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Found 1,039 results
  1. Event
    This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. There will be an extended focus on engaging and involving patients, families and staff following a death, and on learning from deaths including an update from a coroner. The conference will discuss the role of Medical Examiners in learning from deaths which is now being extended to all non-coronial deaths wherever they
  2. Content Article
    Recommendations from the study Just Culture: define an agreed vision of what Just Culture means to the Trust. Investigations: introduce incident management familiarisation training. Learning Culture: increase face-to-face communication of outcomes of investigations and incident review. Investigators: establish an incident investigation team to improve the timeliness and consistency of investigations and the communication and implementation of outcomes.
  3. News Article
    Children came to “significant” harm due to chronically low staffing levels at scandal-hit mental health hospitals, whistleblowers have said. In a third exposé into allegations of poor care at private hospitals run by The Huntercombe Group, former employees have claimed that staffing levels were so low “every day” that patients were neglected, resulting in: Patients as young as 13 being force-fed while restrained. Left alone to self-harm instead of being supervised. Left to “wet themselves” because staff couldn’t supervise toilet visits. One staff member, Rebecca
  4. News Article
    An acute trust has been fined a record sum by the Care Quality Commission for failing to provide safe maternity care, which resulted in the death of a baby after 23 minutes. Nottingham University Hospitals must pay a fine of £800,000 within two years. It is only the second time the regulator has brought a case against a NHS maternity service, and the highest fine ever given for failings of this nature. The trust pleaded guilty earlier this week to two charges of failing to provide safe care and treatment to Sarah Andrews and her baby daughter Wynter Andrews at Queen’s Medical Centre
  5. Content Article
    The Commission will draw up recommendations for reform in the following ten areas: The funding model for health and social care GPs and pharmacists Hospitals, waiting lists and maternity provision Social care Workforce—including recruitment, retention and training Cancer Obesity Mental health The role of new technology Health inequalities
  6. Community Post
    An investigation by The Sunday Times has found that the drug sodium valproate is still being handed out to women in plain packets with the information leaflets missing, or with stickers over the warnings. Sodium valproate, has been given to women with epilepsy for decades without proper warnings, and has caused autism, learning difficulties and physical deformities in up to 20,000 babies in Britain. The government is refusing to offer any compensation to those affected by sodium valproate, despite an independent review by Baroness Cumberlege concluding in 2020 that families should be
  7. Content Article
    Findings The assessment of visual signs of jaundice in newborn babies is subjective and more challenging with babies who have black or brown skin. Stakeholders have differing opinions about the reliability of visual signs to detect jaundice in newborn babies. Some neonatal units have introduced safety measures to mitigate the risk of reliance on visual signs of jaundice. National guidance does not recommend routinely measuring bilirubin levels in babies who are not visibly jaundiced. National guidance for jaundice in newborn babies maybe more applicable to term b
  8. News Article
    The health trust behind the worst maternity scandal in NHS history has accepted responsibility for a boy's brain injury. Adam Cheshire, 11, contracted a Group B Strep (GBS) infection following his birth at the Royal Shrewsbury Hospital in 2011. A High Court judge approved a pay out from Shrewsbury and Telford Hospitals NHS Trust (SaTH) to provide special care for the rest of his life. His case was examined as part of senior midwife Donna Ockendon's investigation into SaTH which found catastrophic failures might have led to the deaths and life-changing injuries of hundreds of bab
  9. News Article
    Ministers have ordered an inquiry into the quality of care in mental health inpatient units in England after a series of scandals in which vulnerable patients were abused or neglected. Maria Caulfield, the mental health minister, announced the establishment of a “rapid review” in a written ministerial statement in the House of Commons on Monday. The inquiry “is an essential first step in improving safety in mental health inpatient settings”, she said. In recent years, coroners and the Care Quality Commission, the NHS care watchdog, have repeatedly raised concerns about dangerously in
  10. Content Article
    At Patient Safety Learning we seek to harness the knowledge, insights, enthusiasm and commitment of health and social care organisations, professionals and patients for system-wide change and the reduction of avoidable harm. The scale of this challenge remains immense. Each year, millions of patients suffer injuries or die because of avoidable harm in healthcare. The World Health Organization (WHO) states that in high-income countries 1 in every 10 patients is harmed when receiving hospital care.[1] In the UK, the NHS pre-Covid estimate was that there were around 11,000 avoidable deaths a
  11. News Article
    Consultants who blew the whistle at a major teaching trust have raised “grave concerns” about the impartiality of three reviews into the safety and bullying allegations they made. Last month, Birmingham and Solihull Integrated Care Board announced three investigations into University Hospitals Birmingham, following worries about bullying and poor workplace culture. Former trust consultants Manos Nikolousis, John Watkinson and Tristan Reuser have now written to the cross-party reference group holding the investigations to account. Their letter, seen by HSJ, outlines their concerns abo
  12. News Article
    A series of concerns about serious incidents at a mental health trust are being investigated by the Care Quality Commission, with a referral also made to the police, HSJ has learned. HSJ understands that various incidents at Black Country Healthcare Foundation Trust have been raised with the Care Quality Commission by whistleblowers. According to a well-placed source, one of the alleged incidents involved alleged inappropriate sexual behaviour, and this has been referred to West Midlands police. Other complaints are understood to include staff using mental health inpatients’ roo
  13. News Article
    Victims and family members affected by the contaminated blood scandal are calling for criminal charges to be considered as the public inquiry into the tragedy draws to a close. While the inquiry, which will begin to hear closing submissions on Tuesday, cannot determine civil or criminal liability, people affected by the scandal are keen for the mass of documents and evidence accumulated over more than four years to be handed over to prosecutors to see whether charges can be brought. About 3,000 people are believed to have died and thousands more were infected in what has been describ
  14. News Article
    The chair of an inquiry into hundreds of deaths at a mental health trust has revealed she may not be able to deliver it in its current form following a ‘hugely disappointing’ lack of staff coming forward to give evidence. Former national clinical director for mental health, Geraldine Strathdee, chair of the non-statutory inquiry into deaths at Essex Partnership University Trust, has penned an open letter warning just 11 of 14,000 staff contacted said they will attend evidence sessions. It was meant to report in spring 2023. However, after raising concerns with ministers, Dr Strathde
  15. News Article
    John Watkinson was one of the country's top ear, nose and throat surgeons. But Mr Watkinson's life and career were turned upside down when he was accused of shortening the lives of three patients, suspended and investigated. General Medical Council investigators would eventually close his case, taking no further action, and Mr Watkinson would receive an apology for what he had experienced from his employer University Hospitals Birmingham (UHB) NHS Trust. But that was six years after he was first suspended - six years that would see him pushed to the brink. "As doctors, we'r
  16. Content Article
    In this blog Helen discusses how Patient Safety Learning is working with Tim Edwards to raise awareness of the findings of his report, and its associated nine calls for action, to help improve pulmonary embolism outcomes. Read the full blog on the National Voices website. Related reading Independent review of pulmonary embolism fatalities in England & Wales – recent trends, excess deaths, their causes and risk management concerns (December 2022, Tim Edwards) Jenny, and why we must learn from her misdiagnosis of pulmonary embolism Pulmonary embolism misdiagnosis
  17. Content Article
    Dear all I write this letter to raise people’s awareness of an imminent advert for a non-executive role at the new independent body, Health Services Safety Investigations Body (HSSIB), aiming to address harm in healthcare. I urge people to think about and share this new role at HSSIB following my own very personal experience and experience from learning from others in trying to improve health service systems following patient harm events. For the last 12 years I have played a role supporting four people, as a carer and advocate for frail older relatives and close friends, includ
  18. News Article
    The Northern Ireland Ambulance Service (NIAS) is investigating whether a delayed response contributed to the deaths of eight people in recent weeks. All eight deaths occurred between 12 December and the start of January. The NIAS is treating four of the deaths as serious adverse incidents, which is defined as an incident that led to unintended or unexpected harm. The remaining four deaths are being investigated to see whether they meet that criteria. The patients' identities have not been disclosed, but it is understood one of the eight people was a man who waited more than
  19. News Article
    Police have carried out more than 5,500 investigations into patients who have been reported missing from NHS facilities in Scotland since 2019. The figures were outlined in a written response from Keith Brown, the justice secretary, to Jamie Greene, the Conservative MSP. Greene, who is the justice spokesman for the Conservatives, said the figures gave serious cause for concern. He said that the complete figure could be much higher because the data provided only included those reported to police. He urged Brown and Humza Yousaf, the health secretary, to provide adequate resources for
  20. Content Article
    10:03:23 Witness(es): Emma Murphy, Founder, Independent Foetal Anti-Convulsant Trust (In-FACT); Janet Williams, Founder, Independent Foetal Anti-Convulsant Trust (In-FACT); Kath Sansom, Campaigner, Sling the Mesh Campaign. 10:36:55 Witness(es): Professor Sir Cyril Chantler, Deputy Chair, Independent Medicines and Medical Devices Safety Review; Simon Whale, Review Member and Communications Lead, Independent Medicines and Medical Devices Safety Review; Baroness Julia Cumberlege, Chair, Independent Medicines and Medical Devices Safety Review. 11:03:10 Witness(es): Maria C
  21. News Article
    The Birmingham MP Preet Gill has called on the UK health secretary to launch a major public inquiry into allegations that a bullying and a toxic culture is risking patient safety at University Hospitals Birmingham (UHB). The MP for Edgbaston, where UHB is based, said she had received complaints from staff alleging elderly patients had been left on beds in corridors outside wards due to mismanagement, and medics were discouraged from speaking out about problems. In a letter to Steve Barclay, seen by the Guardian, Gill said: “I have been inundated by messages from UHB staff, past and p
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