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News Article
How 175 British children were infected with HIV
Patient Safety Learning posted a news article in News
At least 175 children with the blood disorder haemophilia were infected with HIV in the 1980s, according to documents from the national archives seen by BBC News. Some of the families affected are giving evidence at a public inquiry into what has been called the worst treatment disaster in the history of the NHS. It was almost 36 years ago - in late October 1986 - but Linda will never forget the day she was told her son had been infected. She had been called into a consulting room in Birmingham Children's Hospital, with 16-year-old Michael. As a toddler, he had been diagnosed wi -
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News Article
Covid inquiry ‘marginalising’ bereaved on first day of hearing
Patient Safety Learning posted a news article in News
Bereaved families fear their experiences will be “diluted” in the UK Covid-19 Inquiry after it was confirmed their evidence would be submitted to a third-party company. Instead of the usual “pen portraits” heard in the inquiry, families will submit their evidence to a private research company as part of a parallel listening exercise that will analyse the responses and feed back the findings to the inquiry chaired by Baroness Heather Hallett. Matt Fowler, co-founder of the Covid-19 Bereaved Families for Justice campaign, said while families believe the start of the inquiry is a step i -
News ArticleTina Hughes, 59, died from sepsis after doctors allegedly delayed treating the condition for 12 hours while they argued over which ward to treat her on. Ms Hughes was rushed to A&E after developing symptoms of the life-threatening illness on September 8 last year. Despite paramedics flagging to staff they suspected sepsis, it was not mentioned on her initial assessment at Sandwell General Hospital, in West Bromwich. A second assessment six hours later also failed to mention sepsis while medics disagreed over whether to treat her on a surgical ward or a high dependency unit.
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News Article
Tribunal told of 'failure' over girl's blood tests
Patient Safety Learning posted a news article in News
If doctors had tested a nine-year-old girl's blood sooner they may have changed the treatment she received before her death, an expert witness has confirmed to a medical tribunal. The hearing was told this was a "significant failure" in the care of Claire Roberts. Claire died at the Royal Belfast Hospital for Sick Children in 1996. In 2018 a public inquiry concluded she died from an overdose of fluids and medication caused by negligent care. At the time, her parents were told a viral infection had spread from her stomach to her brain. The General Medical Council (GMC) said one o -
Event
Learning from patient safety incidents including Human Factors
Patient Safety Learning posted a calendar event in Community Calendar
This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace and is aligned with the new Patient Safety Syllabus 2021. The new Patient Safety Strategy advises that organisations must adopt a new and broader approach to stimulate learning from patient safety incidents. This course is designed to assist healthcare professionals involved in this important work. The main purpose is to provide learners with a full understanding of the various approaches that can now be used to conduct patient safety incident investigation (PSIIs). Tr -
Event
Human Factors in accident investigation
Patient Safety Learning posted a calendar event in Community Calendar
untilThis free webinar will uncover the intricacies of accident investigation from a human factors perspective. It will feature examples from rail, air and maritime from our speakers who are all specialist human factors investigators. Hear first hand how they tackle investigations and get insights into this vital work that lead to improvements in safety across all travel sectors. Will Tutton will briefly mention the Herald of Free Enterprise, but will mainly talk about the cargo vessel Kaami, which ran aground in Scotland in March 2020. The investigation focused on front line operators. L -
News Article
Covid inquiry first preliminary hearing to begin
Patient Safety Learning posted a news article in News
The first preliminary hearing of the UK Covid public inquiry will begin today. The session, in London, will focus on the UK's pandemic preparedness before 2020. It will be largely procedural, involving lawyers and an announcement about who will be giving evidence. Public hearings where witnesses are called will not start until the spring. The inquiry formally started in the summer, with a listening exercise. But this first preliminary hearing is still being seen as an important milestone for the families who lost loved ones. Lindsay Jackson's mother, Sylvia, 87, died from C -
News ArticleHospital authorities in Wales have been accused of attempting to cover up failings in the delivery of a baby born with significant brain damage. Gethin Channon, who was born on 25 March 2019 at Singleton Hospital, in Swansea, suffers from quadriplegic cerebral palsy, a severe disability that requires 24/7 care. There were complications during his birth, due to him being in an abnormal position that prevented normal delivery, and he was eventually born via caesarean section. An independent review commissioned by Swansea Bay University Health Board (SBUHB), which manages Singleton
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Scottish Government orders review as neonatal deaths higher than expected
Patient Safety Learning posted a news article in News
Healthcare Improvement Scotland have been commissioned to lead a review into the neonatal death rates. It follows the higher than expected deaths in both March 2022 and September last year, as published by Public Health Scotland. At least 18 babies under four weeks old died in March – a rate of 4.6 per 1,000 births. The wider inquiry is understood to have been triggered because the mortality rate passed an "upper control" threshold of 4.4 per 1,000 births. The average mortality rate among newborns is just over 2 per 1,000 births. The Scottish Government said the -
News Article
‘Appalled’ NHSE director orders safety review at all providers
Patient Safety Learning posted a news article in News
The NHS’ mental health director has branded abuse exposed at a city inpatient unit as “heartbreaking and shameful” and ordered a national review of safety across all providers. In a letter to all leaders of mental health, learning disability and autism providers, shared with HSJ, Claire Murdoch responded to BBC Panorama’s exposure of patient abuse at the Edenfield Centre run by Greater Manchester Mental Health FT by warning trusts they should leave “no stone unturned” in seeking to eradicate and prevent poor care. An investigation by the programme found a “toxic culture of humiliatio -
News Article
Hospital’s ‘consistently high’ mortality rate under investigation
Patient Safety Learning posted a news article in News
NHS England and local system leaders are investigating “consistently high” mortality rates over the last two years at an acute hospital after previous reviews failed to find an explanation, an integrated care board meeting was told this week. A Lincolnshire integrated care board member said previous work had “never got to the bottom” of what is happening at Peterborough City Hospital, which sits outside Lincolnshire but provides services to the county’s residents. Gerry McSorley, who chaired the predecessor clinical commissioning group and is now a non executive director on the ICB, -
News Article
NHS 111 failures led to early Covid deaths, investigation finds
Patient Safety Learning posted a news article in News
Multiple failures by the NHS 111 telephone advice service early in the pandemic left Covid patients struggling to get care and led directly to some people dying, an investigation has found. The Healthcare Safety Investigation Branch (HSIB) looked into the help that NHS 111 gave people with Covid in the weeks before and after the UK entered its first lockdown on 23 March 2020. It identified a series of weaknesses with the helpline, including misjudgment of how seriously ill some people with Covid were, a failure to tell some people to seek urgent help, and a lack of capacity to deal w -
News ArticleGreater Manchester Mental Health NHS Foundation Trust said a number of staff at its Edenfield Centre had been suspended after an undercover investigation found what was described as a "toxic culture" of humiliation, verbal abuse, and bullying of patients. BBC Panorama reporter, Alan Haslam, spent 3 months as a support worker at the Centre in Prestwich. Wearing a hidden camera, he said he observed staff swearing at patients, mocking them, and falsifying observation records. A consultant psychiatrist, Dr Cleo Van Velsen, who was asked by the BBC to review its footage, said it showed a
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News Article
Coroner criticises NHS trust’s treatment of family of woman who killed herself
Patient Safety Learning posted a news article in News
An NHS trust has “not covered itself in glory” in its dealings with the family of a vulnerable young woman who killed herself after being refused admission to hospital, a coroner has found. The three-day hearing looked at evidence withheld from the original inquest into the death of Sally Mays, who killed herself in 2014 after being turned away from a mental health unit. Mays was failed by staff “neglect” at Miranda House in Hull, a 2015 inquest ruled, after a 14-minute assessment led to her being refused a place, despite being a suicide risk. Her parents, Angela and Andy Mays, -
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Dying patient should have been seen in person
Patient Safety Learning posted a news article in News
NHS officials ruled a man who died after his ear infection was not picked up in GP telephone consultations should have been seen face to face, a BBC Newsnight investigation has found. David Nash, 26, had four remote consultations over three weeks during Covid restrictions but was never offered an in-person appointment. His infection led to a fatal abscess on his brainstem. David first spoke to the practice on 14 October 2020, after finding lumps on his neck. He sent a photograph but was never examined. With David worried the lumps might be cancerous, the GP asked a series of que -
News Article
CQC triggers two reviews into whistleblowing concerns
Patient Safety Learning posted a news article in News
The Care Quality Commission (CQC) has commissioned an independent review into handling of a high-profile whistleblower case, and a wider internal review of how it responds when it is given “information of concern”. The independent review will be led by Zoë Leventhal KC of Matrix Chambers and will consider how the regulator handled “protected disclosures” from University Hospitals of Morecambe Bay Foundation Trust surgeon Shyam Kumar, alongside “a sample of other information of concern shared with us”. Mr Kumar won a tribunal against the CQC earlier this month, which found he was unf -
News ArticleFamilies have blasted a NHS Trust after it said it did not intend to publish an independent review into their loved ones deaths. Three young people died in nine months at the same mental health unit. A Coroner was told last week that the review will be "ready" this month. Rowan Thompson, 18, died while a patient at the unit, based in the former Prestwich Hospital, Bury, in October 2020, followed by Charlie Millers, 17, in December that year, and Ania Sohail, 21, in June last year. Earlier this year, Greater Manchester Mental Health NHS Foundation Trust (GMMH), which runs the hospital
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EventSEIPS 2.0 is the most widely used model in human factors in healthcare. This one day masterclass will look at the model itself and how it can be applied to healthcare departments. It will look at real world examples as well as the literature. SEIPS 2.0 is the next-generation healthcare human factors model , which embraces 3 principles of Systems orientation, Person-centeredness and Design-driven improvement. Key learning objectives What is SEIPS 2.0? How does SEIPS link to Patient Safety? How to use SEIPS 2.0 clinically? • How to improve technology? En
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News Article
Sickle cell: NHS to investigate racial inequalities for first time
Patient Safety Learning posted a news article in News
Sickle cell patients’ experiences of barriers to treatment and racial inequalities will be investigated by an NHS body next month, The Independent has learned. The NHS Race and Health Observatory has collaborated with Public Digital, a consultancy group, to lead original research into the experiences of people with sickle cell, including listening to NHS patients’ and carers’ first-hand accounts of acute emergency hospital admissions and managing the condition at home. Research will focus on a series of interviews and ‘experience mapping’ workshops, the findings of which are anticipa -
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