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Found 22 results
  1. News Article
    A 33-year-old New Zealand woman who was accused of faking debilitating symptoms has died of Ehlers-Danlos Syndrome (EDS). Stephanie Aston became an advocate for patients' rights after doctors refused to take her EDS symptoms seriously and blamed them on mental illness. She was just 25 when those symptoms began in October 2015. At the time, she did not know she had inherited the health condition. EDS refers to a group of inherited disorders caused by gene mutations that weaken the connective tissues. There are at least 13 different types of EDS, and the conditions range from mild to life-threatening. EDS is extremely rare. Aston sought medical help after her symptoms—which included severe migraines, abdominal pain, joint dislocations, easy bruising, iron deficiency, fainting, tachycardia, and multiple injuries—began in 2015, per the New Zealand Herald. She was referred to Auckland Hospital, where a doctor accused her of causing her own illness. Because of his accusations, Aston was placed on psychiatric watch. She had to undergo rectal examinations and was accused of practising self-harming behaviours. She was suspected of faking fainting spells, fevers, and coughing fits, and there were also suggestions that her mother was physically harming her. There was no basis for the doctor’s accusations that her illness was caused by psychiatric issues, Aston told the New Zealand Herald. “There was no evaluation prior to this, no psych consultation, nothing,” she said. She eventually complained to the Auckland District Health Board and the Health and Disability Commissioner of New Zealand. “I feel like I have had my dignity stripped and my rights seriously breached,” she said. Read full story Source: The Independent, 6 September 2023
  2. News Article
    Despite regular MRI scans at the Royal Preston Hospital showing that the tumour was growing, May Ashford was not offered surgery until five years later. A woman died unnecessarily after doctors failed to operate soon enough on a growing brain tumour, according to the health complaints service. May Ashford, from Blackpool, was diagnosed with a brain tumour in 2010 after experiencing headaches and seizures. Despite regular MRI scans at the Royal Preston Hospital showing that the tumour was growing, she was not offered surgery until five years later. An investigation by the Parliamentary and Health Service Ombudsman (PHSO) said the treatment was too late as medical staff had failed to monitor the scan results properly. Medical experts said Mrs Ashford should have been operated on at least three years earlier, before the tumour had time to grow and affect the surrounding area of the brain. She tragically died aged 71 from a stroke following surgery. Link to full article here
  3. Community Post
    NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. I have just published a post about this challenge and Triscribe's solution. I would love to hear any comments or feedback on the topic... How could we use this information better? What are hospitals already doing? Where are the gaps? Thanks
  4. Content Article
    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.
  5. News Article
    Shrewsbury and Telford hospital NHS trust has uncovered dozens of avoidable deaths and more than 50 babies suffering permanent brain damage over the past 40 years. But how many more babies must die before NHS leaders finally tackle unsafe, disrespectful, life-wrecking services? The NHS’s worst maternity scandal raises fundamental questions about the culture and safety of our health service. Too many hospital boards complacently believe “it couldn’t happen here”. Instead of constantly testing the quality and reliability of their services, they look for evidence of success while explaining away signs of danger. Across the NHS there are passionate clinicians and managers dedicated to building a culture that delivers consistently high quality care. But they are undermined by a pervasive willingness to tolerate and excuse poor care and silence dissent. Until that changes, the scandals will keep coming. Read full story Source: The Guardian, 2 November 2019
  6. Content Article

    Walk on by...

    Anonymous
    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.
  7. Content Article
    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. 
  8. Content Article
    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.
  9. Content Article
    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
  10. Content Article
    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.
  11. Content Article
    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. 
  12. Content Article
    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?
  13. Content Article
    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?
  14. Content Article
    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.
  15. Content Article
    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.
  16. Content Article
    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.
  17. Content Article
    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. 
  18. Content Article
    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.
  19. Content Article
    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. 
  20. Content Article
    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.
  21. Content Article
    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.
  22. Content Article
    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.
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