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Found 1,178 results
  1. Content Article
    The Triangle of Care is a therapeutic alliance between carers, service users and health professionals. It aims to promote safety and recovery and to sustain mental wellbeing by including and supporting carers.
  2. Content Article
    This full-length, award-winning documentary unearths the shattering truth that millions of people worldwide are injured by prescribed psychiatric medications. Interweaving stories of harm with expert testimony, the film reveals how a profit-driven industry hides the risks of long-term use. This untold story is a compelling call to examine the consequences of medicating normal human suffering.
  3. News Article
    Dan Harrison, who had schizophrenia and psychotic delusions about his parents, had been sectioned ten days before he attacked his father. He was detained at Neath Port Talbot Hospital, run by the Swansea Bay University Health Board. During those ten days he received no treatment or medication. He escaped through a door being held open by a member of staff who was talking to someone else and immediately headed for the family home where he killed his father. The attack came after Dan's mother, Jane, and her husband repeatedly asked for help from mental health services as their son’s state of mind and behaviour deteriorated. They were refused. Last month Kirsten Heaven, assistant coroner for Swansea, recorded in a narrative verdict that there had been repeated failings by the Swansea University Health Board and local council. She said multiple system failures had contributed to Kim’s death and warned of more deaths if they were not addressed. Jane is speaking out now, with her son’s permission, after a Sunday Times investigation highlighted the scale of mental health-related killings in Britain. There have been at least 233 reported since 2020 and there have been repeated warnings about NHS services failing to provide crisis care. Read full story (paywalled) Source: The Times, 1 June 2024
  4. News Article
    One out of every six people have symptoms when they stop taking antidepressants - fewer than previously thought, a review of previous studies suggests. The researchers say their findings will help inform doctors and patients "without causing undue alarm". The Lancet Psychiatry review looked at data from 79 trials involving more than 20,000 patients. Some had been treated with antidepressants and others with a dummy drug or placebo, which helped researchers gauge the true effect of withdrawing from the drugs. Some people have unpleasant symptoms such as dizziness, headache, nausea and insomnia when they stop taking antidepressants, which, the researchers say, can cause considerable distress. Previous estimates suggested antidepressant discontinuation symptoms (ADS) affected 56% of patients, with almost half of cases classed as severe. But this review, from the Universities of Berlin and Cologne, estimates one out of every every six or seven patients can expect symptoms when stopping antidepressants and one in 35 will have severe symptoms. Read full story Source: BBC News, 6 June 2024
  5. Content Article
    Acute inpatient mental health services report high levels of safety incidents. The application of patient safety theory has been sparse, particularly concerning interventions that proactively seek patient perspectives. This recently published NIHR report details research to explore safety on acute mental health wards from patient perspectives using real-time technology.
  6. News Article
    Families have warned a health board that more patients could die if lessons about poor mental health care are not learned. A report by the Royal College of Psychiatrists found less than half of 84 recommended improvements to a hospital trust’s mental health department have been made. In the past 10 years, four separate reviews have outlined changes to be implemented by Betsi Cadwaladr University Health Board. Patient watchdog Llais said people had continued to die during this time. At a meeting in Llandudno on Thursday morning, the health board, which runs the NHS in north Wales, apologised to families and said it was committed to improving. Problems with mental health services at the health board first became public in December 2013 when the Tawel Fan dementia ward at Ysbyty Glan Clwyd near Rhyl was closed. A report said elderly patients there were treated "like animals in a zoo". Before that, the board was aware of problems at Hergest mental health unit at Ysbyty Gwynedd in Bangor. An investigation found a culture of bullying and low morale, which meant patient safety concerns were not addressed. During the meeting earlier, Phill Dickaty, who’s mother Joyce Dickety died on Tawel Fan in 2012, told the board families felt “let down again". "As things stand, despite the passage of time and false reassurances offered by BCUHB, the Tawel Fan families have a real and significant concerns over the lack of progress," he said. "Be it patient or otherwise, nobody should ever have to endure a situation like Tawel Fan and the atrocities that took place. As well as the disappointment felt at the lack of progress, the risk of history repeating itself again in the future weighs heavily in the minds of Tawel Fan families." Read full story Source: BBC News, 29 May 2024
  7. Content Article
    In this blog Chris Dzikiti, Director of Mental Health at CQC, and Dr Jacqui Dyer, Mental Health Equalities Advisor at NHS England, talk about the work our two organisations are doing to implement the Patient and Carer Race Equality Framework (PCREF).
  8. Content Article
    This US cross-sectional study in JAMA Network Open aimed to find out whether there is a difference in reported inappropriate antipsychotic medication use between severely and less severely deprived neighbourhoods, and whether this difference is modified by greater total nurse staffing hours. The study included 10,966 nursing homes and found that nursing homes that fell below critical levels of staffing (less than three hours of nurse staffing per resident-day), were associated with higher inappropriate antipsychotic medication use among nursing homes in severely deprived neighbourhoods (19.2%) compared with nursing homes in less deprived neighbourhoods (17.1%). These findings suggest that addressing staffing deficiencies in nursing homes, particularly those located in severely deprived neighbourhoods, is crucial in mitigating inappropriate antipsychotic medication use.
  9. News Article
    Patients taking antidepressants are being warned to beware of side-effects that could leave them 'asexual' even after they stop using them - a problem that could affect millions of Brits. Selective serotonin reuptake inhibitors (SSRIs), the most common class of antidepressant drug in the UK, are relied upon by one in eight Brits - 8.6million in all - who are dealing with mental health issues like anxiety and depression. Common SSRIs prescribed in the UK include citalopram, fluoxetine and sertraline, sometimes known by brand names Cipramil, Prozac and Lustral - but their use has been linked to long-term and even permanent sexual dysfunction by researchers. The NHS has warned that side effects such as a loss of libido and achieving orgasm, lower sperm count and erectile dysfunction 'can persist' after taking them - and patients have described feeling 'carved out', relationships wrecked, from their use. Men and women say SSRI side-effects have hampered their sex lives, even after coming off of the medications - a condition known as Post-SSRI Sexual Dysfunction (PSSD), which is not officially recognised by UK health authorities. For millions, antidepressants can be a life-saving drug - but the authors of a US petition urging more warnings to be applied to the drugs say it can be 'impossible... to weigh the benefits of treatment against the harms'. Read full story Source: Daily Mail, 23 May 2024 Read this opinion piece on the hub by someone who suffers from post-SSRI sexual dysfunction (PSSD) after he was prescribed a selective serotonin reuptake inhibitor. The author calls for widespread recognition, improved risk communication and better support for sufferers. If you have experience of PSSD, you can also share your insights in our community discussion.
  10. News Article
    Children with mental health illnesses are forced to stay in wards not fit to care for them with patients warning these hospital stays are like a “form of torture”, an NHS safety watchdog has found. Children with mental health conditions were admitted to general hospital wards, not intended for mental health care, nearly 44,000 times in 2021 and 2022, the Health Services Safety Investigation Body has warned. These wards which are “noisy, busy and brightly lit” are not often appropriate for these children who require mental healthcare and are unable to keep them safe, HSSIB said in a report on Thursday. The watchdog is calling for new guidance for hospitals on how to adapt their general paediatric wards for children who have mental health support needs. In a new investigation, the watchdog said it found in some hospitals patients were placed in rooms with “little or no consideration of therapeutic elements” which are “stripped of everything” including window blinds and shower curtains. In one hospital, staff said even the mattresses are removed. Between 2021 and 2022 11.7 per cent, or 39,926 admissions to paediatric wards, for physical health, were for children who had a mental health condition. Read full story Read HSSIB investigation report – Keeping children and young people with mental health needs safe: the design of the paediatric ward (23 May 2024) Source: The Independent, 23 May 2024
  11. Content Article
    This cross-sectional study in JAMA Network Open aimed to explore whether prescribing of psychotropic medications for children and adolescents changes in the two years following the onset of the Covid-19 pandemic. The authors retrieved and analysed all 8,839,143 psychotropic medication prescriptions dispensed to individuals aged from 6 to 17 years in France between 2016 and 2022. They found steady increases in prescription trends for all psychotropic medications after the pandemic onset, with prescription rates of all psychotropic medication classes except psychostimulants higher than expected rates.
  12. Content Article
    This investigation by the Health Services Safety Investigations Body (HSSIB) considers how patient safety can be improved in relation to children and young people with mental health needs while they stay on an acute paediatric ward—a ward for children and young people in a hospital that typically treats physical health conditions. It focuses on the risk factors associated with the design of these wards in acute hospitals.
  13. Content Article
    The use of restrictive interventions, such as mechanical restraints, has been a common practice in behavioural health settings since the field’s early infancy. The use of restraints has a harmful impact on both patients and providers alike, working against the therapeutic treatment environment aimed to support the healing journey. In this quality improvement project, the use of mechanical restraints was fully eliminated from a 252-bed inpatient setting in the US. This was achieved using a strategy of leadership, workplace development and data, and performance was sustained over the following year.
  14. Content Article
    Although much of the national press coverage of healthcare in the UK often focuses on the impact of delayed discharges from hospitals, ineffective discharge from mental health settings can lead to higher levels of patient readmission. In this blog CJ Nwasike looks at how discharge without support exacerbates pressure on community mental health services and can risk readmission.
  15. News Article
    More than 30 of the most common antidepressants used in the UK are to be reviewed by the UK’s medicines regulator, as figures point to hundreds of deaths linked to suicide and self-harm among people prescribed these drugs. The medicines, which include Prozac and are prescribed to millions of patients, will all be looked at by the Medicines and Healthcare products Regulatory Agency (MHRA). It follows concerns raised by families in Britain over the adequacy of safety measures in place to protect those taking the drugs, such as warnings about potential side effects. The regulator will look into the effectiveness of the current warnings, according to a letter from mental health minister Maria Caulfield, which has been seen by The Independent. There has been a huge rise in the use of antidepressants in England, with 85 million prescriptions issued in 2022-23, up from 58 million in 2015-16, according to NHS figures. Nigel Crisp, a crossbench peer and chair of the Beyond Pills all-party parliamentary group, told The Independent: “Overprescribing of antidepressants has an enormous cost in terms of human suffering, because so many people become dependent and then struggle to get off them – and it wastes vital NHS resources.” The review comes as it emerged that: More than 515 death alerts linked to these drugs, involving suicidal ideation and self-harm, have been made to the MHRA since the year 2000 (these alerts don’t directly confirm the cause of a person’s death) Some antidepressants have been given to children as young as four, and the total cost of the medication to the NHS in 2022-23 was more than £231m Read full story Source: The Independent, 11 May 2024
  16. Content Article
    In this blog, Kristy Widdicombe-Dutch shares her decades-long experience of harmful healthcare that has left her with a complete loss of trust in the system. She describes how, starting in her 20s, she has experienced disbelief, gaslighting and poor care in relation to her vascular issues, which has left her with long-term physical harm and psychological trauma.
  17. Content Article
    Suicide and non-fatal self-harm represent key patient safety events in mental healthcare services. However, examples of optimal practice that help to keep patients safe also often important learning for organisations and healthcare professionals. This study in BMC Psychiatry aimed to explore clinicians’ views of what constitutes good practice in mental healthcare services in the context of suicide prevention. The study highlighted clinicians’ views on good practice specific to mental health services that focus on enhancing patient safety via prevention of self-harm and suicide. The authors concluded that clinicians possess important understanding of optimal practice, but there are few opportunities to share such insight on a broader scale. A further challenge is to implement optimal practice into routine, daily care to improve patient safety and reduce suicide risk.
  18. Content Article
    Diagnostic errors are associated with patient harm and suboptimal outcomes. However, despite efforts to advance definition, measurement and interventions for diagnostic error, diagnosis in mental health is not well represented in this ongoing work. The authors of this article, published in BMJ Safety & Quality, summarise the current state of research on diagnostic errors in mental health and identify opportunities to align future research with the emerging science of diagnostic safety.
  19. Event
    Safeguards will be delayed until at least the next general election (anticipated to be in Autumn 2024). Even if a new government is keen to implement Liberty Protection Safeguards (LPS), any reform will now be some years away. With the delay to the Liberty Protection Safeguards it is more important than ever to ensure the existing scheme for deprivation of liberty works, including the Deprivation of Liberty Safeguards (DoLS) and the role of the Court of Protection and High Court. It has been widely recognised that there are number of challenges associated with the current system, both in DoLS and in the court, and we have to deal with these challenges with the tools that we have for now. Attention needs to turn to getting deprivation of liberty in the community cases to court more effectively, as well as cases involving children and young people. It is also vital that providers understand the Mental Capacity Act and use it effectively. For further information and to book a place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/liberty-protection-safeguards-mca or email frida@hc-uk.org.uk Follow the conference on Twitter @HCUK_Clare #LPS2024 We have a limited number of free places for this event for members of the hub. Email content@pslhub.org if you are interested.
  20. Event
    A crisis is deepening in NHS psychiatric care - but how can we turn the tide and stop a total collapse? Join The Independent’s health correspondent Rebecca Thomas and a panel of experts as they dive into the heart of the issues plaguing the NHS' mental health services. This exclusive event comes after joint Independent/Sky News investigation Patient 11 uncovered 20,000 sexual abuse, harassment and assault complaints involving both patients and staff in more than 30 NHS mental health trusts in England since 2019. Sparked by the testimony of former patient Alexis Quinn, who joins our panel, the investigation has prompted accusations by healthcare professionals that NHS psychiatric care in England is in a state of "collapse," due to "unsafe" mixed gender care spaces, inadequate safeguarding protections and bed shortages. Register for the webinar
  21. Content Article
    This BMJ opinion piece highlights that seeing women’s health as synonymous with sexual, reproductive and maternal health means that gaps remain in health provision to meet the wider needs of women. The Government recently outlined its 2024 priorities that build on the 2022 Women’s Health Strategy for England. The authors welcome the focus on specific areas of need, but highlight that the priorities reinforce a traditional view of women’s health and miss an opportunity to encourage policymakers, healthcare providers and the public to take a broader view. They argue that a broader approach would reduce critical gaps in the evidence base and care and treatment relating to diseases and conditions that present only in women, disproportionately in women, and differently in women.
  22. Content Article
    This investigation by the Health Services Safety Investigations Body (HSSIB) considers improvements that can be made to patient safety in relation to the use of continuous observation with adult patients in acute hospital wards who are at risk of self-harm. For its reference case, it looks at the case of a patient who self-harmed when receiving care at a high dependency unit while two members of staff were continuously observing her.
  23. Content Article
    The following account and poem has been kindly shared with Patient Safety Learning by Tom Bell.
  24. News Article
    A health system has stopped sending mental health patients to the country’s largest single provider of out-of-area placements. Southern Hill Hospital in Norfolk provided more than 18,000 bed days classed as OAPs for NHS patients last year, with Greater Manchester Integrated Care System (GM) being the main contributor to that total. However, HSJ has learned that GM’s integrated care board and mental health providers have decided not to send any more patients to the provider. The move comes after a recent visit to and review of the service at Southern Hill by GM commissioners. This, in turn, followed concerns about the “co-ordination” of patient care at Southern Hill received by GM. The exact nature of the concerns is unclear, and the ICB said in a statement “no significant safety or quality concerns were found and feedback from patients was positive,” when it carried out its review. The ICB said the decision to cease placements at Southern Hill shortly after the concerns were raised was a coincidence, and that the move was part of its strategy to reduce OAPs. Read full story (paywalled) Source: HSJ, 2 May 2024
  25. News Article
    An inquest jury has found there were “gross failings in care amounting to neglect” before a woman had a heart attack at a private mental health hospital due to complications from drinking excessive amounts of water. Lillian Lucas, 28, known as Lily to her family and friends, died in September 2022 after being found unresponsive in her room on Milton ward at the Cygnet hospital in Kewstoke, near Weston-super-Mare, where she had been an inpatient since June. An inquest jury at Avon coroner’s court found on Wednesday that opportunities were missed by staff to render care that would have prevented Lucas’s death, including a failure to monitor her worsening condition and inadequate response to her deterioration. On 8 September 2022 she was found unresponsive in her room after drinking excessive amounts of water and transferred to Bristol Royal Infirmary (BRI), the jury heard. She died the following day. Postmortem examinations found she died of a heart attack and the impact of psychogenic polydipsia, when due to a mental disorder a person experiences an uncontrollable urge to drink water. The jury concluded on Wednesday that there were “gross failings in her care amounting to neglect”. In the record of the inquest, the jury said the Milton ward was “understaffed at a level deemed to be unsafe”. Read full story Source: Guardian, 24 April 2024
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