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Found 49 results
  1. News Article
    More than 30 members of staff at a major NHS mental health hospital have been suspended over claims of serious misconduct including falsifying medical records and mistreating patients, The Independent has learned. The suspensions come after an internal investigation into serious conduct allegations at Highbury Hospital in Nottinghamshire, which employs hundreds of staff members. The suspended employees include registered professionals – such as doctors, nurses and nursing associates – and non-registered professionals, which would cover healthcare assistants and non-clinical staff. It comes just a week after the same trust – Nottinghamshire Healthcare Foundation Trust – was issued with a warning by the safety watchdog over concerns about the safety of patients at Rampton Hospital, a high secure hospital which has housed patients such as Charles Bronson and Ian Huntley. In an email leaked to The Independent, the trust told staff: “We are saddened to report that over recent weeks it has been necessary to suspend over 30 colleagues due to very serious conduct allegations. “These allegations have included falsifying mental health observations, as well as maltreatment of patients in our care. “We hope we have your understanding in taking action when the conduct of colleagues falls so far outside of what patients deserve.” Read full story Source: The Independent, 23 January 2024
  2. Event
    This conference focuses on recognising and responding to the deteriorating patient and ensuring best practice in the use of NEWS2. The conference will include national developments, including the recent recommendations on NEWS2 and Covid-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, the role of human factors in responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis and Covid-19, involving patients and families in recognising deterioration, using clinical judgement, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. The Recording of NEWS2 score, escalation time and response time for unplanned critical care admissions is now an NHS CQUIN goal. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/deteriorating-patient-summit or email aman@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for the discount code. Follow on Twitter @HCUK_Clare #DeterioratingPatient
  3. News Article
    Hospital neglect contributed to the death of a two month old baby after staff turned off emergency alarms, a coroner has ruled. Louella Sheridan died at Royal Bolton Hospital in on 24 April 2022 after she was admitted with bronchiolitis to the hospital’s intensive care unit before later dying from Covid and a related heart condition. Four alarms on a monitoring machine were silenced and then switched off before the baby collapsed in a high dependency unit, it has been found. On Wednesday coroner John Pollard ruled neglect by staff had contributed to Louella’s death after staff switched off the alarms on the monitors attached to her during the night. Summing up his conclusion Coroner Pollard reportedly said there was a “gross failure “ to provide basic medical care to Louell and that had care been given, had the alarms been switched on to alert staff her life may have been extended at least for a short period of time. He said turning off the alarms was a gross type of conduct. Read full story Source: The Independent, 22 December 2023
  4. Content Article
    This blog calls for action on the careful review of established pain medication when a patient is admitted to hospital. Richard describes the experience of two elderly patients who suffered pain due to their long term medication being stopped when they were admitted to hospital. Pain control needs must not be ignored or undermined, there needs to be carer and patient involvement and their consent, and alternative pain control must be considered.
  5. News Article
    Priory Healthcare faces legal action following the death of a vulnerable man who was hit by a train after leaving Birmingham’s Priory Hospital Woodbourne in September 2020. Matthew Caseby, 23, detained under the Mental Health Act, escaped the hospital by climbing a 2.3-metre fence. The inquest jury, which heard the University of Birmingham graduate should have been under constant observation but was left alone, reached a conclusion that his death “was contributed to by neglect”. Concerns were raised about the hospital's record-keeping, risk assessments, and fence safety. Following the inquest, the Care Quality Commission (CQC) charged Priory Healthcare with two offences under the Health and Safety Act 2008, related to failing to provide safe care and treatment, and exposing a patient to avoidable harm. Read full story Source: ITV, 6 November 2023
  6. News Article
    A private healthcare provider has been ordered to pay more than £1.5m – the largest fine issued for such a case – after pleading guilty in a criminal prosecution brought by the Care Quality Commission (CQC) over the death of a young woman at Cygnet Hospital Ealing in July 2019. It is the highest ever fine issued to a mental health service following a prosecution by the CQC. The firm pleaded guilty to one offence of failing to provide safe care and treatment, acknowledging failures to: provide a safe ward environment to reduce the risk of people being able to use a ligature; ensure staff observed people intermittently in line with the company procedures; and train staff to be able to resuscitate patients in an emergency. The offences related to the case of a young woman who was admitted to a ward in Cygnet Hospital Ealing in November 2018. In July 2019, she took her own life while on the ward. CQC said Cygnet Ealing had been aware the young woman tried to harm herself in an almost identical way four months earlier, but had failed to mitigate the known environmental risk she was exposed to. Read full story (paywalled) Source: HSJ, 21 September 2023
  7. Content Article
    Monitoring and responding to deterioration in social care settings is critical to providing safe, effective and responsive care. Front-line staff are pivotal for highlighting change to wider teams and managing low to medium risk individuals in their place of residence. However, there is a core set of principles that most systems use which may not be used by non-clinical staff in residential settings. This case study explores an intervention to empower non-clinical staff to take observations. The Whzan blue box contains a digital tablet and equipment to take temperature, pulse, oxygen saturation levels and blood pressure measurements. Staff were trained and supported on site to use the system and set up a digital platform to share measurements with wider teams. Staff fed back that they felt empowered and able to better engage in conversation with health care professionals, highlighting the importance of having a common language. This case study was submitted to the Care Quality Commission (CQC) by North East and North Cumbria ICB.
  8. Event
    This conference focuses on recognising and responding to the deteriorating patient and ensuring best practice in the use of NEWS2. The conference will include National Developments including the recent recommendations on NEWS2 and Covid-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, the role of human factors in responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis & Covid-19, involving patients and families in recognising deterioration, using clinical judgement, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit. Twitter @HCUK_Clare #DeterioratingPatient hub members receive a 20% discount. Email info@pslhub.org
  9. Content Article
    According to the UK Sepsis Trust, sepsis affects 245,000 people every year in the UK alone, and 48,000 people die of sepsis-related illnesses. Sepsis arises when the body’s response to an infection injures its own tissues and organs. It may lead to shock, multi-organ failure, and death – especially if not recognised early and treated promptly. At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. We have pulled together six useful resources about sepsis that have been shared on the hub. They include advice on recognising and managing sepsis along with educational materials.
  10. News Article
    The family of a student who died after hospital staff missed that she had developed sepsis despite a string of warning signs have claimed she was the victim of a “lack of care”, as a coroner ruled there were “gross” failures in her treatment. Staff at Southmead hospital in Bristol failed to carry out the sepsis screening and observations needed to keep 20-year-old Maddy Lawrence safe after she was taken to hospital with a dislocated hip sustained in a rugby tackle. Outside court, the student’s mother, Karen Lawrence, said: “It has been a constant struggle to understand how a healthy, strong and fit 20-year-old could lose her life to sepsis which was allowed to develop under the care of professionals. “Her screams of pain and our pleas for help were merely managed, temporarily quietened with painkillers while the infection progressed unnoticed by hospital staff. “Our daughter was failed by a number of nurses and medical staff; symptoms were ignored, observations were not taken, on one occasion for 16 hours. There was no curiosity, basic tests were not completed even when hospital policy required them. “Maddy herself expressed concern on multiple occasions but her pain was not being taken seriously. As well as failing to fulfil their duty, those nurses and medical staff offered no sympathy, no compassion and little attention. “This failure meant Maddy was not given the chance to beat sepsis. Significant delays in its discovery meant the crucial window for treatment was missed. Maddy did not die due to under-staffing or a lack of money. Her death was the result of a lack of care.” Read full story Source: The Independent, 8 September 2023
  11. News Article
    Staff fell asleep while on duty at a mental health trust, inspectors found. The Care Quality Commission (CQC) said it was "very disappointed" to find patient safety being affected by the same issues it had seen previously. It said on acute wards for adults of working age and psychiatric intensive care units, five patients described staff falling asleep at night. Despite CCTV being available, managers told the CQC they could not always immediately prove staff had been sleeping as accessing the pictures could take up to a fortnight. The CQC report added trust data from June to December 2022 recorded 20 incidents of staff falling asleep while on duty but no action was taken because the video evidence had not been viewed. Rob Assall, the CQC's director of operations in London and the East of England, said: "When we inspected the trust, we were very disappointed to find people's safety being affected by many of the same issues we told the trust about at previous inspections. "This is because leaders weren't always creating a culture of learning across all levels of the organisation, meaning they didn't ensure people's care was continuously improving or that they were learning from events to ensure they didn't happen again." Read full story Source: BBC News, 12 July 2023
  12. News Article
    A private hospital facing a police investigation following a patient’s death has been given an urgent warning by the care regulator due to concerns over patient safety. The Huntercombe Hospital in Maidenhead, which treats children with mental health needs, was told it must urgently address safety issues found by the Care Quality Commission (CQC) following an inspection in March. The CQC handed the hospital a formal warning due to concerns over failures in the way staff were carrying out observations of vulnerable patients. The move comes as The Independent revealed police are investigating the hospital in relation to the death of a young girl earlier this year. In a report published last week, the care watchdog said it had received “mainly negative” feedback from young people at the hospital’s Thames ward, a psychiatric intensive care unit which treats acutely unwell children. Commenting on the hospital overall, the report said: “Young people told us that staff did not follow the care plans in relation to their level of observations. They told us that if there was an incident the staff stopped doing intermittent observations. Staff in charge of shifts on wards asked new staff members to do observations before they understood how to do it. Staff had to ask the young person how to carry out their observations as they did not always understand what was expected of them in carrying out different levels of observations.” Read full story Source: The Independent, 19 May 2022
  13. News Article
    A hospital has admitted clinical negligence over maternity care failings that led to the potentially avoidable death of a 10-day-old baby, The Independent has learned. Kingsley Olasupo and his twin sister Princess were born on 8 April 2019 at Royal Bolton Hospital. Kingsley died 10 days later following a catalogue of mistakes, which included failing to screen him for sepsis. Kingsley and his sister were born premature at 35 weeks. Three days later he was admitted to the special care unit due to a low temperature and “poor” feeding. Despite being reviewed by two doctors he was not screened for an infection and not given antibiotics. His condition deteriorated and on 12 April he was diagnosed with bacterial meningitis and sepsis. Days later scans revealed he had severe brain damage and would not survive. Kingsley’s family said they had been “torn apart” by their son’s death and had pursued the trust to ensure a full independent investigation was carried out and lessons learnt. BFT launched an investigation into Kingsley’s care after Mr Olasupo and Ms Daley raised concerns over their son’s death. According to the trust’s investigation report, seen by The Independent, failings in care included that Kingsley was not screened for sepsis despite several “red flags”. Had this been done he would have been given antibiotics. When midwives first escalated concerns to the neonatal team no physical medical review of Kingsley took place. The investigation also found neonatal staff did not carry out daily reviews, and reviews that were done were incomplete and contained “inaccurate” and “misleading” information. Other failings included: “Ineffective” assessment of Kingsley’s wellbeing on the postnatal ward Poor communication between staff and poor handover processes No consideration was given to the fact Kingsley was not feeding well Inadequate recording of observations. Read full story Source: The Independent, 20 April 2022
  14. News Article
    The chief executive of a mental health trust grappling with care quality failures has described his anger at ‘disrespectful’ staff who have ‘now had to leave the organisation’. In a message to staff, seen by HSJ, Brent Kilmurray, chief executive of Tees Esk and Wear Valleys Foundation Trust, said a number of staff had “stepped away from our values”. HSJ has heard reports of 12 staff members within the trust’s forensic secure inpatient services being suspended in recent weeks, and some dismissed, after being caught sleeping on shifts and using electronic devices while meant to be observing patients. The reports are unconfirmed, but appear to be referenced in a message sent by Brent Kilmurray on 14 March, which said: “I’m sorry to say, there’s been a handful of people who have stepped away from our values and in doing so have now had to leave the organisation." Mr Kilmurray said the staff were in a “minority” and that when the trust investigated these matters “we have found far more excellent caring practice”. He added the trust is working with service leaders “to ensure that they understand their accountabilities for ensuring that services are safe”. Read full story (paywalled) Source: HSJ, 14 April 2022
  15. News Article
    A young woman died following “gross failings” and “neglect” by a mental health hospital in Essex which is also facing a major independent inquiry into patient deaths. Bethany Lilley, 28, died on 16 January whilst she was an inpatient at Basildon Mental Health unit, run by Essex Partnership University Hospitals. The inquest examined the circumstances of her death this week and concluded that her death was contributed by neglect due to a “plethora of failings by Essex University Partnership Trust”. Following the three week inquest, heard before coroner Sean Horstead, a jury found “neglect” contributed to Ms Lilley’s death and identified “gross failures” on behalf of the trust. The jury identified a number of failings in her care including evidence that cocaine had made its way onto a ward where she was an inpatient. There was evidence of “very considerable problems in the record-keeping at EPUT psychiatric units.” It was also concluded staff failed to carry out a risk assessment of Ms Lilley in the days leading up to her death, and failed to carry out observations. Ms Lilley’s death is one of a series of patients who have died under the care of mental health services in Essex, which have been brought into the light following the campaigning of bereaved families. Read full story Source: The Independent, 19 March 2022
  16. News Article
    Serious failings by healthcare staff at Broadmoor Hospital were likely to have contributed to the death of a patient from self-asphyxiation, a jury has found. Following a two-week inquest at Reading Coroner’s Court, a jury found staff failed to recognise and reduce the risks that acutely unwell patient Aaron Clamp presented to himself in the minutes leading to his death. Mr Clamp died on 4 January 2021 after choking in his room at the NHS-run high secure mental health hospital Broadmoor. In the weeks prior to his death, Mr Clamp’s mental health had deteriorated. He was transferred into a “psychiatric intensive care” ward at Broadmoor Hospital and placed in long-term segregation. A summary of the jury’s findings shared with The Independent has found there was “a serious failure in the timely manner to recognise and reduce the level of risk, and a serious failure to recognise and execute the steps to remove the item of fabric” that Mr Clamp choked on. “This omission probably contributed to the death,” the jury said. It was also found there was “insufficient” recording by the trust of previous incidents of self-asphyxiation by Mr Clamp when he died. Jurors said the plan for staff to carry out constant eyesight observations was appropriate, but not all aspects of the plan were adequately followed by staff members. Read full story Source: The Independent, 7 March 2022
  17. News Article
    Staff at a mental health trust, run by Norfolk and Suffolk NHS Foundation Trust, falsified records that they had checked on a vulnerable patient the night he died, an inquest has heard. Eliot Harris was found dead in his room at Northgate Hospital in Great Yarmouth, Norfolk, in April 2020. A police witness statement detailed how CCTV footage contradicted 19 log entries. Mr Harris, 48, was admitted to hospital after the care home where he was a resident requested an urgent mental health assessment, an inquest into his death at Norfolk Coroner's Court heard. He had been diagnosed with paranoid schizophrenia, had a history of epileptic seizures and had not been taking his medication. Mr Harris was deemed to be high risk and was supposed to be on regular checks four times an hour. In a witness statement read out in court, Det Sgt Nick Appleton described how police had cross referenced logs of his observations with CCTV recordings. Det Sgt Appleton listed 19 instances in which the observation record was signed by a staff member that night, indicating Mr Harris had been checked, but was not backed up by the CCTV record. He identified a number of "points of concern" in his evidence in which falsifying logs was "normal" and "standard practice" on wards. Read full story Source: BBC News, 1 August 2022
  18. News Article
    A hospital and one of its managers are facing a criminal investigation into the death of a vulnerable man who absconded by climbing a fence. An inquest concluded failings amounting to neglect contributed to the death of Matthew Caseby in 2020, after he fled from Birmingham's Priory Hospital Woodbourne and was hit by a train. The investigation will be carried out by the Care Quality Commission (CQC). Priory said it would co-operate fully "if enquiries are raised by the CQC". Mr Caseby, 23, climbed over a 2.3m-high (7ft 6in) courtyard fence on 7 September 2020. He was found dead the following day after being hit by a train near Birmingham's University station. The inquest in April heard other patients had previously climbed the fence and, despite concerns by members of staff, no action was taken to improve security in and around the courtyard until another patient absconded two months after Mr Caseby's death. Following the inquest, coroner Louise Hunt said she was concerned the fence and courtyard area may still not be safe and urged health chiefs to consider imposing minimum standards for perimeter fences at mental health units. She also criticised record-keeping and how risk assessments were carried out. Read full story Source: BBC News, 23 June 2022
  19. Content Article
    The University Hospital Southampton share their poster on using NEWS2 and SBAR.
  20. Content Article
    The Between the Flags (BTF) system is a 'deteriorating patient safety net system' for patients who are cared for in New South Wales (NSW) public health facilities in Australia. It is designed to assist clinicians to recognise when patients are deteriorating and to respond appropriately when they do.
  21. News Article
    A coroner has raised concerns about a mental heath trust where staff falsified records made on the night a man died. Eliot Harris, 48, died in the Northgate Hospital in Great Yarmouth, run by the Norfolk and Suffolk Foundation Trust (NSFT), in April 2020. Norfolk coroner Jacqueline Lake said that, two years on, staff were still not recording observations properly. The 48-year-old, who had schizophrenia, had been sectioned under the Mental Health Act after he became agitated at his care home and refused to take medication. He was taken to Northgate Hospital and, after a period in a seclusion room, was transferred to a private room on the ward. Mr Harris was discovered unresponsive in bed during the early hours of 10 April and pronounced dead half an hour later. In a Prevention of Future Deaths Report (PFDR), Ms Lake said: "Quality audits undertaken following Eliot Harris's death, show that observations are still not being carried out and recorded in accordance with NSFT's most recent policy - more than two years following Eliot's death." She said that on the night Mr Harris died there was no nurse in charge and instead of being allocated specific tasks, staff were told to "muck in", causing confusion about job responsibilities. These issues were not resolved at the time of the inquest, she said, with no evidence provided about whether specific tasks were allocated on the night shift. Not all staff had been trained in recording observations, there was a lack of evidence about procedures for entering a patient's room over concerns for their welfare, and there was "still some way to go to make sure care plans are completed", Ms Lake said. Read full story Source: BBC News, 6 October 2022
  22. Content Article
    Measures exist to improve early recognition of and response to deteriorating patients in hospital. However, management of critical illness remains a problem globally; in the United Kingdom, 7% of the deaths reported to National Reporting and Learning System from acute hospitals in 2015 related to failure to recognise or respond to deterioration. The current study from Albutt et al. explored whether routinely recording patient-reported wellness is associated with objective measures of physiology to support early recognition of hospitalised deteriorating patients. The preliminary findings suggest that patient-reported wellness may predict subsequent improvement or decline in their condition as indicated by objective measurements of physiology (NEWS). Routinely recording patient-reported wellness during observation shows promise for supporting the early recognition of clinical deterioration in practice, although confirmation in larger-scale studies is required.
  23. Content Article
    Eurocontrol’s HindSight magazine is a magazine on human and organisational factors in operations, in air traffic management and beyond. This issue has articles from front-line staff and specialists in safety, human factors, and human and organisational performance, in aviation and elsewhere. The articles cover all aspects of everyday work, including routine work, unwanted events, and excellence. The authors discuss a variety of ways to learn from everyday work, including observation, discussion, surveys, reflection, and data analysis. There are articles on specific topics to help learn from others’ experience, including from other sectors in ‘views from elsewhere’
  24. News Article
    The proportion of newborn babies receiving a timely health visitor check-in has fallen sharply, with one in five missing out in the most recent statistics available. Official data reveals that only 82.6% of babies received a new birth visit within their first fortnight in 2021-22, as is recommended, and in the fourth quarter of the year it dropped as low as 79.3%. This is the lowest proportion recorded in recent years in the annual dataset on health visitor service delivery metrics, published by the Office for Health Improvements and Disparities. According to the NHS website, a health visitor new birth visit is supposed to take place between 10 and 14 days after birth and is designed to offer advice on issues including safe sleeping, vaccinations, infant feeding, infant development, and adjusting to life as a parent. Kate Holmes, head of support and information at charity The Lullaby Trust, said: “Safer sleep saves babies’ lives and all families should be given advice on how to reduce the risk of sudden infant death syndrome for their baby. The new birth visit is a key opportunity for health visitors to talk to families about safer sleep and to provide them with information and support that takes their individual and family circumstances into account.” Read full story (paywalled) Source: HSJ, 7 November 2022
  25. News Article
    Brain complications, including stroke and psychosis, have been linked to COVID-19 in a study that raises concerns about the potentially extensive impact of the disease in some patients. The study, published in Lancet Psychiatry, is small and based on doctors’ observations, so cannot provide a clear overall picture about the rate of such complications. However, medical experts say the findings highlight the need to investigate the possible effects of COVID-19 in the brain and studies to explore potential treatments. “There have been growing reports of an association between COVID-19 infection and possible neurological or psychiatric complications, but until now these have typically been limited to studies of 10 patients or fewer,” said Benedict Michael, the lead author of the study, from the University of Liverpool. “Ours is the first nationwide study of neurological complications associated with Covid-19, but it is important to note that it is focused on cases that are severe enough to require hospitalisation.” Scientists said the findings were an important snapshot of potential complications, but should be treated with caution as it is not possible to draw any conclusions from the data about the prevalence of such complications. Read full story Source: The Guardian, 26 June 2020
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