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Found 41 results
  1. News Article
    A man with Down’s Syndrome and dementia died in hospital after not being fed for nine days. The 56-year-old was admitted to Poole hospital with a hip fracture after falling over at a Bournemouth care home, where he had been receiving care. On admittance, he was taken to the trauma and orthopaedics ward, where he was listed as ‘nil by mouth’, as he had trouble swallowing. Nine days later, he died of pneumonia after a ‘series of errors’ at the hospital. Now, the man’s father has been given £22,500 in compensation, after an incident investigation at the hospital. Allegations made against the hospital included a failure to feed the patient for nine days, causing "his subsequent severe deterioration and death". The hospital failed to adequately monitor and investigate his condition, while failing to provide senior doctors, it was alleged. This left unsupervised junior doctors who did not have access to senior staff or any way to escalate their concerns, allegations said. This, it was claimed, was not done when the patient was still nil by mouth after nine days, despite the fact he was suffering from pneumonia. Read full story Source: Yahoo News, 9 February 2024
  2. Content Article
    In my 15 years focusing on developing drink thickening solutions for dysphagia patients, the intersection of dysphagia management and patient safety has become increasingly apparent. Dysphagia, or difficulty swallowing, presents not only as a significant health challenge but also as a critical patient safety issue. The condition's underdiagnosis, particularly in vulnerable populations, heightens the risk of severe complications, including choking, aspiration pneumonia, dehydration and the profound fear of choking that can lead to malnutrition.
  3. Content Article
    This project aimed at understanding and tackling the barriers to sufficient hydration, breaks and refreshment facilities for NHS staff. Sherwood Forest Hospitals NHS Foundation Trust was keen to introduce the Royal College of Nursing's (RCN) rest, rehydrate and refuel initiative, and did so through a project led by one of the chief nurse clinical fellows. First, staff were surveyed to understand the current situation and any barriers they may face. This was followed by a trial on two pilot wards, before roll our of a trust-wide campaign.
  4. Event
    This conference focuses on improving safety for hospice patients. The day will highlight best practice in improving safety in hospices, highlight new developments such as the implications of the new Patient Safety Incident Response Framework (PSIRF), and the new CQC Inspection Framework, and will focus on key clinical safety areas such as falls prevention, medication safety, reduction and management of pressure ulcers, nutrition and hydration, improving the response and investigation of incidents, preparing for onsite inspections and developing a compassionate culture in hospices. Register at https://www.healthcareconferencesuk.co.uk/virtual-online-courses/patient-safety-hospices or email aman@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow the conference on Twitter @HCUK_Clare #PSHospices
  5. News Article
    A nurse-led trial has found that a new electronic tool could reduce the number of preventable injuries and deaths caused by wrongly inserting nasogastric tubes. The study, led by Tracy Earley, a consultant nutrition nurse at Royal Preston Hospital, tested a new fibre-optic device which can tell clinicians definitively if a nasogastric tube – which is inserted through the nose and delivers food, hydration and medicine into the stomach – has been placed correctly. Currently, to check if nasogastric tubes – also referred to as NG tubes – are in the right place, nurses have to extract bodily fluid from the patient through the tube. Clinicians then test this fluid on a pH strip to judge whether the placement is correct. Studies show that interpreting the pH level results in mistakes 12-30% of the time, and that in 46% of cases nurses are unable to draw aspirate at all. This means patients have to undergo x-rays, leaving them without nutrition or treatment for longer. The study tested a device called NGPod, which uses a fibre-optic sensor to retrieve the pH reading from the tip of the NG tube leading to a definitive 'yes' or 'no' result in terms of whether it has been placed correctly – removing the need for aspirate or interpretation from the health professional. It found that the device was as accurate as pH strip testing, and removed all of the risks associated with making subjective pH strip judgements. Read full story Source: Nursing Times, 18 July 2023
  6. News Article
    Olly Vickers died of a brain injury in February last year just weeks after two midwives at Royal Bolton Hospital let his mother Emma Clark feed him while she was having gas and air – in breach of guidelines. Despite being well when he was born, Olly was found “pale and floppy” hours later due to his airways being obstructed. He developed a brain injury and died five months later. Coroner Peter Sigee ruled his death was a result of “neglect” and due to a “gross failure to provide basic medical care”. An inquest into his death heard a student midwife placed a pillow under his mother’s arm while she was feeding him, “contrary to accepted practice”. Another midwife then gave Ms Clark gas and air while she was feeding Olly as she was stitched up for a tear obtained during labour – which again went against guidance. No risk assessment was carried out and the coroner said Olly’s breastfeeding should have been stopped before the midwives began to suture Ms Clark. Read full story Source: The Independent, 8 July 2023
  7. News Article
    An 80-year-old woman with coeliac disease died within days of being fed Weetabix in hospital, an inquest has heard. Hazel Pearson, from Connah’s Quay in Flintshire, was being treated at Wrexham Maelor hospital and died four days later on 30 November from aspiration pneumonia. Although her condition was recorded on her admission documents, there was no sign beside her bed to alert healthcare assistants to her dietary requirements. Coeliac disease is a condition where the immune system attacks the body’s own tissues after consuming gluten, a type of protein found in wheat, rye and barley, causing damage to the small intestine. The hospital’s action plan to avoid similar fatal incidents lacked detail and had “narrow vision”, the coroner said. The hospital’s matron, Jackie Evans, told the inquest that changes, including placing signs above the beds of patients with special dietary requirements, had been implemented since Pearson’s death. But Sutherland raised concerns that the hospital had yet to carry out a formal investigation into what went wrong. She said: “The action plan lacks detail. What has happened locally is commendable, but it lacks detail and it has narrow vision.” She added that the plan that had been put in place was “amateurish with no strategic vision”. The assistant coroner said she would be unable to make a decision on a prevention of future deaths report until the Betsi Cadwaladr University Health Board (BCUHB) provided a witness to answer further questions about changes. Read full story Source: The Guardian, 17 June 2022
  8. News Article
    Most health claims on formula milk products have little or no supporting evidence, researchers have said, prompting calls for stricter marketing rules to be introduced worldwide. Millions of parents use formula milk in what has become a multibillion-dollar global industry. But a study published in the BMJ has found most health and nutritional claims about the products appear to be backed by little or no high-quality scientific evidence. “The wide range of health and nutrition claims made by infant formula products are often not backed by scientific references,” said Dr Ka Yan Cheung and Loukia Petrou, the joint first co-authors of the study. “When they are, the evidence is often weak and biased.” Dr Daniel Munblit and Dr Robert Boyle, senior co-authors for the study, added: “There is a clear need for greater regulation and oversight to ensure that these claims are supported by sound scientific evidence and to protect the health and wellbeing of our youngest and most vulnerable populations.” Read full story Source: The Guardian, 15 February 2023
  9. News Article
    CVS Health confirmed last year it was closing half its Coram home infusion branches and firing about 2,000 nurses, dietitians and pharmacists. Their patients with life-threatening digestive disorders depend on parenteral nutrition, or PN — in which amino acids, sugars, fats, vitamins and electrolytes typically are pumped through a catheter into a large vein near the heart. A day later Optum Rx, another big supplier, announced its own consolidation. Suddenly, thousands were scrambling for their complex essential drugs and nutrients. “With this kind of disruption, patients can’t get through on the phones. They panic,” said Cynthia Reddick, a senior nutritionist laid off last summer in the CVS restructuring. “It was very difficult. Many emails, many phone calls, acting as a liaison between my doctor and the company,” said Elizabeth Fisher Smith, a 32-year-old public health instructor in New York, whose Coram branch closed. A rare medical disorder has forced her to rely on PN for survival since 2017. “It added to my mental burden,” she said Home and outpatient infusions in the USA are a growing business, as new drugs for chronic illness expand treatment options and enable patients, providers and insurers to avoid hospitalisation. But while reimbursement for expensive new drugs has attracted corporations and private equity, the industry is constrained by a lack of nurses and pharmacists. The less profitable parts of the business — and the vulnerable patients they serve — are at risk. This includes the 30,000-plus Americans who rely on parenteral nutrition — including premature infants, post-surgery patients and those with damaged bowels because of genetic defects. Read full story (paywalled) Source: The Washington Post, 6 February 2023
  10. News Article
    Exploitative and “underhand” marketing of formula milk is preventing millions of women from breastfeeding, according to a series of reports published in the Lancet. The reports, by 25 experts from 12 countries, including paediatricians, public health specialists, scientists, economists and midwives, finds that the commercial milk formula companies “exploit parents’ emotions and manipulate scientific information to generate sales at the expense of the health and rights of families, women and children”. Breastfeeding promotes brain development, protects infants against malnutrition, infectious diseases and death, while also reducing risks of obesity and chronic diseases in later life. It also helps protect mothers against breast and ovarian cancers. The World Health Organization (WHO) recommends exclusively breastfeeding babies for the first six months and giving breast milk alongside solid food until the age of two or beyond. Over three reports, the series reveals how, more than 40 years since the World Health Assembly developed a voluntary international code prohibiting the marketing of infant formula, widespread violation of the code persists, with promotion of infant formula milk continuing in about 100 countries in every region of the world since the code was adopted. Read full story Source: The Guardian, 7 February 2023
  11. News Article
    Families of people with dementia have said there is a national crisis in care safety as it emerged that more than half of residential homes reported on by inspectors this year were rated “inadequate” or requiring improvement – up from less than a third pre-pandemic. Serious and often shocking failings uncovered in previously “good” homes in recent months include people left in bed “for months”, pain medicine not being administered, violence between residents and malnutrition – including one person who didn’t eat for a month. In homes in England where standards have slumped from “good” to “inadequate”, residents’ dressings went unchanged for 20 days, there were “revolting” filthy carpets, “unexplained and unwitnessed wounds” and equipment was ”encrusted with dirt”, inspectors’ reports showed. Nearly one in 10 care homes in England that offer dementia support reported on by Care Quality Commission inspectors in 2022 were given the very worst rating – more than three times the ratio in 2019, according to Guardian analysis. Read full story Source: 29 December 2022
  12. News Article
    A US organisation that supports people with eating disorders has suspended use of a chatbot after reports it shared harmful advice. The National Eating Disorder Association (Neda) recently closed its live helpline and directed people seeking help to other resources, including the chatbot. The AI bot, named "Tessa," has been taken down, the association said. It will be investigating reports about the bot's behaviour. In recent weeks, some social media users posted screenshots of their experience with the chatbot online. They said the bot continued to recommend behaviours like calorie restriction and dieting, even after it was told the user had an eating disorder. For patients already struggling with stigma around their weight, further encouragement to shed pounds can lead to disordered eating behaviours like bingeing, restricting or purging, according to the American Academy of Family Physicians. Read full story Source: BBC News, 2 June 2023
  13. News Article
    A son has accepted a settlement and an apology from the north Wales health board nearly 10 years after his mother was a patient in a mental health unit. Jean Graves spent nine weeks at the Hergest unit in Ysbyty Gwynedd in Bangor in 2013 after struggling with anxiety and depression. Her son David said she was left "severely malnourished" and fell. He previously said his mother - who was 78 when she was treated at the unit - collapsed six times and, over the course of six weeks, lost 25% of her body mass. The health board also apologised for the "distress" the family experienced while seeking answers "over many years" and said it hopes to "learn and improve" from Mr Graves's experience. In a letter to him, executives said: "It is very clear to us that we have failed your mother and that she should have had a better care whilst in our services." It said her records were incomplete or were "amended without proper evidence" and she was placed on a ward with a mix of patients with both psychiatric illness and older organic mental illness, which was not "best practice". Read full story Source: BBC News, 26 March 2023
  14. Content Article
    The number of children and young people admitted to children’s wards with an eating disorder has increased significantly since the start of the Covid-19 pandemic. In the most extreme cases, those with severe malnutrition may need to be fed via a nasogastric tube without their consent. Children’s nurses working on hospital wards may therefore care for children and young people who need to receive nasogastric tube feeding under physical restraint. This article offers an overview of eating disorders and their detrimental effects as well as practical advice for children’s nurses, supporting them to provide safe, compassionate and person-centred care to their patients.
  15. News Article
    Vulnerable parents may be forced to resort to unsafe practices to feed their babies because of sharp increase in the cost of infant formula, charities have warned. The price of the cheapest brand of baby formula has leapt by 22%, according to analysis by the British Pregnancy Advisory Service (BPAS). BPAS said the cost of infant formula needed to safely feed a baby in the first six months of their life was no longer covered by Healthy Start vouchers, which are worth £8.50 a week and provided to women in England, Wales and Northern Ireland who are pregnant or have young children. The charity Feed said families that were unable to afford enough infant formula had resorted to watering down the product or feeding their babies unsuitable food such as porridge. BPAS’s chief executive, Clare Murphy, said: “We know that families experiencing food poverty resort to unsafe feeding methods, such as stretching out time between feeds and watering down formula. The government cannot stand by as babies are placed at risk of malnutrition and serious illness due to the cost of living crisis and the soaring price of infant formula. “The government must increase the value of Healthy Start vouchers to protect the health of the youngest and most vulnerable members of our society.” Read full story Source: The Guardian, 6 December 2022
  16. News Article
    It has been revealed that three patients a day are dying from starvation or thirst or choking on NHS wards. In 2017, 936 hospital deaths were attributed to one of those factors, with starvation the primary cause of death in 74 cases.The Office for National Statistics data reveals malnutrition deaths are 34% higher than in 2013. Over-stretched nurses are simply too busy to check if the sick and elderly are getting nourishment. However, Myer Glickman from the ONS says the data is not conclusive proof of poor NHS care. He said:“There has been an increase over time in the number of patients admitted to hospital while already malnourished. This may suggest that malnutrition is increasingly prevalent in the community, possibly associated with the ageing of the population and an increase in long-term chronic diseases.” Yet campaigners say too many vulnerable people are being “forgotten to death” in NHS hospitals and urgent action is needed to identify and treat malnutrition. In a recent pilot scheme the number of deaths among elderly patients with a fractured hip was halved by simply having someone to feed them. Six NHS trusts employed a junior staff member for each ward tasked with getting 500 extra calories a day into them. More survived and the patients spent an average five days less in hospital, unblocking beds and saving more than £1,400 each. It wasn’t just the calories though – it helped keep their morale up. Because, as one consultant said: “Food is a very, very cheap drug that’s extremely powerful.” Read full story Source: Mirror, 4 February 2020
  17. News Article
    Hundreds of patients have been warned supply problems with the specially made IV feed they need to stay alive is likely to continue for months. NHS England, which declared a national emergency incident in the summer because of the delays in production of intravenous nutrition, has written to patients warning the problems are far from resolved. Dozens of patients have been admitted to hospital in the past six months because of the supply shortage, which was sparked in June when the main manufacturer, Calea, based in Runcorn, was hit by overnight restrictions by the Medicines and Healthcare products Regulatory Agency (MHRA). Since the shortages started the NHS has been forced to fly in feed from other European countries, while some patients have had to switch from their bespoke feed to so-called off-the-shelf bags which don’t contain everything they need in the right quantities. Some hospitals have admitted patients to hospital to make sure they receive what they need because of fears for their health or lack of supplies in the community. Initially it had been hoped the delays in production would be improved by the end of the year, but in a letter sent to some patients, seen by The Independent, NHS bosses warn patients could be facing many more months of delays. Read full story Source: The Independent, 1 January 2020
  18. Content Article
    Van Thai Tuyen was admitted to the Royal London Hospital on 1 August 2021 for treatment of a stroke. A nasogastric tube was inserted to administer medication and food, due to Mr Tuyen being assessed as having an unsafe swallow. Despite an x-ray showing that the nasogastric tube had been misplaced into his right lung the tube was used to administer approximately 300ml of liquid feed. This caused the cavitating necrotising pneumonia from which he died.
  19. Content Article
    A review of government policies tackling smoking, poor diet, physical inactivity and harmful alcohol use in England.
  20. Content Article
    Use of misplaced nasogastric and orogastric tubes was first recognised as a patient safety issue by the National Patient Safety Agency (NPSA) in 2005 and three further alerts were issued by the NPSA and NHS England between 2011 and 2013. Introducing fluids or medication into the respiratory tract or pleura via a misplaced nasogastric or orogastric tube is a Never Event. Never Events are considered ‘wholly preventable where guidance or safety recommendations that provide strong systemic protective barrier are available at a national level, and should have been implemented by all healthcare providers.’ Between September 2011 and March 2016, 95 incidents were reported to the National Reporting and Learning System (NRLS) and/or the Strategic Executive Information System (StEIS) where fluids or medication were introduced into the respiratory tract or pleura via a misplaced nasogastric or orogastric tube. While this should be considered in the context of over 3 million nasogastric or orogastric tubes being used in the NHS in that period, these incidents show that risks to patient safety persist. Checking tube placement before use via pH testing of aspirate and, when necessary, x-ray imaging, is essential in preventing harm.
  21. Content Article
    This article looks at NHS safety advice on reducing the harm caused by nasogastric feeding tubes that have been wrongly inserted. The alert, from the National Patient Safety Agency, followed 11 deaths of patients in two years, including that of one child.
  22. Content Article
    Dr Frances Healey provides her personal perspective on the continuing persistence of harm caused by misplaced nasogastric tubes from her experience both as a nurse and head of patient safety insight at NHS Improvement.  
  23. Content Article
    Misplacement of nasogastric tubes can have disastrous consequences for patients and is listed as a “never event” by NHS England. When Lancashire Teaching Hospitals NHS Foundation Trust had two of these never events, the nutrition nursing team carried out a system-wide evaluation to identify problems and develop plans to address them. An e-learning package, robust standardisation in staff’s approach to patient care, re-setting “red lines” to support and empower staff, and the introduction of monitoring and reporting systems have contributed to improving patient safety.
  24. Content Article
    Continuing Professor Martin Langham's 'Why investigate' blog series, colleague Bobbie Enright turns to the topic of fatigue, looking at the causes and preventions, how it can impact on our work and how we can manage it.
  25. Event
    The Everywoman festival is a one day event aimed at all women over the age of 16 and aims to empower women to understand what is normal and when to seek help for issues that can affect 90% of women at some point in their life. The festival combines more than 40 workshops and 6 themed seminar sessions with a fun, relaxed environment with art workshops, food and drink, music and charity stands. Themes are wide ranging and include periods and endometriosis, pelvis pain and bladder, childbirth injury, menopause and sexual wellbeing. Additional drop in sessions to meet the consultant experts as well as book readings and signings will be available on the day. The Everywoman Festival will be held in the heart of Cardiff in the beautiful venue of Insole Court. It will feature a range of interactive workshops and talks from leading health experts. Attendees will have the opportunity to learn about everything from nutrition and fitness to mindfulness through art. For those who are looking for something a little more active, there will be a variety of fitness classes and workshops taking place throughout the day. From seated yoga, Pilates to Belly dancing and dancing lessons from Heels empowerment, there's something for everyone, regardless of their fitness level. Charities attending with stalls and information include Coppa feel, Endometriosis UK, Womens Aid, the Menstrual project and Fair Treatment for Women of Wales. Health stalls from Muslim Doctors Cymru, Medtronic, Mcgregor, THD will be on hand to provide information and signpost for everything from your bladder and bowels, childbirth to high blood pressure. Some of the highlights of the festival are the wellness market, where attendees can shop for a wide variety of health and wellness products and in the creative market products from artists such as Black and Beech, Melin Trygwynt and Eliza Eliza. Further tickets and information Follow on instagram @Theeverywomanfestival A5leaflet Everywoman (2).pdf
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