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Found 117 results
  1. News Article
    Hospital bosses have been accused of launching a witch hunt to find a whistleblower who told a widower about blunders in the treatment his wife received. The row emerged as an inquest began into the death of Susan Warby who died five weeks after bowel surgery. The 57-year-old died at West Suffolk Hospital in Bury St Edmunds after a series of complications in her treatment. Her family received an anonymous letter after her death highlighting errors in her surgery, the inquest in Ipswich heard, and both Suffolk Police and the hospital launched investigations. These investigations confirmed that there had been issues around an arterial line fitted to Ms Warby during surgery, Suffolk’s senior coroner Nigel Parsley said. Doctors were reportedly asked for fingerprints as part of the hospital’s investigation, with an official from trade union Unison describing the investigation as a “witch hunt” designed to identify the whistleblower who revealed the blunders. Read full story Source: The Independent, 17 January 2020
  2. News Article
    The inquiry into Britain's worst maternity scandal is now reviewing 900 cases, a health minister has confirmed. The Ockenden Review, which was set up to examine baby deaths in the Shrewsbury and Telford Hospital Trust, was initially charged with examining 23 cases, but Nadine Dorries, a health minister, confirmed to the Commons that an additional 877 cases are being reviewed. A leaked report in November said a "toxic culture" stretching back 40 years reigned at the hospital trust as babies and mothers suffered avoidable deaths. The review will conclude at the end of the year. Jeremy Hunt, the former health secretary, said it was "deeply shocking" to hear of the new details and asked that the inquiry is "resolved as quickly as possible". Read full story Source: The Telegraph, 16 January 2020
  3. News Article
    Ten years on from the Mid Staffordshire NHS trust scandal, the man who led the inquiry into one of the worst care disasters in the service’s history has said he remains worried about the safety of patients and a culture that leaves staff too frightened to speak up. Sir Robert Francis QC said some safety risks highlighted a decade ago remain unresolved and he threw his weight behind calls for senior managers in the NHS to be regulated. The barrister said he believed the NHS was safer now than a decade ago but added he worried whether actions taken since the disaster had made a real difference. “What keeps me awake at night is not so much has anyone implemented recommendation 189 or not, but more whether the collectivity of what has happened since has actually resulted in things being better for patients and staff,” he told The Independent. Read full story Source: The Independent, 15 January 202
  4. News Article
    Public confidence in the health service is being undermined by a lack of transparency from hospitals about patient complaints, the man who led the investigation into one of the NHS’s worst care disasters has warned. Sir Robert Francis QC, who chaired the public inquiry into the Mid Staffordshire hospital scandal, has called for a new national organisation with powers to set standards on the handling of patient complaints after research found seven in eight hospital trusts do not follow existing rules. The prominent barrister is now chair of Healthwatch England, a statutory body, which analysed 149 hospitals’ handling of complaints. Under current legislation every hospital is required to collect and report on the number of complaints they receive, what they were about and what action has been taken. Healthwatch England found just 12% of NHS trusts were compliant with all the rules. Only 16% published the required complaints reports while just 38% reported any details about learning or actions taken after a grievance. Speaking to The Independent, Sir Roberts said better reporting, including the outcome and changes made after a complaint, would create a “collaborative” environment to improving the system with patients and staff alike seeing complaints as a valuable resource. One persistent problem remained the gap, he said, between hospitals and the national Parliamentary and Health Service Ombudsman. Sir Robert argued commissioners of NHS services should be more involved. Read full story Source: The Independent, 15 January 2020
  5. News Article
    The NHS 111 helpline for urgent medical care is facing calls for an investigation after poor decision-making was linked to more than 20 deaths. Experts say that inexperienced call handlers and the software used to highlight life-threatening emergencies may not always be safe for young children. At least five have died in potentially avoidable incidents. Professor Carrie MacEwen, Chairwoman of the Academy of Medical Royal Colleges, said: “These distressing reports suggest that existing processes did not safeguard the needs of the children in these instances.” Since 2014 coroners have written 15 reports involving NHS 111 to try to prevent further deaths. There have been five other cases where inquests heard of missed chances to save lives by NHS 111 staff; two other cases are continuing and one was subject to an NHS England investigation. Read full story (paywalled) Source: The Times, 5 January 2020
  6. News Article
    The Care Quality Commission (CQC) has raised concerns about the treatment of patients at mental health units run by Cygnet. It follows inspections in the wake of a BBC Panorama investigation about alleged abuse at Wharlton Hall in County Durham. The CQC found that patients under the firm's care were more likely to be restrained. Higher rates of self-harm were also noted by inspectors who quizzed managers and analysed records at the company's headquarters. The regulator also found a lack of clear lines of accountability between the executive team and its services. It said directors' identity and disclosure and barring service checks had been carried out, butd that required checks had not been made to ensure that directors and board members met the "fit and proper" person test for their roles. Systems used to manage risk were also criticised, while training for intermediate life support was not provided to all relevant staff across services where physical intervention or rapid tranquilisation was used. Cygnet runs more than 100 services for vulnerable adults and children, caring for people with mental health problems, learning disabilities and eating disorders. The CQC says Cygnet must now take immediate action to address the concerns raised. Cygnet said a number of the services highlighted have since been improved, but "we are not complacent and take on board recommendations where we must improve". Read full story Source: BBC News, 14 January 2020
  7. News Article
    Multiple failings have been found in the Parliamentary Health Service Ombudsman's (PHSO) investigation into the death of a young woman with anorexia. PHSO has admitted to multiple failings in how it handled a three-and-a-half year investigation into the systemic failings by NHS providers in Cambridgeshire and Norfolk which led to the death of Averil Hart in 2012. The findings come as a senior coroner in Cambridgeshire investigates whether there are links between the failures in Averil’s care and that of four other women with an eating disorder who were under the care of the same services. The PHSO’s failings have been revealed in an internal review, published today, which ruled the regulator’s investigation took too long and should’ve been completed in half the time. It also found “insufficient” resource was allocated to the Averil’s investigation, despite staff requesting it, which led to significant delays. Read full story Source: HSJ, 10 January 2020
  8. Content Article
    Key recommendations It is recommended that the Royal College of Ophthalmologists, working with relevant stakeholders, develop models and review workforce required for the optimal delivery of glaucoma care. The models should be tested and evaluated. It is recommended that NHS England/Improvement require commissioners to agree, under their service contracts, the action that providers will take to ensure compliance with the Portfolio of Indicators for Eye Health and Care follow-up performance standard. Where the standard has not been met, there should be a requirement for providers to demonstrate that they have reviewed individual pathways and taken action to mitigate risk, as well as to understand the causes of any unnecessary delays to inform improvement. It is recommended that NHS England/Improvement commission NHS Digital to publish reports of hospital eye services’ compliance with the follow-up appointments performance standard included in the Portfolio of Indicators for Eye Health and Care. It is recommended that NHS England/Improvement review the payment for the ongoing management of patients with glaucoma, regardless of setting. Pricing should reflect the complexity and costs of follow-up appointments and encourage new ways of working. It is recommended that NHS Digital include provision for identifying, prioritising and monitoring patients at risk of developing sight loss within the next version of the national Commissioning Data Set. Provision should include the ability to record a risk rating and the recommended follow-up date for each patient, meaning these are mandated data items for collection by hospital eye services. It is recommended that the Royal College of Ophthalmologists agree criteria for the risk stratification of patients with glaucoma so that practice can be standardised across NHS hospital eye services. It is recommended that the International Glaucoma Association facilitate the funding of research into the development and evaluation of an automated, predictive risk stratification tool. Further reading Surveillance of sight loss due to delay in ophthalmic treatment or review: frequency, cause and outcome (Jan 2017) National Patient Safety Agency: Preventing delay to follow up for patients with glaucoma (11 June 2009)
  9. News Article
    Delays to follow-up appointments for glaucoma patients leaves them at risk of sight loss, the Healthcare Investigation Safety Branch (HSIB) warns in their new report. The report highlights the case of a 34-year old woman who lost her sight as a result of 13 months of delays to follow-up appointments. Lack of timely follow-up for glaucoma patients is a recognised national issue across the NHS. Research suggests that around 22 patients a month will suffer severe or permanent sight loss as a result of the delays. In HSIB’s reference case, the patient saw seven different ophthalmologists and the time between her initial referral to hospital eye services (HES) and laser eye surgery was 11 months. By this time her sight had deteriorated so badly, she was registered as severely sight impaired. The investigation identified that there is inadequate HES capacity to meet demand for glaucoma services, and that better, smarter ways of working should be implemented to maximise the current capacity. The report makes several safety recommendations focused on the management and prioritisation of appointments. Helen Lee, RNIB Policy and Campaigns Manager, said: “This report has brought vital attention to a serious and dangerous lack of specialist staff and space in NHS ophthalmology services across the country. We know that thousands of patients in England are experiencing delays in time-critical eye care appointments, which is leading to irreversible sight loss for some." “Without immediate action, the situation will only continue to deteriorate as the demand for appointments increases. RNIB urges full and immediate implementation of the recommendations set out in this report to improve the capacity, efficiency and effectiveness of ophthalmology services.” Read full story Source: HSIB, 9 January 2020
  10. News Article
    The Healthcare Safety Investigation Branch (HSIB) has launched an investigation looking at nasogastric tubes and how previously identified safety improvements for the placement of these tubes are put into practice. Nasogastric (NG) tubes are used to deliver fluid, food and medication to patients via a tube that passes through the nose and down into the stomach. There is a risk of serious harm and risk to life if NG tubes are incorrectly placed into the lungs, rather than the stomach, and feed is passed through them. HSIB has started this investigation after they were notified of a patient who inadvertently had a nasogastric tube inserted into his lung. Further information Source: HSIB, 7 January 2020
  11. Content Article
  12. Content Article
    Overview in numbers (2018/19) 12 national investigations launched. 440 maternity referrals received. 100 safety awareness notifications submitted for national investigations. 127 investigators trained. 174 members of staff recruited.
  13. News Article
    A Dublin mental health centre has failed to comply with the code of practice on physical restraint for four consecutive years, an inspection report has found. The 39-bed Elm Mount Unit at St Vincent’s University Hospital said the issue was now high risk. Two episodes were recorded by the Mental Health Commission (MHC) where the staff member responsible for leading the physical restraint did not monitor the person’s head or airway, and that this went undocumented. In another case, inspectors noted, the physical restraint was not reviewed by members of the multidisciplinary team and recorded correctly. There was also concern regarding the administration of medicine, specifically deficits in the prescription and administration record “which could potentially lead to medication errors”. Read full story Source: The Irish Times, 17 December 2019
  14. News Article
    Safety inspections have been carried out at 20 health and care providers, in response to a high level of assaults, including three staff killed by patients in the last five years. Read full story (paywalled) Source: HSJ, 18 December 2019
  15. Content Article
    The PSHO found that the Trust failed to: act on the results of the ECG and chest X-ray consider Baby K’s history and symptoms ask for input from specialist staff escalate his care when his condition was getting worse. If these failings had not occurred, it is likely that the Trust would have recognised that Baby K had a problem with his heart. In these circumstances he would have received the correct treatment instead of being treated for suspected pneumonia. The PSHO found that on the balance of probabilities, his cardiac arrest would not have occurred and it is more likely than not that his death would have been avoided. The PHSO also found that the Trust was not open and accountable in its handling of Miss K’s complaint, as it failed to acknowledge and apologise for its mistakes in a timely manner. It also failed to signpost Miss K to the PSHO at the right time and in the right way.
  16. Content Article
  17. Content Article
    Building on its successful predecessors, the third edition of The Field Guide to Understanding ‘Human Error’ will help you understand a new way of dealing with a perceived 'human error' problem in your organisation. It will help you trace how your organisation juggles inherent trade-offs between safety and other pressures and expectations, suggesting that you are not the custodian of an already safe system. It will encourage you to start looking more closely at the performance that others may still call 'human error', allowing you to discover how your people create safety through practice, at all levels of your organisation, mostly successfully, under the pressure of resource constraints and multiple conflicting goals. The Field Guide to Understanding 'Human Error' will help you understand: how to move beyond 'human error' how to understand accidents how to do better investigations how to understand and improve your safety work. You will be invited to think creatively and differently about the safety issues you and your organisation face. In each, you will find possibilities for a new language, for different concepts, and for new leverage points to influence your own thinking and practice, as well as that of your colleagues and organisation.
  18. Content Article
  19. Community Post
    Dear hub members We've a request to help from New South Wales. They and their RLDatix colleagues request: The public healthcare system in New South Wales (NSW), Australia is changing how we investigate health care incidents. We are aiming to add to our armoury of investigation methods for serious clinical incidents and would love to hear your suggestions. Like many health care settings worldwide, in NSW we have solely used Root Cause Analysis (RCA) for over 15 years. We are looking for alternate investigation methods to complement RCA. So we are putting the call out … Are there other serious incident investigation methods (other than RCAs) you would recommend? What’s been your experience with introducing and/or using these methods? Do you have learnings, data or resources that you could share? Do you have policy or procedure documents about specific methods? Any journal articles – health care or otherwise – that are must-reads? We've many resources on investigations on the hub and recent thinking in the UK and internationally that might be of value including: UK Parliamentary report - Investigating clinical incidents in the NHS and from that the creation of A Healthcare Safety Investigation Branch applying a wide range of methodologies in national learning investigations informed by ergonomics and human factors UK's NHS Improvement recent engagement on a new Serious Incident Framework (due to piloted in early 2020) Dr Helen Higham work with the AHSN team in Oxford to improve the quality of incident investigations Patient engagement in investigations Lessons to be learned from Inquiries into unsafe care and reflections on the quality of investigations Insights by leading investigators and resources written specifically for us by inclusion our Expert Topic Lead @MartinL Do check these out in this section of the hub https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/ Please add to this knowledge and give us your reflections. We'd be happy to start up specific discussions on topics of interest. Thank you all, Helen
  20. Content Article
  21. News Article
    A hospital A&E department has been rated "inadequate" after warnings over urgent and emergency care. The Care Quality Commission (CQC) reported a lack of support for staff and safety concerns in Weston General hospital's A&E department. Dr Nigel Acheson, deputy chief inspector of hospitals for the South NHS , said it was "disappointing". Weston Area Health NHS Trust "fully recognises that while improvements have been made... further work is required." Read full story Source: BBC News, 17 December 2019
  22. Content Article
  23. Content Article
    Emotional and other long-term impacts of harmful events can have profound consequences for patients and families. Stakeholders designed a path forward to inform approaches that better support harmed patients and families, with both immediately actionable and longer-term research strategies. '[There's the] long-term responsibility of the institution, that we don't talk about....If we [had] some sort of [understanding of the] trajectory of the harm, [we could ask] What roles do institutions play at different parts? [What roles] should they play?'
  24. News Article
    Doctors at a hospital accused of bullying its staff have told the NHS care regulator that they are too scared to report lapses in patient safety in case they end up facing disciplinary action. The Guardian revealed earlier this week that West Suffolk hospital stands accused by its own medics of secrecy, bullying and intimidation after it demanded they take fingerprint tests in its effort to identify a whistleblower. Senior staff have privately passed on serious concerns to the Care Quality Commission (CQC) about the behaviour of the trust’s leadership. They used confidential meetings with CQC inspectors, who visited twice in the autumn, to explain why they lack confidence in Steve Dunn, the trust’s chief executive, Dr Nick Jenkins, its medical director, and Sheila Childerhouse, who chairs the hospital’s board. The CQC is due to publish its report into the trust, including the performance of its leadership, in January. “Staff are scared that they’ll face disciplinary action [if they raise concerns about patient safety],” said one doctor, who declined to be named. “As a result of recent events I can’t imagine that anyone at the trust will feel comfortable to speak out or whistleblow in the future. I fear that any future patient safety concerns will not be expressed and will simply be brushed under the carpet.” The trust demanded fingerprints and handwriting samples after a staff member wrote anonymously to the family of Susan Warby, who died in August 2018 after undergoing treatment at the hospital, which was investigated as a “serious incident”. Read full story Source: The Guardian, 11 December 2019
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