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Found 83 results
  1. Content Article
    I believe all clinicians should read this latest report. There is so much to be learned and so many changes in clinical practice that can be made right away. Since 2018, I have been teaching using Oliver's tragic story to promote reflection on best practice in prescribing and in implementing the Mental Capacity Act. I could write a lot here; however, I believe this is a report all clinicians, and especially all prescribers, need to read in full. A summary of how I see this (or indeed how any individual sees it) it will not be adequate.
  2. News Article
    A major acute trust has confirmed the health service inspectorate has begun a criminal investigation into three incidents at its hospitals. University Hospitals Birmingham FT told HSJ the Care Quality Commission (CQC) has started a criminal investigation into incidents involving potential errors around the provision of anti-coagulant medication. The trust received a letter from the CQC this month informing it that the regulator has begun the investigation under regulation 22 of the Health and Social Care Act 2008 (regulated activities) regulations 2014. The incidents happened at Queen Elizabeth Hospital in Birmingham and Good Hope Hospital — the trust’s two main sites. Regulation 22 says: “In order to safeguard the health, safety and welfare of service users, the registered person must take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced persons employed for the purposes of carrying on the regulated activity.” The CQC launched a prosecution into East Kent Hospitals University FT this month for failing to meet fundamental standards of care. The regulator also successfully prosecuted University Hospitals Plymouth Trust in September after it pleaded guilty to breaching the duty of candour. Read full story (paywalled) Source: HSJ, 23 October 2020
  3. Event
    Whether your role is in the NHS or in private healthcare, it is vitally important to take consent for any intervention safely. This webinar brings together clinical and legal perspectives, advising healthcare professionals of all levels how to take consent safely to avoid litigation and improve patient safety. Receive guidance from NHS Consultant, Michael Kelly, who has provided expert witness evidence at Court, combined with input from Andrew Bershadski, a highly experienced Barrister who has proceeded to Trial and won for the medical profession on a number of separate informed consent cases. Ed Glasgow, a Partner specialising in Healthcare Law, will Chair the event, which it is hoped will provide valuable practical insight.
  4. Event
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    The Westminster Health Forum is a division of Westminster Forum Projects, an impartial and cross-party organisation which has no policy agenda of its own. Forums operated by Westminster Forum Projects enjoy considerable support from within Parliament and Government. The agenda: The impact of investigations in the NHS and the priorities of the Healthcare Safety Investigation Branch Progress of improving patient safety in the NHS Maintaining patient safety during COVID-19 - rapid learning to respond to the virus, continuity of care, and adapting care delivery practices Delivering safe care in the NHS - preventing errors, utilising data and technology, supporting the workforce, and promoting high quality leadership Learning from the voice of parents and families How to improve patient safety by reducing unwarranted variation and learning from clinical negligence claims The role of technology in reducing errors, enhancing care, and ensuring safety in remote healthcare and telemedicine Taking forward the National Patient Safety Syllabus and supporting the workforce to deliver care safely during the presence of COVID-19 Learning from harm, reducing the cost of litigation in the NHS, and the impact of COVID-19 Assessing findings from the Independent Medicines and Medical Devices Safety Review The role of the regulator in reducing avoidable harm and informing future practice Register
  5. News Article
    Saskatchewan's highest court has ruled in favour of a nurse who was disciplined after she complained on Facebook about the care her grandfather had received in a long-term care facility. In a decision delivered Tuesday, the Saskatchewan Court of Appeal set aside a decision by the province's Registered Nurses Association that found Carolyn Strom guilty of unprofessional conduct. Strom was off-duty when she aired her concerns on Facebook in 2015, a few weeks after her grandfather's death. In her Facebook post, she said staff at St. Joseph's Integrated Health Centre in the town of Macklin, about 225 kilometres west of Saskatoon, needed to do a better job of looking after elderly patients. The lawyer for the Saskatchewan Registered Nurses Association argued that Strom personally attacked an identifiable group without attempting to get all the facts about her grandfather's care. In 2016, she was found guilty of professional misconduct by the Saskatchewan Registered Nurses Association and ordered to pay a $1,000 fine and $25,000 to cover the cost of the tribunal. After the association's decision, she received support from the Saskatchewan Union of Nurses, as well as nurses and civil liberties groups across the country. "Once I understood what this case meant ... once it was past being just about me, I didn't want someone else to have to go through the same thing. Because it's been rough," Strom said. Strom says she continued to fight the decision because she wanted nurses to be able to talk about, and advocate for, better care for family members publicly and in a respectful manner. "You should be able to properly advocate for family members, regardless of whether you're a health-care member." "And I felt that if this decision went wrong, it would actually hurt people who have healthcare members as family members. because they would have to be a little more careful and not express concerns for fear of punishment." Appeal court Justice Brian Barrington-Foote wrote in his decision that Strom's freedom of expression was unjustifiably infringed, and she had a right to criticise the care her grandfather received. The judge ruled that criticism of the healthcare system is in the public interest, and when it comes from front-line workers it can bring positive change. Read full story Source: CBC News, 6 October 2020 .
  6. News Article
    An anaesthetist who had been drinking before an emergency caesarean that led to the death of a British woman should serve the maximum three years in jail if convicted and should be banned from working as a doctor, a French prosecutor has demanded. Helga Wauters is on trial in Pau, south-west France, for the manslaughter of Xynthia Hawke in 2014. She is accused of starving Hawke of oxygen for up to an hour after pushing a ventilation tube into the wrong passageway. Orlane Yaouang, prosecuting, described the scene in the operating theatre when Hawke turned blue as “carnage” and spoke of the “surreal situation” in which the panicked hospital staff called the emergency services. Read full story Source: The Guardian, 9 October 2020
  7. News Article
    The Care Quality Commission (CQC) has launched the first prosecution of an acute trust for failing to meet fundamental standards of care. East Kent Hospitals University Foundation Trust faces two charges relating to the death of Harry Richford and the risks posed to his mother during his birth. Both charges are under regulation 12 of the Health and Social Care Act 2008. The trust is accused of failing to discharge its duty under regulation 12 in that it failed to provide safe care and treatment exposing Harry and his mother Sarah to a significant risk of avoidable harm. It is only the fourth prosecution of a trust over the “fundamental standards” which were brought in following the Mid Staffordshire care scandal and are meant to be enforced by the CQC. It is also thought to be the first related to the safety of clinical care. Read full story (paywalled) Source: HSJ, 9 October 2020
  8. Event
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    Based on the participant feedback and interest in the 'Reimagining Healing after Harm: the Potential for Restorative Practices' webinar, Patients for Patient Safety Canada is pleased to offer this follow up session. Restorative practices involve inclusive democratic dialogue between all those affected by healthcare harm. They are guided by concern to address harms, meet needs, restore trust, and promote repair or healing for all involved. This webinar will further explore New Zealand's approach to healing after healthcare harm from surgical mesh: What was the impetus for a restorative approach? What inspired the choice of a relationship-centric and reconciliatory model? How did restorative practices support the co-design process between consumer advocates and Ministry of Health representatives? How do restorative approaches support New Zealand's commitment to Te Tiriti o Waitangi- The treaty that determines the partnership between the Crown and indigenous peoples? It will follow with a participant discussion about what this means for Canada. Further information and registration
  9. News Article
    Experts say robust legal protections are needed to inspire public confidence. The UK government has set out plans to amend drug regulations in case it decides that COVID-19 vaccines should be used before they are licensed, in a bid to roll them out more quickly. In a consultation on the proposals that ran from 28 August to 18 September the Department of Health and Social Care for England explained that if a suitable vaccine emerged with strong evidence of safety, quality, and efficacy the government would seek to license it through the usual route but could supply it in the meantime. The document added, “A COVID-19 vaccine would only be authorised in this way if the UK’s licensing authority was satisfied that there is sufficient evidence to demonstrate the safety, quality, and efficacy of the vaccine. ‘Unlicensed’ does not mean ‘untested.” The consultation, and the timeframe in which it was conducted, prompted some people to post their concerns on social media. However, the Human Medicine Regulations 2012 already allow the licensing authority to temporarily authorise the supply of an unlicensed product in response to certain public health threats, including the suspected spread of pathogens. The proposed change would allow conditions to be attached “to ensure product safety, quality, and efficacy” The 2012 regulations also give healthcare professionals and manufacturers immunity from being sued in the civil courts for the use of some unlicensed products recommended by the licensing authority in response to a public health threat. The new regulations would extend the immunity to drug companies that have not manufactured the product but placed it on the market with the approval of the licensing authority, and they clarify the consequences for a breach of conditions imposed by the authority. Social media posts play into existing concerns that many people might not accept the vaccine, as surveys indicate. Lawyers have told the Department for Health and Social Care that to inspire public confidence it must provide redress for the few people who might experience adverse effects. Bozena Michalowska, a partner specialising in product liability at the law firm Leigh Day, said, “I do not believe that people will want to play Russian roulette with their health by taking a vaccine which they know nothing about, especially when they know that the risks they take are just taken by them and not a shared risk and they will not have sufficient protection should things go wrong.” Read full story Source: The BMJ, 28 September 2020
  10. News Article
    A hospital trust has been fined for failing to be open and transparent with the bereaved family of a 91-year-old woman in the first prosecution of its kind. Elsie Woodfield died at Derriford hospital in Plymouth after suffering a perforated oesophagus during an endoscopy. The Care Quality Commission (CQC) took University Hospitals Plymouth NHS trust to court under duty of candour regulations, accusing it of not being open with Woodfield’s family about her death and not apologising in a timely way. Judge Joanna Matson was told Woodfield’s daughter Anna Davidson eventually received a letter apologising over her mother’s death, which happened in December 2017, but she felt it lacked remorse. Davidson said she still had many unanswered questions and found it “impossible to grieve”. The judge said: “This offence is a very good example of why these regulatory offences are very important. Not only have [the family] had to come to terms with their tragic death, but their loss has been compounded by the trust’s lack of candour.” Speaking afterwards, Nigel Acheson, the CQC’s deputy chief inspector of hospitals, said: “All care providers have a duty to be open and transparent with patients and their loved ones, particularly when something goes wrong, and this case sends a clear message that we will not hesitate to take action when that does not happen." Lenny Byrne, the trust’s chief nurse, issued a “wholehearted apology” to Woodfield’s family. “We pleaded guilty to failure to comply with the duty of candour and fully accept the court’s decision. We have made significant changes in our processes.” Read full story Source: The Guardian, 23 September 2020
  11. News Article
    An NHS trust is to appear in court today charged with breaking the law on being open and transparent after a woman’s death in the first ever court case of its kind. The Care Quality Commission (CQC) has brought a criminal prosecution against University Hospitals Plymouth Trust which will appear at Plymouth Magistrates Court tomorrow morning. The trust is charged with breaching the duty of candour regulations under the Health and Social Care Act 2008 which require hospitals to be honest with families and patients after a safety incident or error in their care. Hospitals are legally required to notify patients or families and investigate what has happened and communicate the findings to families and offer an apology. The case relates to how the Plymouth trust communicated with a woman’s family after her death which happened after she underwent an endoscopy procedure at Derriford Hospital in December 2017. The trust was required by law to communicate in an open and transparent way. The CQC has accused the trust of failing to do this. Read full story Source: The Independent, 22 September 2020
  12. News Article
    Accidents on maternity wards cost the NHS nearly £1 billion last year, Jeremy Hunt, the chairman of the Commons health committee, has revealed. The former health secretary said the bill for maternity legal action was nearly twice the amount spent on maternity doctors in England. It was part of the NHS’s £2.4 billion total legal fees and compensation bill, up £137 million on the previous year. Mr Hunt has also told the Daily Mail there is evidence that hospitals are failing to provide details of avoidable deaths despite being ordered to do so three years ago as he highlighted “appalling high” figures which showed that up to 150 lives are being lost needlessly every week in public hospitals. Responding to the figures, Mr Hunt said: "Something has gone badly wrong." In 2017, he told trusts to publish data on the number of avoidable deaths among patients in their care. But freedom of information responses from 59 hospital trusts, about half the total, found less than a quarter gave meaningful data on avoidable deaths. Mr Hunt cited “major cultural challenges” which he blamed for preventing doctors and nurses from accepting any blame. He blamed lawyers who get involved “almost immediately” once something goes wrong with a patient’s care. “Doctors, nurses and midwives worry they could lose their licence if they are found to have made a mistake. Hospital managers worry about the reputation of their organisation,” he added. Mr Hunt said: “We have appallingly high levels of avoidable harm and death in our healthcare system. We seem to just accept it as inevitable.” An NHS spokesman said: “Delivering the safest possible health service for patients is a priority, and the national policy on learning from deaths is clear that hospitals must publish this information every three months, as well as an annual summary, so that they are clear about any problems that have been identified and how they are being addressed. Read full story Source: The Telegraph, 18 September 2020
  13. News Article
    The human rights watchdog for England and Wales has backed a grieving daughter’s court action against the health secretary, Matt Hancock, over his handling of the coronavirus pandemic in care homes. Cathy Gardner, who lost her father, Michael Gibson, to COVID-19 in a care home that accepted hospital discharges, is seeking a judicial review of policies that she alleges “failed to take into account the vulnerability of care home residents and staff to infection and death, the inadequacy of testing and PPE availability”. The government denies acting illegally over care homes in England, where more than 15,000 people have died with confirmed or suspected COVID-19. But the Equalities and Human Rights Commission said the case “raises potentially important issues of public interest and concern as to the way in which the rights of care home residents have been and will be protected during the current coronavirus pandemic”. “The bereaved families group isn’t backing down in its call for a public inquiry and I am not backing down in my call for a judicial review into policies I believe led to deaths in care homes,” Gardner said. ”I am delighted the EHRC have written to the court. This is a Human Rights Act case.” Read full story Source: The Guardian, 3 September 2020
  14. Event
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    This meeting will focus on some of the key medico-legal issues that impact GPs, primary care and patient safety, with a specific emphasis on inquests, clinical negligence and incidents. This comprehensive programme will review and explore the latest legal and regulatory developments from national leaders in each of these fields. Delegates will gain an understanding of: The role of coroners and inquests, what to expect and what GPs and those working in primary care need to do to prepare and actively learn from deaths The role of Medical Examiners and how they will impact on primary care The support, including education and training, available to GPs in dealing with medico-legal issues and how to access practical support (e.g. via the Medical Defence Organisations) when necessary The role of NHS Resolution and the Clinical Negligence Scheme for GPs (CNSGP) and their impact upon GPs and patient safety Developments in learning from incidents in primary care, including feedback from the CQC regarding best practice and areas for improvement Book here
  15. Event
    David Sellu FRCS, distinguished Consultant Colorectal Surgeon, will be joining RSM President Professor Roger Kirby for an extraordinary discussion about his unfair trial, his imprisonment, and his subsequently quashed conviction for Gross Negligence Manslaughter. He will be talking about his highly acclaimed and candid book, Did He Save Lives? A Surgeon's Story, patient safety and the practice of defensive medicine, as well as what the future now looks like for him. In February 2010, David operated on a patient and despite his efforts, the patient died two days later. There followed a sequence of extraordinary events that led to David being convicted of Gross Negligence Manslaughter. He served 15 months in prison and eventually released on licence. His licence to practise medicine was suspended, his career cut short. It was later discovered that David's trial was unfair, and with Dr Jenny Vaughan leading the campaign along with friends, family and colleagues, David won the appeal against his conviction and is now a free man. The shock waves caused by David’s conviction has led more medical professionals to practise defensive medicine. This could have a huge impact on patient care in the future as our population ages and their health needs become more complex. Register
  16. Content Article
    This edited collection can be seen to facilitate global learning. This book will, hopefully, form a bridge for those countries seeking to enhance their patient safety policies. Contributors to this book challenge many supposed generalisations about human societies, including consideration of how medical care is mediated within those societies and how patient safety is assured or compromised. By introducing major theories from the developing world in the book, readers are encouraged to reflect on their impact on the patient safety and the health quality debate. The development of practical patient safety policies for wider use is also encouraged. The volume presents a ground-breaking perspective by exploring fundamental issues relating to patient safety through different academic disciplines. It develops the possibility of a new patient safety and health quality synthesis and discourse relevant to all concerned with patient safety and health quality in a global context.
  17. News Article
    A High Court judge has ruled that an NHS trust was negligent in failing to consider early enough that a toddler with fever, lethargy, and vomiting might have had a serious bacterial infection and to give her intramuscular antibiotics. Mr Justice Johnson said that doctors from University Hospital Southampton NHS Foundation Trust should have ordered a lumbar puncture on the 15 month old girl on the day she was first seen or the next day. The girl, referred to in court as SC, was sent by her GP to the hospital by ambulance on 26 January 2006 with a note describing his findings on examination and ending “?meningitis.” The GP, Mark Dennison, had given her intramuscular penicillin. Read full story (paywalled) Source: BMJ, 22 June 2020
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