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Found 147 results
  1. Content Article
    What is an Adjournment Debate? There is a 30 minute Adjournment Debate at the end of each day's sitting of the House of Commons. They provide an opportunity for an individual backbench MP to raise an issue and receive a response from the relevant Minister. Unlike many other debates, these take place without a question which the House of Commons must then make a decision on.[1] NHS Hysteroscopy Treatment In this debate Lyn Brown MP outlined the issue of significant numbers of women who experience extreme levels of pain when undergoing a hysteroscopy, highlighted by groups such as the Campaign Against Painful Hysteroscopy. She noted concerns around: Lack of access to pain relief. Lack of informed consent - noting that while improved information leaflets have been produced by the Royal College of Obstetricians and Gynecologists, many women are still not being provided with this information prior to the procedure. Lasting trauma for patients. Best Practice Tariff and perverse financial incentives Lyn Brown also noted a particular issue of a financial incentive that deters the use of pain relief in hysteroscopy procedures. She noted that NHS trusts are encouraged to perform hysteroscopies as outpatient procedures, through the NHS best practice tariff. She noted that the way the tariff is designed means that a trust will lose money if it provides general anesthetic for such procedures. In her response the Minister for Patient Safety, Mental Health and Suicide Prevention, Nadine Dorries MP, indicated that forthcoming technical changes to the tariff for 2021-22 may address this issue for hysteroscopy procedures. References UK Parliament, Adjournment Debates, Last Accessed 25 September 2020.
  2. Content Article
    In our recent blog Analysing the Cumberlege Review; Who should join the dots for patient safety? we identified a number of key patient safety issues which were reflected in the Review’s findings. One theme running throughout the Review was a failure to engage patients in their care, most noticeably around the issue of informed consent. What is informed consent? The NHS definition of informed consent is that “the person must be given all of the information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead”.[1] The landmark UK Supreme Court judgement Montgomery v Lanarkshire Health Board case in 2015 reaffirmed this principle in law, setting out the legal duty of doctors to disclose information to patients regarding risks.[2] Review findings Patients being unable to make decisions on the basis of informed consent was a recurring theme in the review, manifesting itself in several ways: Patients’ consent not being sought - the Review heard from patients where consent was not given for the procedure carried out, particularly in cases for implanting pelvic mesh. The authors of the Review state that they were “appalled by the numbers of women who have come forward to say they never knew they had had mesh inserted, or where they gave consent for ‘tape’ insertion they did not know they were being implanted with polypropylene mesh”.[3] Patients lacking information – this was a consistent issue concerning patients regarding the three interventions considered by the Review: hormone pregnancy tests, sodium valproate and pelvic mesh implants. One specific example of this is the case of pregnant women taking sodium valproate as an epilepsy treatment without knowing that doing so could harm their unborn child. Despite efforts to make patients aware of this, it remains an issue, with women who are taking sodium valproate as a epilepsy treatment “still becoming pregnant without any knowledge of the risks”, lacking the information to make the decision about whether to continue with this medication.[4] Patients not being involved in decision making – the Review also heard from patients who raised concerns about the failure of informed consent as a result of doctors choosing not to share relevant information with patients for their decision-making. They refer to cases where doctors did not discuss the risks with women taking sodium valproate prior to pregnancies and “gave advice based on their own assumptions, without involving patients in the decision-making process”.[5] Concerns around the absence of informed consent go beyond the procedures focused on in the Review. On the hub, we have featured community discussions and patient accounts of these issues in relation to hysteroscopy procedures, while earlier in the year the Paterson Inquiry highlighted concerns about this, recommending that a short period should be introduced into surgical procedures to allow for patients to provide their consent.[6] How can we ensure informed consent is gained? The Cumberlege Review notes that, since the Montgomery ruling in 2015, there has been a significant increase in patient safety leaflets sharing information on risks of specific treatments, but that the sheer variety of these and differing consent forms can be “bewildering and a major source of confusion”.[7] The Review is supportive of an approach where information is conveyed in a clear and direct way, and where patient decision aids are used in complex conversations to support the consent process.[8] At Patient Safety Learning, we believe it is important that patients are not simply treated as passive participants in the process of their care. Informed consent is vital to respecting the rights of the patient, maintaining trust in the patient-clinician relationship and ensuring safe care. We have identified three calls for action which we believe are needed to tackle the failure of informed consent: All patient information should be co-produced with patients to ensure that it meets patient needs for decision-making. Repositories of information and good practice are put in place so that organisations don’t have to re-invent the wheel but instead can learn from experience. Patient information for medication and medical devices should be reviewed and signed off by the NHS to ensure that it is not solely the responsibility of manufacturers. What are your thoughts on this issue? Have you had an experience where you feel that you have not given informed consent before receiving medical care? Are you a healthcare professional who can share resources for good practice? Let us know in the comments below to ensure our calls for action are informed by your experience and insights. References NHS England, Consent to treatment, Last Accessed 16 July 2020. https://www.nhs.uk/conditions/consent-to-treatment/ UK Supreme Court, Montgomery v Lanarkshire Health Board, 2015. https://www.supremecourt.uk/cases/docs/uksc-2013-0136-judgment.pdf; Lee, Albert. “'Bolam' to 'Montgomery' is result of evolutionary change of medical practice towards 'patient-centred care'.” Postgraduate medical journal vol. 93,1095 (2017): 46-50. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5256237/#R3 The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020. https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf Ibid. Ibid. Campaign Against Painful Hysteroscopy, Patients Stories Essay, September 2018. https://www.hysteroscopyaction.org.uk/wp-content/uploads/2018/10/sept-2018.pdf; The Right Reverend Graham Jones, Report of the Independent Inquiry into the Issues raised by Paterson, 2020. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/863211/issues -raised-by-paterson-independent-inquiry-report-web-accessible.pdf The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020. https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf Ibid.
  3. Content Article
    Unicef UK Baby Friendly Initiative has updated its policy guidance in the light of these investigations and some organisations are using posters and checklists to help staff understand and carry out their responsibilities. HSIB has also observed the impact of high task load, environment and staffing levels on the ability of staff to detect SUPC. Recommendations Maternity services should consider the following learning observations to ensure safe delivery of skin-to-skin care. • Based on the evidence, a baby who is born apparently well, with good Apgar scores, can be safely laid skin-to-skin with the mother or parent and requires close observation in the first minutes after birth. • Apgar scores must be attributed using close clinical observation of the baby. This can be achieved with the baby remaining in skin-toskin contact. There may be a need to interrupt skin-to-skin contact briefly to ensure Apgar scoring is assessed accurately. • Vigilant observation of the mother and baby should continue, with prompt removal of the baby if the health of either gives concern. • Mothers should be encouraged to be in a semirecumbent (half lying, half sitting) position to hold and feed their baby, ensuring the mother can see the baby’s face. • Care should be taken to ensure that the baby’s position is such that their airway remains clear and does not become obstructed. • Staff should have a conversation with the mother and her companion about recognising any changes in the baby’s condition. • Always listen to parents and respond immediately to any concerns raised. • Medicines given to the mother should be considered when discussing skin-to-skin contact. Pain relief given to mothers can affect their ability to observe and care for their baby. • Additional risk factors should also be considered. The level of risk for SUPC when a baby is in skin-to-skin contact can increase with, for example, increased maternal body mass index, antenatal use of opiate medication, sedation, and staff’s focus on other tasks.
  4. News Article
    Like most women affected by incontinence, 43-year-old Luce Brett has her horror stories. As a 30-year-old first time mum she recalls wetting herself and bursting into tears in the “Mothercare aisle of shame”, where maternity pads and adult nappies sit alongside the baby nappies, wipes and potties. But, she adds, these isolated anecdotes don’t really do justice to what living with incontinence is really like. “It’s every day, it’s all day. People talk about leaking when you sneeze or when you laugh, but for me it was also when I stood up, or walked upstairs. It was always having two different outfits every time I left the house to go to the shops. Incontinence robbed me of my thirties; it made me suicidally depressed,” Luce explains. “Everyone kept telling me it was normal to be leaky after a vaginal birth. It took quite a long time for me to find the courage or the words to stop them and say: ‘Everybody in my NCT (National Childbirth Trust) class can walk around with a sling on, and I can’t do that without wetting myself constantly’,” she adds. Read full article here.
  5. News Article
    Hospital trust ‘truly sorry that mistakes were made in care’ of Luchii Gavrilescu, who died after being sent home from hospital with undiagnosed tuberculosis. An NHS trust investigated over maternity care failings has apologised after a six-week-old child was found to have died due to mistakes at one of its hospitals. East Kent Hospitals University Trust was embroiled in a major scandal after The Independent revealed the trust had seen more than 130 babies over a four-year period suffer brain damage as a result of being starved of oxygen during birth. A report into the trust concluded in April that there had been “recurrent safety risks” at its maternity units. Read full article here.
  6. News Article
    A national investigation has been launched into the equipment used by NHS staff to monitor babies heart rates during labour because of concerns they could be contributing to deaths and disabilities. The independent Healthcare Safety Investigation Branch (HSIB), which investigates systemic safety risks in the NHS, has opened an inquiry after reviewing hundreds of maternity incidents. It found equipment used to record cardiotocographic (CTG) traces were linked to 138 maternity investigations since 2018 with more than 238 separate findings referencing the use of CTG as a factor in the error. Read the full article here
  7. News Article
    The safety of maternity services in the NHS are to be investigated by MPs after a string of scandals involving the deaths of mothers and babies highlighted by The Independent. The Commons health select committee, chaired by former health secretary Jeremy Hunt, has announced it will hold an inquiry looking at why maternity incidents keep re-occurring and what needs to be done to improve safety. The committee will also examine whether the clinical negligence process needs to change and the wider aspects of a “blame culture” in the health service and its affects on medical advice and decision making. Read the full article here
  8. News Article
    The Royal College of Obstetricians and Gynaecologists ( (RCOG) has today launched a Race Equality Taskforce to better understand and tackle racial disparities in women’s healthcare and racism within the obstetric and gynaecology workforce. Addressing health inequalities is a key priority area for RCOG President Dr Edward Morris, who is co-chairing the Taskforce alongside Dr Ranee Thakar, Vice President of the RCOG, and Dr Christine Ekechi, Consultant Obstetrician & Gynaecologist and RCOG Spokesperson for Racial Equality. Statistics show, for example, that black women are five times more likely to die in pregnancy, childbirth or in the six-month postpartum period compared with White women and the risk for Asian women is twice as high. During the pandemic, 55% of pregnant women admitted to hospital with coronavirus were from a Black, Asian or other minority ethnic background despite the fact 13% of the UK population identify themselves as BAME. It is also clear that there is a significant gap in understanding the factors that result in a higher risk of morbidity and mortality for Black, Asian and other ethnic minority women in the UK. The Taskforce will collaborate with groups across healthcare and government as well as individual women to address these concerning trends and will ensure that the work of the RCOG is reflective of its anti-racist agenda. Read full story Source: RCOG, 15 July 2020
  9. Content Article
    Episodes include: BeginningsApprenticeFlying SoloDetourBalanceNight ShiftMotherhood Part 1Motherhood Part 2ContinuityHomebirthCaesareanFlexibleMistakes DadsGuidelines
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