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Found 67 results
  1. News Article
    An NHS mental health trust, recently found guilty of serious failings in the care of a young patient who took her own life, has had serious concerns raised over the deaths of 20 other patients over the last 10 years, the BBC has found. Coroners have repeatedly highlighted issues about the North East London NHS Foundation Trust (NELFT), including about the quality of risk assessments and record-keeping. In two cases patient notes were found to have been falsified. Including one man who was recorded as eating breakfast three days after he had died. An Old Bailey jury last week found the trust guilty of health and safety breaches in the care of 22-year-old Alice Figueiredo who was an inpatient at NELFT's Goodmayes hospital. The BBC can now reveal in the decade since Alice's death, NELFT has been repeatedly criticised by coroners for failures in patient care. In the last decade, nearly 30 prevention of future deaths (PFD) reports from coroners have mentioned NELFT. Of these, the BBC has analysed 20 which raise the most serious concerns. In two cases where patients took their own lives inquests concluded records had been altered after their deaths. The most common criticism found the assessment of the risk patients posed to themselves was poor or incomplete. Cases also highlighted poor record-keeping, a lack of communication between teams, staff shortages and high caseloads. Two patients who died of overdoses were said to have been on short-term medication for 18 years and 20 years, with no record of that having been reviewed. Read full story Source: BBC News, 18 June 2025
  2. Content Article
    This paper identifies some of issues around transitions of care when a patient leaves an intensive care unit (ICU) for ‘a general medical ward (or other de-escalated care settings, such as a step-down unit) for observation, treatment, and discharge planning.’ The authors describe a checklist to support safe ICU transfers of patients to medical wards or step-down units.  The proposed 7-step checklist has the mnemonic SIMPLER: Stable vital signs Intact aeration Medications reviewed Prepared psychology Lingering catheters Extreme laboratory findings, and Return plans. The authors state: "The first 3 steps are prerequisites in a medical ward and denote the importance of stable vitals signs, intact aeration, and a diligent medication check. The next 3 steps are priorities in the ICU and involve determining patient expectations, managing catheters or other devices, and reviewing laboratory results. The final step concerns contingency plans for unforeseen deteriorations and goals of care."
  3. News Article
    A mother whose daughter was found to have been neglected by a hospital before taking her own life has blamed the “failures of the system” for her daughter’s death and has demanded improved care for future patients. Court documents show Iona Imogen Lee’s suicide is one of at least five deaths that failures at Derbyshire’s mental health units caused or contributed to in the past decade. The health and social care regulator is currently reviewing information over three deaths at the units. Morag Lee opened up about her “inspiring, friendly, loved” daughter Iona’s heartbreaking final hours on the Hartington Unit at the Chesterfield Royal Hospital in Chesterfield, before the 24-year-old was transferred to the ICU where she died on 18 September 2023. The 57-year-old mother, from Derby, spoke to The Independent after a coroner ruled in January that her child had died by “suicide contributed to by neglect” on the ward where she had been detained under the Mental Health Act on 15 September 2023. It was found at the inquest into Iona’s death in January that “there were a series of errors in the planning, management and implementation of Iona's observations after admission” and that “instruction, information and supervision were all inadequate, as was the primary induction”. The jury concluded that Iona’s observation level should have been raised to being kept within staff’s eyesight, but due to staff shortages on the ward, she was only being checked intermittently. Even then, this should have been at least every 15 minutes, but the 24-year-old was not found until 43 minutes after she was last seen. MS Lee raised “serious concerns” about the management of the Hartington Unit and believes blame also lies with this and previous governments in their role overseeing a crippled NHS. Inquests over the last 10 years identified failures by the Hartington and Radbourne Units that caused or contributed to at least five deaths, including over incorrect decisions around patients being granted leave or discharged from the wards, wrongful prescription of medications, and inadequate risk assessment. In a report, coroner issued a warning to the Trust asking for policy change for fear of risking future deaths. Calling for change for future patients, Ms Lee said: “In the past year, the hospital have changed their policies, but guidance was in place two years ago that wasn’t followed and led to my daughter’s death – so how do we know that what’s in place now will continue being implemented? What reassurances does the public have?” Read full story Source: The Independent, 13 April 2025
  4. News Article
    A coroner has voiced serious concerns over a recurring "lack of observations" at London's Royal Free Hospital following the death of a teenager. Sixteen-year-old Billie Wicks died after suffering her first ever asthma attack. Her parents rushed her to the Hampstead hospital on 17 September last year, but a new report reveals the A&E department was "understaffed" that night. The coroner's concerns highlight a potential systemic issue at the hospital regarding patient monitoring. Senior coroner for Inner North London, Mary Hassell, said that Billie should have had routine checks, or observations, taken every hour. If she had these observations, then medics would have recognised the severity of Billie’s illness, Ms Hassell said. “Billie was inappropriately discharged at approximately 3.30am without adequate repeat observations or senior clinical review, and so her asthma was not diagnosed or treated. If it had been, she probably would have survived,” she wrote in a prevention of future deaths report. “Billie should have had observations every hour. If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review. “That senior medical review would have changed the course of her management and saved her life.” Read full story Source: The Independent, 18 March 2025
  5. Content Article
    On 17 September 2024, Edwin Buckett, commenced an investigation into the death of Billie Wicks aged 16 years. The investigation concluded at the end of the inquest on 6 March 2025. Billie had been brought to the Royal Free Hospital just before midnight the night before her death with an asthma attack.   A first presentation of asthma at the age of 16 years without any family history is unusual, and it was a busy night in the accident and emergency department. Billie was inappropriately discharged at approximately 3.30am without adequate repeat observations or senior clinical review, and so her asthma was not diagnosed or treated. If it had been, she probably would have survived. The MATTERS OF CONCERN are as follows: On the night Billie attended, the Royal Free emergency department was understaffed, and that it remains understaffed of doctors, nurses, and even a healthcare assistant who could take basic observations. Billie should have had observations every hour. If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review. That senior medical review would have changed the course of her management and saved her life. The registrar who saw Billie the night before her death prescribed an antibiotic, but he was not in the habit of giving the first dose in the department and he did not on this occasion. This meant that Billie’s infection was not tackled as quickly as it could have been. This seems to indicate a training and potentially a guideline need. At the time of Billie’s presentation, the registrar was unaware of the possibility of adult onset asthma. This seems to indicate a training and potentially a guideline need. I heard that Billie was safety netted when she was discharged. Her parents were told to bring her back if they had any concerns. I have heard this safety netting advice being described many, many times in different inquests. What worries me about it in this context is that Billie’s parents had brought her to hospital because they were concerned. They were then reassured by hospital staff. It is therefore difficult to see how this particular advice could be a meaningful instruction. In reality, her parents’ initial concern was well placed and they had responded to it appropriately by bringing Billie to hospital. When Billie began to deteriorate again, her parents’ natural instinct had been blunted by their first visit to the hospital. Whilst I doubt that it would have made a difference in this case, I understand that blood pressure is not yet an observation included in the national paediatric early warning score (PEWS).
  6. Content Article
    More information about "Acute Behavioural Disturbance: preventing future deaths"
    In December 2022, Harry Vass died after experiencing Acute Behavioural Disturbance (ABD) and a complex disturbance in normal physiology.     In her first blog, Harry’s mother Julie told us about Harry and the events that preceded his death, during which he suffered with anxiety, addiction and psychosis. She talked about the inquest and how they learned of gaps in Harry’s care, that led the coroner to deem it an avoidable death.  In this second blog, Julie explains more about Acute Behavioural Disturbance and the changes she believes are needed to make sure patients like Harry are cared for appropriately.  Right after Harry was pronounced dead, a paramedic presented us with his belongings in a plastic hospital bag and we were sent home. We were told to ring the hospital bereavement office the following morning. We did so to be told that they didn’t have anything to do with coroner cases, so we knew then that Harry had been referred to the coroner. Our inquest was an article 2 inquest as Harry had died whilst detained under section 136 of the Mental Health Act and his liberty had been taken away for his own, and others, safety. This allows for the scope of the inquest to be slightly wider in exploring the issues prior to, and the cause, of death. The jury concluded that Harry had died of: “…sudden death, most likely as a result of terminal cardiac arrhythmia on a background of psychosis and recent cocaine use leading to an acute disturbance in behaviour and complex disturbance in normal physiology.” Acute Behavioural Disturbance is not a condition in its own right, so the term cannot be used on the death certificate as a standalone cause of death. As the coroner felt that this death was avoidable, a Prevention of Future Deaths Report was written and later a response was received from the Royal College of Nursing. What is Acute Behavioural Disturbance? Acute behavioural disturbance is an umbrella term used to describe a presentation which can include abnormal physiology and/or behaviour. Acute Behavioural Disturbance has previously been called excited delirium, acute behavioural disorder, or agitated delirium. The below represent signs which may be present in Acute Behavioural Disturbance - one or more may be present. Agitation Constant physical activity Bizarre behaviour (incl. paranoia, hypervigilance) Fear, panic Unusual or unexpected strength Sustained non-compliance with police or ambulance staff Pain tolerance, impervious to pain Hot to touch, sweating Rapid breathing Tachycardia.[1] Although the term Acute Behavioural Disturbance has been used over a long period, it is still not consistently known, used or understood across different professional groups. Seven key areas for change Throughout the last two years we have become more aware of the gaps in Harry’s care and support in the lead up to his death. I believe focusing on the seven areas below would help to prevent future deaths. 1. Raising awareness and understanding Making sure that healthcare professionals working in emergency departments and mental health units (especially those caring for acutely ill patients) receive training and education in Acute Behavioural Disturbance. This must include nurses who are the professionals most likely to detect physical changes in a patient’s condition. 2. Consistent terminology Although much has been published since Harry’s death, there is procrastination over terminology used to describe this presentation. There should be collaboration on immediate actions needed, using agreed reference terms, for example; “physiological disarray with psychosis, particularly following the use of illicit drugs”. The simple addition of a few words to training policies and packages could be very powerful in saving lives. 3. Collaborative guidance The National Institute for Health and Care Excellence, the Royal College of Nursing, Royal college of Psychiatrists and Royal College of Emergency Medicine need to agree on the wording of appropriate policies to guide and educate professionals facing this presentation. It is essential to bring nurses to this forum as they have previously been excluded. 4. Post-mortem training The Royal College of Pathologists/ Forensic Pathologists could think about training and education for those undertaking post-mortems for these patients. Knowing what to look for and finding evidence is extremely difficult. In our case, we were told that Harry had previously damaged heart muscle caused by illicit drugs which was not the opinion of the expert witness. 5. Data collection and coding NHS England should have the coding reviewed/ adjusted. “Psychosis with physiological disarray with or without illicit drug use“ (or similar wording) should be available as a coding choice for clinicians and coders. This would allow for proper data capture for these presentations in the NHS. 6. Monitoring of prevention of future deaths reports I believe there should be an overarching body to monitor prevention of future deaths reports, and the responses to these. This body should support any learning and the required remedial actions within appropriate timeframes. It should hold organisations accountable for investment and implementation of remedial plans and ongoing measurement of agreed set outcomes. 7. Research and early intervention We need more research to fully understand those at risk of the presentation of Acute Behavioural Disturbance and why. Early warning signs would then be identified and recommendations made for care pathway interventions for better outcomes. What else can healthcare professionals do? Simply be aware of patients presenting with psychosis, particularly with a history of illicit drug use and previous mental health difficulties. Patients with extreme and prolonged agitation can become physically unwell leading to the medical emergency of cardiac arrhythmia and arrest. Take frequent basic physical observations to be alerted to any changes in physical condition. Healthcare professionals already have training and policies on dealing with a deteriorating patient should a change be detected. What else can Trusts do? Make sure relevant staff receive training, education and support in Acute Behavioural Disturbance. Patients taking illicit drugs who may have mental health issues already should be offered support at the earliest possible opportunity to avoid an escalating situation. Drug and alcohol liaison teams working in emergency departments is good practise and can offer clear pathways to support for these patients. Consider partnership working with wider public services to improve mental health support – Avon and Somerset Constabulary have made changes including working with the ambulance service. Trusts should be proactive in providing an appropriate environment for the care and safety of the patient, staff and other patients. An appropriate environment also avoids the potentially discriminatory actions of removing a patient from a busy emergency department because they are disruptive, without proper examination and care. There is a conflict of interest in offering a family a duty of candour when care doesn’t go to plan, and the need to protect the Trust from potential litigation. We found this so frustrating as it meant that what happened to Harry was not fully shared and understood until the inquest some 18 months after his death. I’m not sure how this could be addressed but it’s a wider issue for Trusts to consider. Our family would have felt far less stressed and emotionally exhausted if we had been told more of the facts and what had not gone to plan at an earlier point. Support and advice for other families Over the weeks and months leading up to the inquest there were periods of so much activity that I found it helpful to write a journal. Journal keeping allowed for thoughts to be put down on paper and “parked” but it has also proved to be good for checking back on dates and events. I would recommend keeping a journal to anyone in a similar position. On the good side, there were people and organisations that we were so grateful for and would highly recommend having their support and input. We would not have made it through this period without them. The Mental Health NHS Trust had a Family Liaison Officer who was able to field our questions, update us on issues such as the serious incident investigation and organise meetings with professionals at which she would support us. I don’t know if this is common practice, but we had clear benefit from this role. We found our way to INQUEST, a charitable organisation which supports families like us through the inquest process. We had our own case worker who was amazing at supporting us in both practical ways as well as giving us valuable information and guidance. We really felt we were not alone as she checked on us regularly. She assisted in the appointment of lawyers and a barrister for the inquest and was able to respond to our questions which were many given we had never been in this situation before. We still have contact now. Final thoughts Since Harry’s death there have been further deaths in hospitals with very similar stories to Harry’s. There is a general feeling that there has been an increase of cases. Use of cocaine and illicit drugs, increase of poor mental health in the population and a developing awareness of this presentation are possible associated factors. We have looked at other recent prevention of future deaths reports to find that Acute Behavioural Disturbance is mentioned fairly consistently. Our concern is that these reports are either not responded to, or are responded to inadequately and no effective action is taken. There is no body responsible for the oversight of these reports and to hold those organisations who can effect change to account. Our lives have changed for ever now. We try not to be angry as we know that no one intended for this to happen. We do want learning to be taken away from this unthinkable event in the hope that something similar will not happen to other families, this is so important to us. [1] Royal College of Emergency Medicine, October 2023. Acute Behavioural Disturbance in Emergency Departments (version 2). Share your insights Do you have insights to share around patient safety? Could your experiences help guide improvements? Or perhaps you're a healthcare professional making changes to reduce risk to patient safety? If you would like to contribute, please comment below (you'll need to sign up here first for free) or contact the editorial team at [email protected]. Related reading Harry’s story: Acute Behavioural Disturbance Prevention of future deaths report: Harry Vass (13 June 2024) Mental Health improvements and initiatives implemented in Avon & Somerset Constabulary Consensus on acute behavioural disturbance in the UK: a multidisciplinary modified Delphi study to determine what it is and how it should be managed (9 May 2023) INQUEST: Skills and support toolkit Acute behavioural disturbance: a physical emergency psychiatrists need to understand (14 October 2020)
  7. Content Article
    Harry Vass was a 24yr old, he had a history of ADHD, poor mental health, psychosis, paranoia secondary to recreational drug use and illicit drug dependency including cocaine.  Harry attended the A&E department of Southmead Hospital on 26th December 2022 at 16.42hrs, with the reason recorded as “mental health”, he was expressing paranoid thoughts. He had a high heart rate and was sweating. He underwent a physical assessment and was assessed by the Mental Health Team.   At some point he took cocaine in the toilet of the hospital after which he became more agitated and there were concerns being raised that others in the department felt threatened. At one point he absconded from the unit but was brought back, a doctor in the emergency department gave him medication to calm him down. The police were called but when they attended Harry was calm from the effects of the medication.    The police were called and attended again when Harry’s agitation increased. It was during this discussion that the police officer raised the possibility of Harry having ABD (acute behavioural disturbance). The police officer said that he’d seen close to a dozen cases, that Harry had similar symptoms.   The two mental health practitioners said that they knew very little about ABD. After some discussions with the police officer, the two mental health practitioners and the consultant in emergency medicine Harry was deemed medically fit and he was admitted under s136 Mental Health Act to The Mason Unit (a place of safety) within the hospital at around 23.00hrs.  Once on the Mason Unit Harry continued to be distressed and agitated, he was given further medication to calm him. Harry remained disturbed but had periods of calm, he became fearful of isolation, he became sleepy and at around 3.30hrs on 27th December 2022, he vomited. Observations were carried out confirming that Harry had low oxygen saturations and a high temperature. At 4.45hrs his extremities were discolouring, and he became unresponsive, an ambulance was called. He was transferred back to the A&E department but died at 06.36hrs.  The coroner's report included the following matters of concern: Due to Harry’s level of agitation, he did not undergo the level of observations that would and should have happened either in the emergency department or once on the Mason Unit which may have assisted in assessing his physical health. It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a medical emergency. The decision as to whether a person has ABD is important, Dr Delaney said that” this group are vulnerable to cardiac arrest”, that “deaths are multifactorial”, that “normally in the background a body is maintaining safe limits for e.g. pulse rate, blood pressure, temperature, but with acute disturbance in behaviour the body loses control of these safe parameters.” The full report can be found via the link below. You can also read the Royal College of Nursing response here.
  8. News Article
    A mental health trust where a "toxic culture" saw patients abused in 2022 has been rated as inadequate again despite some improvements. The secure unit the Edenfield Centre in Prestwich, Greater Manchester, was the subject of a BBC Panorama investigation which revealed how patients were humiliated and bullied. In its latest report into forensic inpatient and secure wards at the Greater Manchester Mental Health NHS Foundation Trust (GMMH), the Care Quality Commission (CQC) found issues with patient safety and pressures on staff and said some still felt unable to speak up about their concerns. GMMH, which runs Edenfield, said it accepted the findings and had "worked at pace" to address the problems identified. Inspectors from the CQC made an unannounced inspection in April and May 2024, giving the trust an overall rating of inadequate. Alison Chilton, its deputy director of operations in the north, said: "The trust's processes didn't always ensure the environment was safe for people. "We found some wards which carried out 15-minute security checks to keep people safe had gaps and missing signatures in their records." Other issues included staff being asked to carry out observations for hours without a break, ligature risks not being identified and unsafe management of medicines. Read full story Source: BBC News, 18 January 2025
  9. Content Article
    More information about "Insights from a reducing falls project at the University Hospital Southampton"
    At a recent Patient Safety Education Network meeting, Karen Male, ward leader at the University Hospital Southampton, gave a presentation on how she reduced falls on her ward. We asked Karen to share her journey and insights in a blog for the hub. The Patient Safety Education Network is a informal voluntary peer network for those in patient safety education and training roles. It provides a monthly drop-in session with guests to talk through issues of importance to those in patient safety education and training roles and now has over 470 members. You can find out about the network here. The challenge I joined the ward 14 months ago at a time when there was a high number of falls. In one year there was 72 falls, including four high-harm falls, and we would regularly have three falls a day. Falls prevention and staff confidence was low in the management and assessment of falls, and policies and procedures were not being followed. The ward layout was challenging—a corridor with three-bedded bays, long and narrow. Many of the patients were older and there had been a lot of Covid infections. My goal was simple: to reduce the falls in our ward. What I did I organised an entire ward awayday focusing on falls education, prevention, management of falls, and policies and procedures—everyone attended at the same time. This allowed the staff to discuss the way they worked ('work as done'). Back at the ward a Baywatch bay and a PHUDD scoring system was set up with the aim to reduce falls, particularly unwitnessed falls, by identifying if someone is high, medium or low risk of falling. The ward is a long corridor so one to two Baywatch bays are required. The PHUDD scoring system was used to identify those patients most at risk and to identify where they can go on the ward for the safest outcomes and if additional support is needed. It’s completed at least once daily for patients. On the PHUDD scoring system, 1 point was given to each question where the answer is yes. A point was added for any fall in the hospital. This was then used to decide which patient needed to be in the Baywatch bay. This score is on the handover and reviewed daily and at catch ups. Outcomes We have significantly reduced our falls—there has been 61.7% reduction in falls. There has been two long periods with no falls (one for a 48-day period and one for a 50-day period). Since the education day, we have had 1 or 2 falls a month rather than 5-11 falls every month. In the last 4 month we have had 6 falls instead of the potential 44. Staff are now educated on policies and procedure around the prevention of falls and the management of falls. Staff are proactive in the prevention of falls. Everyone knows that the Baywatch bay is the priority. And then everyone has their ends of the bay but we all cover each other. We have signs to say that’s it’s a Baywatch bay—for staff but also for relatives to say we can’t leave this bay. PHUDD score gives us evidence. You might have enough staff but we might have five patients with a particularly high score. So we have more staff around the bays to even it out where it’s needed. Night staff feel empowered to move patients who were most at risk to higher observation beds as they are the staff group most affected by falls on the ward. Bay nursing introduced handovers conducted outside of the bays, which enhanced the communication as opposed to being in an area away from the patients. We have completed a falls After Action Review and were praised for our significant improvement in post falls management and documentation. Senior management across our Trust have asked to learn more about the falls reduction plan. Barriers faced I met barriers. Staff were not acting in the way I wanted so I met resistance. But I was very honest with them. Told them what the consequences were. Got the most resistant on board first and then everyone else was easier. At the beginning the staff were demotivated and didn’t feel part of a team. We need to keep our teams valued and motivated. It’s an ongoing commitment to staff. We are always looking at how we can improve and asking staff what their ideas are. I think the biggest thing I did was look at what was my one main priority. And that’s what we focused on—falls. Now we are moving to pressure ulcers. If you pick one big thing to work on it’s easier. Give it a big focus and then, once sorted, move on to the next thing rather than trying to do everything at once. Next steps Training and education is essential—this has continued regularly from the ward leadership team. I’d like to do some simple quantification—more cost effective, efficient. PHUDD score gives us evidence. You might have enough staff but we might have five patients with a particularly high score. So we have more staff around the bays to even it out where it’s needed. We are now doing another nurse-led trial setting daily goals for patient mobility. We are very clear what the goals are, to increase mobilisation, and these goals are on the handover sheets for everyone to see. Further reading on the hub Yellow kits - an innovation to reduce the risk of falls in Accident and Emergency departments "The greatest part of this adventure has been the sharing of information." The Patient Safety Education Network one year on Implementing the aSSKINg pressure ulcer care bundle – a blog by Susan Martin Have you implemented a new initiative in your organisation? Have you improved patient safety where you work? We would love to hear from you and share on the hub your journey. If you are a member, you can share directly on the hub or please contact [email protected] to discuss further.
  10. Content Article
    Medical Care are joined by Dr Marisa Mason, chief executive of NCEPOD, and Dr Alison Tavare, GP, primary care clinical lead at Health Innovation West of England, and clinical coordinator as NCEPOD, as part of their ‘navigating patient safety’ series. In this session, they explore how NCEPOD's work has driven vital patient safety initiatives, including national early warning scores and the management of sepsis.
  11. 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 [email protected]. hub members receive a 20% discount. Email [email protected] for the discount code. Follow on Twitter @HCUK_Clare #DeterioratingPatient
  12. 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 [email protected]. hub members receive a 20% discount. Email [email protected] for the discount code. Follow on Twitter @HCUK_Clare #DeterioratingPatient
  13. Content Article
    More information about "Top picks: 10 resources about sepsis"
    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. Dr Ron Daniels, Founder & Joint CEO of the UK Sepsis Trust, and Topic Lead for the hub, said: “During the Covid-19 pandemic, attention to sepsis care understandably diminished, leading to gaps in timely and effective treatment. As we emerge from the pandemic, it’s crucial to refocus our efforts on this life-threatening but often treatable condition. We’re calling on the government to commission clear and efficient pathways within the NHS, supported by integrated care boards, to ensure that suspected sepsis is taken seriously – every time – in Accident & Emergency (A&E) departments nationwide.” 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 10 useful resources about sepsis that have been shared on the hub. They include advice on recognising and managing sepsis along with educational materials. 1 THINK SEPSIS THINK SEPSIS is a Health Education England programme aimed at improving the diagnosis and management of those with sepsis. Prompt recognition of sepsis and rapid intervention will help reduce the number of deaths occurring annually. The resources that are available on their website support the early identification and management of sepsis. It includes a film and a wide range of learning materials for primary care, secondary care and paediatrics. 2 Dr Ron Daniels: Recognising sepsis Dr Ron Daniels, Chief Executive of the Global Sepsis Alliance, has filmed a short video for the hub on the importance of recognising sepsis quickly and acting early to not only save lives but also to improve the quality of the lives we do save. He highlights the tools available to recognise and manage sepsis, the Red Flag Sepsis start bundle, and discusses why it is important to know when to act and what to do, and why healthcare professionals and the public need to work collaboratively. 3 UK Sepsis Trust: Get Sepsis Savvy video Five-minute video to help protect yourself and your loved ones against sepsis. 4 Patient Safety Learning interview with double sepsis survivor, Dave Carson, and his wife Margaret A Patient Safety Learning interview with sepsis survivor, Dave Carson, and his wife, Margaret Carson, who tell us how things have improved and what more still needs to be done for sepsis. 5 Managing deterioration using NEWS A series of videos from NHS England Workforce, Training and Education on managing deterioration. 6 Sepsis: National Education Scotland resources Some of NHS Education for Scotland (NES) sepsis educational resources, including NHS Scotland National Early Warning Score (NEWS) and Sepsis Screening Tool, and the Maternal Sepsis e-Learning Package. 7 NHS England: Improving the blood culture pathway NHS England’s report into blood culture practices outlines key improvement steps in the pre-analytical phase of the blood culture pathway. Through targeted recommendations to trust chief executives, clinical and pathology staff, there's an opportunity to improve the blood culture pathway, antimicrobial stewardship and patient outcomes from sepsis. 8 Spotlight on sepsis: your stories, your rights This report from the Parliamentary and Health Service Ombudsman(PHSO) looks at some of the sepsis complaints people have brought to PHSO, to shine a light on their experiences and encourage others to let their voices be heard. It shares case summaries and guidance to help people complain and help NHS organisations understand and learn from the issues raised 9 Sepsis alert systems, mortality, and adherence in emergency departments: a systematic review and meta-analysis Early detection and management of sepsis is an important patient safety target. This systematic review included 22 studies and examined the use of sepsis alert systems in the Emergency Department (ED) on patient outcomes. The researchers found that sepsis alert systems were associated with reduced risk of mortality and decreased length of stay, as well as increased adherence to sepsis management guidelines, such as timely administration of antibiotics. 10 Improving sepsis compliance with Human Factors interventions in a community hospital emergency room Adherence to best practices for sepsis management at a small community hospital was below system, state and national benchmarks and affected vital indicators, including mortality. This study aimed to improve sepsis best practice compliance by implementing human factors–influenced interventions. Do you have a resource or story about sepsis to share? We’d love to hear about it - leave a comment below or join the hub to share your own post.
  14. 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.
  15. 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
  16. 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
  17. 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
  18. 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.
  19. 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’
  20. News Article
    A hospital trust has admitted that a young autistic boy should still be alive had they delivered the appropriate level of care. In an exclusive interview with ITV News, the day before the inquest into his death, Mattheus Vieira's heartbroken parents described him as "special", adding: "And special in a good way, not just special needs." "People may think because he was autistic he was difficult, but it's not the case, he was very easy. "He was the boss of the house, we just miss his presence." Mattheus, aged 11, was taken to King's Lynn Hospital, in Norfolk, with a kidney infection. He struggled to cope with medical staff taking observations, and his notes recorded him as "uncooperative". His dad, Vitor Vieira, told ITV News: "He doesn't like to be touched, even a plaster he doesn't like. "And they say 'Oh he does not co-operate'. He was an autistic boy, what do you expect? Mr Vieira believes staff did not understand his son's behaviour. Mattheus was non verbal and so unable to articulate his distress. Observations were dismissed as "inaccurate" by some medical staff. In fact, they were accurate and indicated that his kidney infection had developed into septic shock. He suffered a cardiac arrest and died, aged 11. Read full story Source: ITV News, 26 February 2024
  21. 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
  22. 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
  23. 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 [email protected]
  24. Event
    The Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include national developments, including the recent recommendations on NEWS2 and Covid-19, and implementing the recommendations from the HSIB 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, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis and Covid-19, involving patients and families in recognising deterioration, 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 or email [email protected] hub members receive a 20% discount. Email [email protected] for discount code Follow on Twitter @HCUK_Clare #DeterioratingPatient
  25. Event
    The Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. 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, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis & Covid-19, involving patients and families in recognising deterioration, 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 or email [email protected] hub members receive a 20% discount. Email [email protected] for the discount code Follow the conference on Twitter @HCUK_Clare #DeterioratingPatient

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