising concerns and negatively impacting patient safety. It is vital that investigations are robust and conducted in a timely manner. Guidance has been put in place to ensure that concerns are taken seriously, appropriate action taken and that robust investigation processes are implemented, and that clarity on when to exclude a healthcare professional is provided. Recommendation 12b – If the healthcare professional also works at another provider, any concerns about them should be communicated to that provider. Government response – accept in principle. The government agrees that, where patient safety is at risk, information should be shared with other providers. However, there must be an element of judgement by providers as they will be taking on responsibility to ensure that this information is appropriate and accurate. Regulators have taken key steps to make it easier for people and organisations to share information regarding patient safety risks. The Medical Profession (Responsible Officers) Regulations 2010 (revised in 2013), which apply to all medical practitioners, have also set out prescribed connections for sharing information regarding performance concerns between health organisations. Recommendation 13 – In the NHS, consultants are employees and the NHS hospital is responsible for their management, and accepts liability when things go wrong. The situation is very different in the independent sector where most consultants are self-employed. Their engagement through practising privileges is an arrangement recognised by CQC. However, this recognition does not appear to have resolved questions of hospitals’ or providers’ legal liability for the actions of consultants. We recommend that the government addresses, as a matter of urgency, this gap in responsibility and liability. Government response – accept in principle. The government is clear that independent sector providers must take responsibility for the quality of care provided in their facilities, regardless of how the consultants are engaged. The Medical Practitioners Assurance Framework (MPAF), published in 2019 by the Independent Healthcare Provider Network (IHPN), was created to improve consistency around effective clinical governance, and to set out provider and medical practitioner responsibilities in the independent sector. CQC will continue to assess the strength of clinical governance in providers as part of its inspection activity, taking account of relevant guidance such as the MPAF. As covered in our response to recommendation 10, we have set out a programme of work that will consider the case for reforms to the provision of indemnity cover. We will use this as our initial approach to dealing with the challenges faced by patients of Ian Paterson in accessing compensation. Recommendation 14 – We recommend that, when things go wrong, boards should apologise at the earliest stage of investigation and not hold back from doing so for fear of the consequences in relation to their liability. Government response – accept. Recommendation 15 – We recommend that, if the government accepts any of the recommendations concerned, it should make arrangements to ensure that these are to be applicable across the whole of the independent sector’s workload (meaning private, insured and NHS-funded) if independent sector providers are to be able to qualify for NHS-contracted work. Government response – do not accept – keep under review. This recommendation, if implemented, would change the way in which independent sector providers qualify for NHS contracts. As demonstrated in our response to the other recommendations, independent sector providers are fully committed to implementing changes alongside NHS providers. They must already meet the same regulatory standards, as required by CQC. We will continue to monitor the independent sector uptake of the other recommendations and we will review our position on this recommendation in 12 months’ time, setting out further steps if necessary. Read full response here Related reading A year on from the Paterson Inquiry: Reflections on the Government’s initial response (Patient Safety Learning, 26 March 2021 Patient Safety Learning’s response to the Paterson Inquiry (11 February 2020)- Posted
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- Surgeon
- Patient harmed
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Content Article
The Regulation and Quality Improvement Authority (RQIA) is the independent body responsible for regulating and inspecting the quality and availability of Health and Social Care services in Northern Ireland. The (RQIA) was commissioned to examine the application and effectiveness of the Procedure for the Reporting and Follow-up of Serious Adverse Incidents in Northern Ireland. The review was conducted by an Expert Review Team established by the RQIA and made five recommendations for implementation. 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 families in the review process. Health and Social Care organisations should be required to evidence they are achieving these critical success factors to the Department of Health. The Department of Health should implement an evidence-based approach for determining which adverse events require a structured, in-depth review. This should clearly outline that the level of SAI review is determined by significance of the incident and the level of potential deficit in care. The Department of Health should ensure the new Regional procedure and its system of implementation is underpinned by ‘just culture’ principles and a clear evidence-based framework that delivers measurable and sustainable improvements. The Department of Health should develop and implement a regional training curriculum and certification process for those participating in and leading SAI reviews.- Posted
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- Patient safety incident
- Investigation
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Content Article
"The inestimable, magnificent, Will Powell speaking on Radio Ombudsman about the long struggle to discover the truth about his son's death and the subsequent failure of accountability mechanisms" - Rob Behrens, Parliamentary and Health Service Ombudsman UK, Vice-President IOI Europe, Visiting Professor UCL. MCFC. 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 whistleblowers in #healthcare. When staff don't/can't speak out, or are ignored and bullied, it falls to patients or relatives to do this, at huge cost. #Robbieslaw Related post: English and Welsh Ombudsman set out the case for '... a proper public inquiry into the tragic death of Robbie Powell'- Posted
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- Medication
- Patient death
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Content Article
This report by the Healthcare Safety Investigation Branch (HSIB) has been published as part of a pilot launched to evaluate HSIB’s ability to carry out effective local investigations at specific hospitals and trusts, while still identifying and sharing relevant national learning. After an evaluation, it will be decided whether this model can be implemented more widely by HSIB. The investigation reviewed the case of a patient who had a stroke and was due to be taken to his local hospital emergency department (ED), but the ED advised paramedics this was not possible as their stroke service was closed. The alternative was to take him to a neighbouring hospital, but they also advised that they could also not take the patient. This was then referred back to the original ED, who restated their position, eventually leading to the neighbouring hospital agreeing to accept the patient. Once the patient arrived he then had to wait 40 minutes in an ambulance as the ED was very busy. 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 hospital (Trust B). Trust B advised that they could not take the patient as he was outside of the window for immediate stroke treatment and should be taken to Trust A. Trust A then reiterated that they could not accept the patient. The paramedic phoned Trust B again and they agreed to accept the patient. Once at Trust B, the patient had to wait 40 minutes in an ambulance as the ED was very busy. It was then confirmed by CT scan that he had suffered an ischaemic stroke (a stroke caused by a blood clot in the brain), and he was taken to the intensive care unit. Findings The investigation found that: There was no cross-trust policy in place that clearly defined which FAST-positive patients (patients who show symptoms outlined by the Face, Arms, Speech, Time acronym) should be taken to Trust B overnight. This resulted in different local interpretation of the overnight stroke arrangement. The different local interpretation resulted in the patient being “double bounced” between the two hospitals. Staff stated that this was “not uncommon” but would likely resolve once a centralised regional stroke treatment unit (a hyper-acute stroke unit) is in place. The electronic search tools accessible to ambulance crews provided inconsistent information about the availability of local stroke services. This was particularly confusing for the paramedics in the safety event, who did not routinely work in the local area. When the patient arrived at the hospital, his care was not handed over within the recommended 15 minutes. Recommendations The report makes the following local safety recommendations: HSIB recommends that Trust A and Trust B update the information provided to the Directory of Service on the availability of stroke services once they have created a harmonised cross-trust stroke policy. HSIB recommends that the Ambulance Trust works with Trust A and Trust B to ensure that their local stroke policies are aligned and direct ambulance crews to the most appropriate service. HSIB recommends that Trust B works collaboratively with Trust A to develop a harmonised, cross-trust stroke policy with a clearly defined joint emergency department overnight stroke protocol for FAST-positive patients.- Posted
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- Stroke
- Emergency medicine
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Content Article
In this blog, Lotty Tizzard, Patient Safety Learning’s Content and Engagement Manager, looks at the difficulties people experience in disposing of needles and injection devices safely at home. Variation in services across the UK can lead individuals to dispose of sharps incorrectly, posing a risk to refuse workers and the wider public. 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 working group on standardising injection technique in diabetes care to reduce the risk of needlestick injuries, which will include research to better understand the incidence and causes. But a related area that has received little attention is the disposal of sharps at home, where a healthcare worker is not involved. There are many people who self-administer injectable medication and need to dispose of sharps at home, either on a long- or short-term basis. People with diabetes make up a large proportion of this group, but there are many others, including those self-administering warfarin, biologic drugs for autoimmune conditions, IVF and cancer treatments. And although “all HCPs, downstream workers and members of the public are at risk of sharps/needlestick injury,”[4] regulatory guidance outside of healthcare settings is minimal. It makes sense that “safe disposal requires that… safe sharps disposal systems and processes be present and known to all persons at risk for sharps contact.”[5] But anecdotal evidence and lack of national policy on the issue suggest that this is not always the case for people in the UK who inject at home. Although legislation requiring the safe disposal of sharps in healthcare and occupational settings was passed in 2013,[6] it does not cover sharps waste generated by individuals at home. Indeed, there is lack of clarity about who is responsible for making sure these sharps are disposed of safely. The NHS website states that, “If you have a medical condition… and use needles at home, your local council may be responsible for collecting your full sharps bin.” This statement demonstrates this lack of clarity for people who self-inject—that the local council ‘may’ help doesn’t speak of a clear, accessible safety process. Improper sharps disposal is a global public health risk This is a problem, because when needles and other sharps are not disposed of safely, they pose a considerable health risk to refuse workers, other household members and the general public. The TREND Diabetes ‘Correct Injection Technique in Diabetes Care Best Practice Guideline’, widely used by healthcare workers in the UK, states that “sharp medical devices present a potential risk for both injury and transmission of disease [such as] hepatitis and HIV.”[4] Sharps injuries can also have a significant psychological impact on individuals who experience them. A 2021 study into unsafe sharps disposal around the world found that “a substantial number of patients with diabetes mellitus improperly discard their sharps” and described the situation as an “emerging global crisis and significant public health risk”.[7] There have been a number of other studies in the last five years into the situation with household disposal in multiple countries around the world including the US,[8] Ghana,[9][10] India [11] and Sri Lanka,[12] but no study of this kind has been conducted in the UK in the last decade. The most recent study that examined the UK situation was a global survey of people with type 1 diabetes carried out in 2009, which found that 21% of people with diabetes in the UK and Ireland were disposing of sharps directly into their household rubbish,[13] but we do not have a clear picture of the current extent of this problem. The impact of improper sharps disposal is also difficult to assess. Like in the healthcare sector, there are very specific criteria for reporting needlestick injuries (NSIs) within waste disposal services. This means that the true number of sharps injuries as a result of improperly discarded domestic sharps in the UK is nearly impossible to quantify. However, we can look at the picture in the US, where recent research by The Environmental Research & Education Foundation into NSIs at municipal recycling facilities estimated that between 781 and 1,484 NSIs occur each year at recycling facilities.[14] Home sharps disposal - the UK picture Services and advice about safe sharps disposal vary geographically, and uncertainty about the process contributes to some people throwing their medical sharps in the general household waste, sometimes with no protective container at all. To get an idea of experiences in different areas, I asked social media contacts with type 1 diabetes in the UK about how they dispose of their sharps and the response was, as expected, mixed.[15] The NHS website points to local councils as having responsibility, but a quick look at the provision offered by different local authorities in London demonstrates a varied picture. Some councils provide free pick up services, while Hackney council charges residents for the service. Some councils require a referral from a healthcare professional and some require individuals to drop sharps off at a designated location themselves. Looking across the UK, evidence from patients suggests even wider variations in provision. Some areas of Scotland have no provision for sharps disposal at all, and one Twitter user in Scotland reported being asked by their diabetes specialist nurse to put their sharps in an empty detergent bottle before putting them in the normal household waste.[15] In the absence of a local clinical waste disposal service, this approach does offer some protection from injury, but it is clearly far from ideal. The TREND Guideline advises that, “Under no circumstance should sharps material be disposed of into the public refuse or rubbish system,”[4] indicating a mismatch between best practice recommendations and local policy. There are also stark differences in how local councils present information. Some provide clear and thorough guidance on the process and how to access the service. For example, the Enfield Council website includes details of areas served and waste items covered, and an online form. But this is not the same everywhere, and one Twitter user described the information on their council website as “a horror show.” Healthcare workers can also be unclear about home sharps disposal, particularly when someone is using them for short-term treatments. One patient told me, “I used needles at home for a short time whilst having my treatment and was given a bin to dispose of them in, but the nurses seemed unclear what I should do with it when full. They didn't give me any information on what to do with it, where to take it, or the dangers of just chucking it away.” This lack of knowledge demonstrates a process and knowledge gap that runs right the way through the healthcare system. Tackling the problem of improper sharps disposal So what needs to be done to improve the situation and reduce the safety risks associated with home use of needles and other sharps? Building an evidence base We need up-to-date research about the scale of improper home sharps disposal in the UK, and the prevalence and impact of injuries that occur as a result. National policy In response to this evidence, access to sharps disposal needs to be made consistent across the country, and national policy is needed to clarify the responsibility of local councils and NHS services. This would lead to greater clarity and easier access. Clear information on disposal processes If they are to fulfil their role in ensuring safe disposal, people who use sharps at home need clear, easy-to understand information. A national policy needs to be accompanied by clear information on who is providing the clinical waste services and where. Ongoing education on sharps disposal The TREND Guideline states that “safe disposal of sharps should be taught to people with diabetes who inject… from the beginning of the injection therapy initiation and reinforced thereafter.”[4] However, a 2018 US study found that people who had diabetes for more than 30 years had the lowest rate of correct sharps disposal,[16] suggesting that continued education is important. Related reading Injection technique and dual safety in diabetes care - a new SHBN working group to tackle safety risks Needlestick injuries – making the point for safety Sharps injuries and Covid (research by Ipsos MORI on behalf of European Biosafety Network) References 1 Safer sharps. NHS Supply Chain. Accessed 5 January 2022 2 Pressures of pandemic and lack of training see 50% rise in sharps injuries. Royal College of Nursing, 21 May 2021 3 Sharps injuries and Covid. European Biosafety Network and Ipsos Mori, 24 July 2021 4 Hicks D, James J, Smith M. Correct injection technique in diabetes care: Best practice guideline, 2nd edition. Trend Diabetes. March 2021 5 Frid A, Kreugel G, Grassi G et al. New Insulin Delivery Recommendations. Mayo Clinic Proceedings. 1 September 2016 6 Health and Safety (Sharp Instruments in Healthcare) Regulations 2013: Guidance for employers and employees. Health and Safety Executive. March 2013 7 Thompson B, Cook C. Unsafe Sharps Disposal Among Insulin-Using Patients With Diabetes Mellitus: An Emerging Global Crisis. Journal of Diabetes Science and Technology. 1 December 2021 8 Montoya J, Thompson B, Boyle M et al. Patterns of Sharps Handling and Disposal Among Insulin-Using Patients With Diabetes Mellitus. Journal of Diabetes Science and Technology. 22 October 2019 9 Udofia E, Gulis G, Fobil J. Solid medical waste: a cross sectional study of household disposal practices and reported harm in Southern Ghana. BMC Public Health. 18 May 2017 10 Egbenyah F, Udofia E, Ayivor J et al. Disposal habits and microbial load of solid medical waste in sub-district healthcare facilities and households in Yilo-Krobo municipality, Ghana. Plos One. 10 December 2021. 11 Moray K, Manjunath K, Shalini A et al. The insulin sharps disposal study: Evaluation of a structured patient education initiative in an urban community health centre in India. Journal of Family Medicine and Primary Care. 31 December 2020 12 Atukorala K, Wickramasinghe S, Sumanasekera R et al. Practices related to sharps disposal among diabetic patients in Sri Lanka. Asia Pacific Family Medicine. 7 December 2018 13 De Coninck C, Frid A, Gaspar R et al. Results and analysis of the 2008–2009 Insulin Injection Technique Questionnaire survey. Journal of Diabetes. 16 August 2010 14 Kantner D. Study Quantifies Needlestick Injury Rates for Materials Recovery Facility Workers. Waste 360. 10 September 2018 15 Twitter thread @LottyTizzard, 13 December 2021 16 Huang L, Katsnelson S, Yand J et al. Factors Contributing to Appropriate Sharps Disposal in the Community Among Patients With Diabetes. Diabetes Spectr. 2018:31:155-158- Posted
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- Patient engagement
- Diabetes
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Content Article
In this opinion piece, Kath Sansom, founder of the Sling the Mesh campaign, highlights the many issues that women face when trying to get pelvic mesh slings surgically removed. She calls for the NHS to give patients a voice and to develop a robust and consistent plan to tackle the issues faced by patients harmed by surgical mesh. 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 harm - of mesh removal surgery being hard to access and inconsistent, and of hopelessly long waiting lists. Mesh specialist centres - inconsistent and inaccessible There are seven mesh complication centres in the UK[1] - six in England, one in Scotland and none in Wales or Northern Ireland - but assessment and surgical procedures vary hugely between these centres: There is no consistent training for surgeons undertaking mesh removal, with each centre taking its own approach. This needs to be addressed urgently with centralised training and standards to ensure that the most effective, evidence-based approach is taken for each and every woman. Some surgeons seem reluctant to undertake mesh removal and many women are sent away with no treatment other than to ‘keep taking painkillers’. It shouldn’t be that the care a patient is offered depends on a surgeon’s preference. There are only seven mesh specialist centres, meaning some women have to travel hundreds of miles for every appointment. Many have to undergo surgery without a family member or friend with them because of travel costs. In addition, there is only one centre in the country, in London, that will consider removing rectopexy mesh. This mesh may have been implanted in a smaller number of patients, but the incidence and severity of harm seems to be even greater than for women with transvaginal mesh. When patients are offered mesh removal surgery, waiting times are often in excess of two years. As with many other areas of the healthcare system, the problem has been worsened by the Covid-19 pandemic. Emerging victims of the surgical mesh scandal The Cumberlege Review began to shed some light on the harm caused to women who had pelvic mesh implanted. But the story is so much bigger than pelvic mesh - new patients who have had mesh implanted in other areas of the body are increasingly approaching Sling the Mesh, reporting pain and other side effects. There has been no review in England into the use of mesh to treat hernias[2], and we are seeing an increasing number of women reporting complications after mesh has been inserted into the abdomen following TRAM flap surgery[3], a procedure where abdominal tissue is used in breast reconstruction. Many of these people report being told by their surgeons that their pain is caused by ‘anxiety’; much the same story women with transvaginal mesh complications were given six years ago before the media started covering this issue extensively. This amounts to medical gaslighting and adds to the harm caused by the initial insertion of mesh devices. The NHS needs to learn from the hard lessons of the pelvic mesh scandal and take a joined-up and patient-centred approach to dealing with these emerging issues. The NHS needs to listen and take action Baroness Cumberlege’s review should have marked a sea change in the treatment of women who have suffered harm as a result of transvaginal mesh. But the NHS response has lacked will and focus, leaving thousands of patients still living with pain and distress as a result of surgical harm. Those individuals and agencies with the power to bring consistency and compassion to mesh removal surgery need to listen to the patients who have suffered life-changing injury. And taking the time to meet with us would be a good first step. Suggested reading Regulatory flaws: Women were catastrophically failed in the mesh, Primodos and Sodium Valproate tragedies - a blog by Kath Sansom Ineffective medical device recalls are a patient safety scandal - a blog by Kath Sansom A year on from the Cumberlege Review: Initial reflections on the Government’s response (Patient Safety Learning, 23 July 2021) Transvaginal Mesh Timeline (7 December 2017) References 1. 'England Mesh Complication Centres Announced'. British Society of Urogynaecology website, 5 February 2021 2. 'Hernia mesh complications "affect more than 100,000"'. BBC website, accessed 22 November 2021 3. 'Breast reconstruction using tissue from your tummy'. Macmillan Cancer Support website, accessed 22 November 2021- Posted
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- Surgeon
- Womens health
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Content Article
Christopher Collinson was admitted to the Medical Assessment Unit at Birmingham Heartlands Hospital with suspected deep vein thrombosis and pulmonary embolism. He was admitted at 1.28pm on 14 June 2021, but was not seen by a Doctor until 9.33pm. He was later prescribed a prophylactic dose of Enoxaparin, rather than the therapeutic dose which the doctor had intended to prescribe. He collapsed at 11.00pm suffering a cardiac arrest and could not be revived. He died at 2.14am on 15 June 2021. 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 that the current system for allocating patients requires a manual check to see whether a patient has actually been seen once they have been allocated. She noted that if they are not seen, there is currently no way of other clinicians being aware of that, and therefore patients could be left for long periods of time without being assessed. Flaws in the electronic prescribing system process The doctor who saw Mr Collinson prescribed a prophylactic dose of Enoxaparin rather than the therapeutic dose which she had intended to prescribe. The reason for this was that the electronic prescribing system involves a drop-down box with confusing tables to select the medication. The doctor was under pressure due to the busy department and accepted that this was human error, having accidently selected the wrong medication. The coroner stated that the current electronic prescribing system does not require a doctor to perform a secondary check to ensure that they have selected the correct medication. She expressed concerns that it is easy to select the wrong medication, particularly when the department is busy and doctors are under pressure. She suggests that this could lead to further fatal outcomes for patients if they are given incorrect medication. This report was sent to University Hospitals Birmingham NHS Foundation Trust.- Posted
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- Deep vein thrombosis
- Medication
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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) system had emerged "frequently" in reports on avoidable deaths. The system sees each patient given an overall score based on a number of vital signs such as heart rate, oxygen levels, blood pressure and level of consciousness. Doctors and nurses can then prioritise patients with the most urgent NEWS scores. But some professionals have argued that the system has reduced nursing duties to a checklist of tasks rather than a process of providing overall clinical assessment. Professor Alison Leary, a fellow of the Royal College of Nursing and chair of healthcare and workforce modelling at London South Bank University, told The Independent: “In our analysis of prevention of future death reports from coroners, early warning scores and misunderstanding around their use feature frequently". “It's clear that some organisations use scoring systems and a more tick box approach to care as they lack the right amount of appropriately skilled staff, mostly registered nurses.” “Early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care,” the authors of the research conclude. “Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice.” Read full story Source: The Independent, 21 May 2020- Posted
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News Article
NHS is ‘losing its memory’ warns new report on patient safety alerts
Patient Safety Learning posted a news article in News
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 abolished National Patient Safety Agency and NHS England are no longer monitored – even though patient safety incidents continue to be reported to the NHS National Reporting and Learning System. David said: “The NHS is losing it memory concerning preventable harms to patients. Important known risks to patient safety are being ignored by the NHS. The National Reporting and Learning System, the NHS Strategy and new format patient safety alerts, all managed by NHS Improvement, now ignore the majority of ‘known/wicked harms’ which have been the subject of patient safety alerts in the past and have now been archived." “Implementation of guidance in new Patient Safety Alerts can be delayed, for years in some cases. The Care Quality Commission that inspects NHS provider organisations also no longer appear to check that safeguards to major risks, recommended in patient safety alerts, have been implemented, or continue to be implemented, as part of their NHS inspections. Read full story Source: AvMA, 28 January 2020- Posted
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Revealed: Dozens of hospitals ignoring NHS safety warnings
Patient Safety Learning posted a news article in News
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 hospitals ignoring the deadlines. National bodies issue safety alerts to hospitals after patient deaths and serious incidents where a solution has been identified and action needs to be taken. Despite the system operating for almost 20 years, the NHS continues to see patient deaths and injuries from known and avoidable mistakes. NHS national director for safety Aidan Fowler has reorganised the system to send out fewer and simpler alerts with clear actions hospitals need to take, overseen by a new national committee. Last year the CQC made a recommendation to streamline and standardise safety alerts after it investigated why lessons were not being learnt. Professor Ted Baker, Chief Inspector of hospitals, said: “CQC fully supports the recent introduction of the new national patient safety alerts and we have committed to looking closely at how NHS trusts are implementing these safety alerts as part of our monitoring and inspection activity.” He stressed: “Failure to take the actions required under these alerts could lead to CQC taking regulatory action.” Read full story Source: The Independent, 30 December 2019- Posted
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Content Article
For some time now I've been looking to find out more about mental health services in Trieste, Italy. Then I met Vincenzo Passante Spaccapietra, co-host of the Place of Safety? podcast series. This has enabled me to learn more about the closure of the mental institutions in Trieste, Italy, and the work of Franco Basaglia. I was keen to find out what really took place, what this really means in practice and how we can adopt this model in the UK. We were delighted to have become involved and to have recorded a couple of podcasts. I recommend this resource to everyone interested in safe, compassionate, patient led mental health care. "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 unpack the main objections Episode 27 - Substance dependency, colonialism and sexism with Dr Sonia Soans (@PSYfem) Episode 26 - From the horse's mouth...patient & nurse teaching together as equals Listen to all the podcasts from link below.- Posted
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Rob Hackett, Patient Safe Network, in the video below discusses the danger of Indistinct chlorhexidine which can easily be mistaken for other colourless solutions. He highlights the story of Grace Wang, who in 2010 had antiseptic solution injected into her epidural. She nearly died and was left paralysed. Indistinct chlorhexidine was mistaken for saline. The investigation recommended all skin antiseptic solutions to be coloured in a way that distinguished them. Sadly this recommendation isn't followed. Accidental chlorhexidine injections continue to occur and there are many more examples. This same error continues to play out again and again throughout the world. There’s no need for these indistinct solutions and safer distinct versions and those enclosed in swab sticks are already in use in many hospitals without problem and at no extra cost.- Posted
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The cost of uncoordinated responses to COVID-19
lzipperer posted an article in Data, research and statistics
This blog post from Aral and Eckles highlights a study done at the Social Analytics Lab at the Massachusetts Institute of Technology (MIT) examining the impact of the uncoordinated responses to COVID-19 across the United States. The blog links to the original study and other related materials.- Posted
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In April 2017, Ian Paterson, a surgeon in the West Midlands, was convicted of wounding with intent, and imprisoned. He had harmed patients in his care. The scale of his malpractice shocked the country. There was outrage too that the healthcare system had not prevented this and kept patients safe. At the time of his trial, Paterson was described as having breached his patients’ trust and abused his power. In December 2017, the Government commissioned this independent Inquiry to investigate Paterson’s malpractice and to make recommendations to improve patient safety. This report presents the Inquiry’s methodology, findings and recommendations. More importantly, it tells the story of the human cost of Paterson’s malpractice and the healthcare system’s failure to stop him, and something of the enduring impact this has had on the lives of so many people. This report is not simply a story about a rogue surgeon. It would be tragic enough if that was the case, given the thousands of people whom Ian Paterson treated. But it is far worse. It is the story of a healthcare system which proved itself dysfunctional at almost every level when it came to keeping patients safe, and where those who were the victims of Paterson’s malpractice were let down time and time again. This video report was streamed live on ITV News on 4th February 2020.- Posted
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Technology is often viewed as either positive or negative. On one hand weight loss apps are usually seen as a positive influence on users. From the sociocultural perspective, on the other hand, media and technology can negatively impact body satisfaction and contribute to eating disorders; however, these studies fail to include weight loss apps. While these apps can be beneficial to users, they can also have negative effects on users with eating disorder behaviours. Yet few research studies have looked at weight loss apps in relation to eating disorders. In order to fill this gap,these researchers conducted interviews with 16 women with a history of eating disorders who use(d) weight loss apps. While findings suggest these apps can contribute to and exacerbate eating disorder behaviours, they also reveal a more complex picture of app usage. Women’s use and perceptions of weight loss apps shift as they experience life and move to and from stages of change. This research troubles the binary view of technology and emphasises the importance of looking at technology use as a dynamic process. This study contributes to the understanding of weight loss app design.- Posted
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In April 2017, Ian Paterson, a surgeon in the West Midlands, was convicted of wounding with intent, and imprisoned. He had harmed patients in his care. The scale of his malpractice shocked the country. There was outrage too that the healthcare system had not prevented this and kept patients safe. At the time of his trial, Paterson was described as having breached his patients’ trust and abused his power. In December 2017, the Government commissioned this independent Inquiry to investigate Paterson’s malpractice and to make recommendations to improve patient safety. This report presents the Inquiry’s methodology, findings and recommendations. More importantly, it tells the story of the human cost of Paterson’s malpractice and the healthcare system’s failure to stop him, and something of the enduring impact this has had on the lives of so many people. 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 patients, outlining their condition and treatment, in simple language, and copy this letter to the patient’s GP, rather than writing to the GP and sending a copy to the patient. Differences between how the care of patients in the independent sector is organised and the care of patients in the NHS is organised, should be explained clearly to patients who choose to be treated privately, or whose treatment is provided in the independent sector but funded by the NHS. This should include 219 Recommendations clarification of how consultants are engaged at the private hospital, including the use of practising privileges and indemnity, and the arrangements for emergency provision and intensive care. There should be a short period introduced into the process of patients giving consent for surgical procedures, to allow them time to reflect on their diagnosis and treatment options. We recommend that the GMC monitors this as part of ‘Good Medical Practice’ The CQC, as a matter of urgency, should assure itself that all hospital providers are complying effectively with up-to-date national guidance on MDT meetings, including in breast cancer care, and that patients are not at risk of harm due to non-compliance in this area. Information about the means to escalate a complaint to an independent body is communicated more effectively in both the NHS and independent sector. All private patients should have the right to mandatory independent resolution of their complaint. The University Hospitals Birmingham NHS Foundation Trust board should check that all patients of Paterson have been recalled, and to communicate with any who have not been seen. We recommend that Spire should check that all patients of Paterson have been recalled, and to communicate with any who have not been seen, and that they should check that they have been given an ongoing treatment plan in the same way that has been provided for patients in the NHS. A national framework or protocol, with guidance, is developed about how recall of patients should be managed and communicated. This framework or protocol should specify that the process is centred around the patient’s needs, provide advice on how recall decisions are made, and advise what resource is required and how this might be provided. This should apply to both the independent sector and the NHS. The Government should, as a matter of urgency, reform the current regulation of indemnity products for healthcare professionals, in light of the serious shortcomings identified by the Inquiry, and introduce a nationwide safety net to ensure patients are not disadvantaged. The Government should ensure that the current system of regulation and the collaboration of the regulators serves patient safety as the top priority, given the ineffectiveness of the system identified in this Inquiry. If, when a hospital investigates a healthcare professional’s behaviour, including the use of an HR process, any perceived risk to patient safety should result in the suspension of that healthcare professional. If the healthcare professional also works at another provider, any concerns about them should be communicated to that provider. The Government addresses, as a matter of urgency, this gap in responsibility and liability.- Posted
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