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Samuel Howes was 17 when he died by suicide in September 2020. Samuel had ongoing mental health issues including anxiety and depression. This led to his use of drugs and dependency on alcohol, which in turn further worsened his mental health. This blog by his mother Suzanne details her experience of the final day of the inquest into her son's death, which found multiple failings on the part of Child and Adolescent Mental Health Services (CAMHS), social services and the police.

BAPEN’s web-based self-screening tool is designed for people who are worried about their weight or the weight of somebody they care about to quickly and easily work out if there is a risk of malnutrition. To use the tool, you just need to enter your height and weight into the online calculator, along with your height and weight 3-6 months ago. You will be given a rating that will tell you if you are at high, medium or low risk of malnutrition. You will then be able to download a dietary advice sheet that gives basic information and suggestions for improving nutritional intake. If you are worried about your weight or having difficulty eating, make sure you talk to your GP or a healthcare professional. The dietary advice sheet was developed in partnership with a number of professional organisations. NB this site is intended for adult self-screening only.

I-Hydrate was a collaborative research project, which used service improvement methodology, and was undertaken at two privately operated North West London care homes in partnership with care home staff, residents and their carers and families. I-Hydrate aimed to optimise the hydration of residents in nursing homes, improve the quality and safety of care and decrease dehydration and the morbidity associated with it.  The study used quality improvement methods to develop and test interventions to extend drinking opportunities and choice in two care homes. Initial activity included observation of the systems for delivering fluids and involving staff, residents and carers in describing and mapping the organisation of care. An interactive training programme was indicated by staff as an important priority and was therefore introduced as a first step to improve hydration care. Subsequent interventions were co-designed with care staff and tested using Plan Do Study Act (PDSA) cycles. Their efficacy was measured through data captured on the amount of fluids served and consumed, and staff and resident feedback. The long-term impact of the interventions was assessed by measuring daily laxative and antibiotic consumption, weekly incidence of adverse health events, and average fluid intake of a random sample of six residents captured monthly. The link below shows the I-Hydrate presentation which summarises the project and its findings.

This anonymous blog is about a patient with learning disabilities, his treatment and outcome while coming in for a 'routine' procedure. This blog highlights the need for adequate training for all staff around caring for patients with learning disabilities to prevent harm and protracted length of stay. It's midnight on the acute floor, just before Christmas. As I walk through the Emergency Department (ED), I can hear the ambulances reverse up to the door, people shouting, doors opening and closing, phones ringing and the general white noise of the department. You wouldn’t know it was night-time at all, the lights are beaming and it's as noisy now as it is in the day. I am a junior doctor. I’m on my fourth night shift of six. I have a patient on the acute medical admission unit that I need to check up on. I take the opportunity to seek some darkness and quiet away from the hustle and bustle of the ED. As I go into the unit, I spot a young man in his 20s. He has a carer at his bedside. I stop. I say "hi"’ to the carer and just take a quick glance at the saturation probe that is on the young man’s finger. It’s reading 94% (normal is >95%). "Is that number of 94% normal for Eddie*?" I ask the carer. "Yes" he confirms. "What about the heart rate, that’s reading 140?" I asked, but didn’t want to come across alarmed, as this is quite high. "No. It usually reads 90. I was worried, but assumed you were dealing with it". My time is limited, I should be checking on my patient I originally came in to see. I have now seen a vulnerable adult with an abnormally high heart rate. However, the nurses are here… they can act on it , can’t they? I need to see my patient. I have patients backing up in ED, what about the four-hour target? Those thoughts go through my head in a split second. I now find myself pulling up a chair alongside Eddie and his carer. I find out that he has been admitted as his feeding tube had fallen out; he is here to have it replaced in the morning in theatre. I find out that it had fallen out 18 hours ago. As Eddie is unable to swallow without the risk of choking, he relies on the tube for all his medication and fluids. I take a look at the observations. Respiratory rate 18, heart rate 140, blood pressure 89/48, aprexial, not confused. He has a NEWS2 Score of 6. I see a sepsis screening tool that has been completed. It has been deemed that Eddie has a high suspicion of sepsis. But... he’s only come in for a tube change? I use the expertise of the carer. I find out that Eddie hasn’t had any fluids all day and his pads have been dry. At this point he should have had 3 litres of fluid via his tube. He also has not had his medication for his seizures. This is vitally important as it is highly likely he will seize this admission. I put some fluids up. I need to be quite aggressive with replacing his fluids as he may go into acute kidney injury. I write up his epilepsy medication, this time via his cannular. I explain to the nurses to give hourly observations and to call me if there are any problems. I check on Eddie that morning. He’s bright as a button. Smiling and ready for his tube replacement. If I walked on by, what might have happened? Eddie would continue to be treated for sepsis when he wasn’t septic and received antibiotics he didn’t need. Eddie would become more dehydrated and possibly acquired an acute kidney injury. Eddie may have suffered a seizure that could have been prevented. Due to these complications, Eddie may not have been fit for his tube replacement. Eddie's length of stay may have been increased, therefore increasing his risk of contracting a hospital acquired infection. What stopped me from walking by? Eddie reminded me of my brother, *Sam. My brother has cerebral palsy and needs 24-hour care. He’s funny, he can wrap mum around his little finger, he can play pranks on you, he is still my annoying little brother but coming into hospital always poses such a huge stress on us as a family, not to mention Sam. He always has people around him that know him. So, coming into this environment is alien. Due to his physical problems, he doesn’t ‘fit the normal patient mould'. Will he get the right treatment? Will he get his medication on time? Will there be anywhere for the carer to stay? Will the nurses know how to re-position Sam? How will they communicate to Sam? Will they read his patient passport? Will they act on his patient passport? Or will they walk on by? *Names in this blog have been changed for confidentiality purposes.

Diane Vaughan is an American sociologist who devoted most of her time on topics such as 'deviance in organisations'. One of Vaughan's theories regarding misconduct within large organisations is the normalisation of deviance. Here, she uses healthcare to explain how harmful behaviours can become normalised and offers up solutions.  Social normalisation of deviance means that people within the organisation become so much accustomed to a deviant behaviour that they don’t consider it as deviant, despite the fact they exceed their own rules for the elementary safety. People grow more accustomed to the deviant behaviour the more it occurs . To people outside of the organisation, the activities seem deviant; however, people within the organisation do not recognise the deviance because it is seen as a normal occurrence. In hindsight, people within the organisation realise that their seemingly normal behaviour was deviant. Diane Vaughan uses healthcare to illustrate why deviance is normalised in companies. She gives four major reasons why it happens: "The rules are stupid and inefficient." System operators will often invent shortcuts or workarounds when the rule, regulation, or standard seems irrational or inefficient. Knowledge is imperfect and uneven. System operators might not know that a particular rule or standard exists; or, they might have been taught a system deviation without realising it. "I’m breaking the rule for the good of my patient!" This justification for rule deviation is where the rule or standard is perceived as counterproductive. Workers are afraid to speak up. The likelihood that rule violations will become normalised increases if those who witness them refuse to intervene. Yet, studies show that people feel it is difficult or impossible to speak up. Solutions Vaughan offers the following suggestions for helping to prevent deviant behaviours from becoming normalised: Education is the best solution for the normalisation of deviance. Diane Vaughn states, "the ignorance of what is going on is organisational and prevents any attempt to stop the unfolding harm." Being clear about standards and rewarding whistleblowers is part of the education that should take place. A company must be transparent about their standards and consequences of not meeting them. Also, creating a culture that is less individualistic and more team-based is helpful to stop the normalisation of deviance. Each person should be looking out for the company and team as a whole. If it were more team-based, each person would feel like they were letting their colleagues down if they were to break the rules. A top-down approach is very important. If the employees see executives breaking rules, they will feel it is normal in the company's culture. Normalisation of deviance is easier to prevent than to correct. Companies must make sure they take the correct steps to prevent it.

The Parliamentary and Health Service Ombudsman (PHSO) were set up by Parliament to provide an independent complaint handling service for complaints that have not been resolved by the NHS in England and UK government departments. They share findings from casework to help Parliament scrutinise public service providers. They also share their findings more widely to help drive improvements in public services and complaint handling. Miss K complained to the PSHO about the care and treatment that her son, Baby K, received at the Trust in November 2015. She said that the Trust failed to act following various checks on Baby K, and it failed to escalate his care in line with the seriousness of his condition and he died as a result. Miss K also complained about the Trust’s handling of her complaint. The PSHO found that the Trust failed to: act on the results of the ECG and chest X-ray consider Baby K’s history and symptoms ask for input from specialist staff escalate his care when his condition was getting worse. If these failings had not occurred, it is likely that the Trust would have recognised that Baby K had a problem with his heart. In these circumstances he would have received the correct treatment instead of being treated for suspected pneumonia. The PSHO found that on the balance of probabilities, his cardiac arrest would not have occurred and it is more likely than not that his death would have been avoided. The PHSO also found that the Trust was not open and accountable in its handling of Miss K’s complaint, as it failed to acknowledge and apologise for its mistakes in a timely manner. It also failed to signpost Miss K to the PSHO at the right time and in the right way.

The ‘c’ word, 'cost' is often used to defend the status quo in patent safety. This article, published by PatientSafe Network, highlights the importance of assessing the financial loss in not introducing the safety intervention. It includes examples on how to overcome barriers like 'we don't have the money for that' when it comes to delivering safer care.  After all, the price of safer care is priceless

Healthcare is advancing at a quicker rate than ever before. With the introduction of Artificial Intelligence (AI), you can now get a cancerous mole diagnosed with a mobile device. The reliance on technology has never so great. With technology predicted to replace as much as 80 per cent of a physician’s everyday routine, we must question what the new threats posed to patient safety are? This article, written by CFC Underwriting, explains some of the pitfalls of the new technology. CFC is a specialist insurance provider. and a pioneer in emerging risk.

Last year, 63 healthcare professionals in England were found stealing controlled drugs and/or providing care whilst working under the influence of controlled drugs. By law, designated bodies must have a Controlled Drug Accountable Officer (CDAO).  This is a case study demonstrating the role of the CDAO and safety of controlled drugs. 

Museum of Failure is a collection of failed products and services from around the world. The majority of all innovation projects fail and the museum showcases these failures to provide visitors a fascinating learning experience. Every item provides unique insight into the risky business of innovation.The idea for the museum was born out of frustration. ‘I was so tired of reading and hearing the same boring success stories, they are all alike’ says the museum’s curator, Samuel West. ‘It is in the failures we find the interesting stories that we can learn from.’ Innovation and progress require an acceptance of failure. The museum aims to stimulate discussion about failure and inspire us to have the courage to take meaningful risks.Could we learn from our 'failures' in healthcare in the same way? The museum is curated by Dr. Samuel West, licensed psychologist, PhD in Organisational Psychology.

Dorit describes the assessment and subsequent death of her much loved daughter-in-law who died during a psychotic episode having been discharged the previous evening. Her story raises a number of questions: How should families be included in making judgements and assessments about the patient and their well-being? What support do they need to care for a very distressed loved one? Why aren't written care and contingency plans provided to the patient and their family? What more needs to be done to ensure standard practices are in place to protect patients with psychosis? My much loved daughter-in-law, Mariana Pinto, died on 16 October 2016. She was 32. Her tragic and unexpected death raised many questions for us about standard practice by psychiatric services and about patient safety. The evening before she died, Mariana was taken by ambulance to her local A&E department, escorted by four police officers, and handcuffed for her own safety. She was psychotic – delusional, paranoid, violent and very distressed. She had attacked her husband (my son) who had visible bite marks, scratches and bruises. It was a first episode and totally out of character. She had not eaten or slept for several days. In A&E she was brought food and drink but spat it out, believing it to be poisoned. She kept trying to escape from the cubicle. The police stayed, stating that she was extremely vulnerable. Eventually she agreed to take a sedative – but not before she had held it under her tongue for some time, and only after we, her family, were able to persuade her that she should take it. Once she was finally sedated, she was given various tests to rule out any physical cause, and a mental health act assessment. This was done with her and her husband together. There was no attempt to see him separately. She was deemed competent to make decisions about her care, and as she wanted to go home, was discharged, with a referral to the local Crisis Team, who we were told would receive the referral at 8 am the following morning and would arrange to visit. The psychiatric team operate within A&E but for a separate mental health trust. This same trust runs the Crisis Team. It is deemed outstanding by the Care Quality Commission (CQC). The following morning, there was no contact from the Crisis Team. My son rang them at midday to ask when they would visit. They said normally between 5 and 7 pm on Sundays and to ring back if he needed to. He rang back at 3.30 pm stating that she had deteriorated rapidly and asking for the visit to be brought forward. He was told that it could not be. At 4.00 pm Mari ran out of the open door to the roof terrace and jumped off it. She did not survive her injuries. The Coroner gave a narrative verdict, making it clear that Mariana did not know what she was doing, though her actions were deliberate. She also gave a Prevention of Future Deaths Report. Whilst the trust is obliged to reply, there is no statutory obligation to demonstrate that the actions they have promised have actually been taken. There was no attempt at any risk assessment. There was no attempt to check that my son could speak freely (he could not – it was a studio apartment). There was no attempt to call the emergency services on his behalf, and no attempt to check he had been able to do so. None of this is regarded as negligent or especially problematic. Since her death the Crisis Team do visit on Sunday mornings. We also found out that the number we were given to call was for service users already allocated a key worker, rather than a more general number – but as my son spoke to senior staff on each call, this should not have made a difference. After her death we raised the following questions: Surely given the bite marks and bruising, her husband should have been allowed to give his information to the psychiatric team separately? No, it turns out that while this would have been good practice, it was not negligent. Surely, given that her family knew and loved her, we should have been asked post sedation if she seemed like herself (she did not). No, it turns out that this is not seen as necessary. It’s not even regarded as good practice. Surely, given that she was paranoid and had told the police that she did not trust her husband, her husband should have been given private space to discuss the discharge and rehearse what to do if things went wrong once the sedative wore off? And surely we should have been told that the Crisis Team is not instead of calling 999 in an emergency. And efforts made to help us to decide if the situation was an emergency. No, it turns out that while this would have been good practice, it was not negligent. The mental health trust has now introduced a written discharge template for care and contingency planning. We have been told that the circumstances of Mariana’s death were unusual and could not have been foretold. That may be. But there are still lessons to be learnt. To improve patient safety in mental health crisis and to learn from deaths, we need to change standard practice. It should become standard to: See family and friends separately if someone is paranoid, to understand the family’s concerns, learn more about the patient and work together to consider how best the patient can be kept safe and helped. Provide written care and contingency plans to patients and their family Use one number for a Crisis Team helpline, with clear policies to offer help and support to service users and to their carers, and proper protocols in place to assess risk and intervene if someone is at immediate risk of harm. Make it very clear to patients that a referral to a Crisis Team is not a substitute for calling 999 in an emergency (where there is an immediate risk of harm to the patient or others) and to distinguish between a crisis and an emergency. Other professionals have a role in this too: On discharge, the A&E staff (who were very kind and very concerned) could invite the family to come back if the situation deteriorates, making it clear that it was an emergency, was a legitimate use of 999 and of A&E, and that the Crisis Teams are not for emergencies. The police could do the same, if they are trusted by the family (in many cases they are not).

In this BMJ article, James Reason discusses how the human error problem can be viewed in two ways: the person approach and the system approach. Each has its model of error causation and each model gives rise to quite different philosophies of error management. Understanding these differences has important practical implications for coping with the ever present risk of mishaps in clinical practice. Key learning points Two approaches to the problem of human fallibility exist: the person and the system approaches. The person approach focuses on the errors of individuals, blaming them for forgetfulness, inattention, or moral weakness. The system approach concentrates on the conditions under which individuals work and tries to build defences to avert errors or mitigate their effects. High reliability organisations—which have less than their fair share of accidents—recognise that human variability is a force to harness in averting errors, but they work hard to focus that variability and are constantly preoccupied with the possibility of failure.

In this blog, Joanne Hughes, founder of Mother's Instinct and hub topic leader,  gives her response to the recent news that childrens' deaths at Great Ormond Street Hospital (GOSH) have not been investigated properly. Amid claims GOSH put reputation above patient care, former health secretary, Jeremy Hunt, urged it to consider a possible "profound cultural problem". Joanne's daughter, Jasmine, died in 2011 following failures in her care. Soon after Joanne set up Mother’s Instinct with the ambition to provide a source of support specifically for families whose children die following medical error, and a platform to share their stories and experiences for learning to improve patient safety for children, patient engagement in patient safety, and care of avoidably bereaved parents.

Medical errors are the third leading cause of death in the United States. Putting patients first — listening to their own and their families’ concerns — can help eliminate medical errors altogether. A patient-centric approach encourages patients to communicate their ‘gut feelings’ when something seems wrong, thereby working to end the pervasive and dangerous culture of silence and fear in hospitals. In a blog in the Patient Safety Movement newsletter, James Titcombe talks about his son's death and how speaking out can save lives.

The Coroners and Justice Act 2009 allows a coroner to issue a Regulation 28 report to an individual, organisations, local authorities or government departments and their agencies where the coroner believes that action should be taken to prevent further deaths. Eileen Pollard died of a myocardial infarction. This coroners report was due to concerns raised by the patient numerous times around the call bell either not being near the patient or not working. This regulation 28 is around testing of patient call bells in care homes. Questions: Have you got a system for checking call bells where you work? Are the call bells always in reach of the patient?

When James Titcombe is hit by the biggest tragedy imaginable to any parent, he and his wife need to confront a tragedy on a bigger scale still: the structural learning disabilities of the organisation that robbed them of their child. The ‘complexity of failure’ video documents the struggle to get the largest employer of the land to account for what was lost. Behind the bureaucracy and posturing, the lies and denials, it discovers a humanity and a richly facetted suffering by many others. It drives a determined James Titcombe to change how we learn from failure forever.

This book is an account of the life of a surgeon: what it is like to cut into people's bodies and the life and death decisions that have to be made. 

Between 2005 and 2008 conditions of appalling care were able to flourish in the main hospital serving the people of Stafford and its surrounding area. During this period this hospital was managed by a Board which succeeded in leading its Trust (the Mid Staffordshire General Hospital NHS Trust) to foundation trust (FT) status. The Board was one which had largely replaced its predecessor because of concerns about the then NHS Trust’s performance. In preparation for its application for FT status, the Trust had been scrutinised by the local Strategic Health Authority (SHA) and the Department of Health (DH). Local scrutiny committees and public involvement groups detected no systemic failings. In the end, the truth was uncovered in part by attention being paid to the true implications of its mortality rates, but mainly because of the persistent complaints made by a very determined group of patients and those close to them. This group wanted to know why they and their loved ones had been failed so badly. The report was laid before Parliament in response to a legislative requirement. This Inquiry examines the involvement of numerous agencies with the events at the Mid Staffordshire NHS Foundation Trust within a defined period: January 2005 to March 2009. This is the executive summary which includes 290 themed recommendations.

Oliver McGowan died due to a reaction to a drug he was known to react adversely to. The learning disability mortality review (LeDeR) into his death said that "if Oliver had been assessed correctly on admission to hospital and staff had read his hospital passport, he may never have needed to be intubated and sedated". This is the second report into Oliver's case, following campaigning from Oliver's family. #oliverscampaign I believe all clinicians should read this latest report. There is so much to be learned and so many changes in clinical practice that can be made right away. Since 2018, I have been teaching using Oliver's tragic story to promote reflection on best practice in prescribing and in implementing the Mental Capacity Act. I could write a lot here; however, I believe this is a report all clinicians, and especially all prescribers, need to read in full. A summary of how I see this (or indeed how any individual sees it) it will not be adequate.