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Showing results for tags 'Patient / family involvement'.
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News ArticleAcross the country there have been reports of “do not resuscitate” (DNR) orders being imposed on patients with no consultation, as is their legal right, or after a few minutes on the phone as part of a blanket process. Laurence Carr, a former detective chief superintendent for Merseyside Police, is still angry over the actions of doctors at Warrington Hospital who imposed an unlawful “do not resuscitate” order on his sister, Maria, aged 64. She has mental health problems and lacks the capacity to be consulted or make decisions and has been living in a care home for 20 years. As her main relative, Mr Carr found out about the notice on her records only when she was discharged to a different hospital a week later. Maria had been admitted for a urinary tract infection at the end of March. Although she has diabetes and an infection on her leg her condition was not life threatening. Mr Carr said: “My sister has no capacity to effectively be consulted due to her mental illness and would not understand if they did try to explain, so I was furious that I had not been consulted." He later learnt that the reason given by the hospital for imposing the DNR was "multiple comorbitidies". In a statement, Warrington and Halton Teaching Hospitals Foundation Trust said it was fully aware of the law, which was reflected in its policies and regular training. It said: “We did not follow our own policy in this case and have the requisite discussions with the family. The template form which was completed in this case indicates that discussion with the family was ‘awaiting’. Regretfully due to human error this did not occur." Mr Carr and his sister are not alone. National charity Turning Point said it had learnt of 19 inappropriate DNARs from families, while Learning Disability England said almost one-fifth of its members had reported DNARs placed in people’s medical records without consultation during March and April. Read full story Source: The Independent, 14 July 2020
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News ArticleA woman whose father died in a care home has launched a judicial review case in the High Court over the government’s “litany of failures” in protecting the vulnerable elderly residents who were most at risk from COVID-19. Cathy Gardner accuses England’s health and social care secretary, Matt Hancock, NHS England, and Public Health England of acting unlawfully in breaching statutory duties to safeguard health and obligations under the European Convention on Human Rights, including the right to life. Her father, Michael Gibson, who had Alzheimer’s disease, died aged 88 of probable COVID-19 related causes on 3 April at Cherwood House Care Centre, near Bicester, Oxfordshire. She claims that before his death the care home had been pressured into taking a hospital patient who had tested positive for the virus but had not had a raised temperature for about 72 hours. “I am appalled that Matt Hancock can give the impression that the government has sought to cast a protective ring over elderly residents of care homes, and right from the start,” Gardner said. “The truth is that there has been at best a casual approach to protecting the residents of care homes. At worst the government has adopted a policy that has caused the death of the most vulnerable in our society.” Read full story Source: BMJ, 15 June 2020
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Content ArticleThis report will set-out our family engagement process. It will also summarise the feedback received to date from the families who have been involved in HSIB investigations. The purpose is to for HSIB to share their family engagement process with other healthcare organisations involved in patient safety investigations and raise awareness of the value of an effective family engagement process in such investigations. The report will: Describe HSIB’s approach to family engagement in our investigations and what has informed our practice. Describe what has worked well in our approach to family engagement. Summarise what families and staff tell us about our approach. Explain what we have learned and plans for future work.
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Content ArticleThe paper acknowledges the success, failure and efficiency of all safety efforts is fundamental to the experience of patients and families. In addition, the safety systems in place in an organisation directly shape and define the clinician’s experience. Generated from these concepts, key recommendations in integrating safety and experience are explored: • acknowledge safety as a primary driver for overall experience of both patients and clinicians • approach safety and patient experience through a unified lens • make financial choices that reflect a commitment to the experience of safety • make a conscious, accountable and strategic effort to build a culture of caring • optimise technology to care for the caretakers • engage patient and family voice to lead change and drive future solutions.
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Peri-operative care of people with dementia, 2019
Claire Cox posted an article in Dementia
These guidelines by the Association of Anaesthetists are a concise document designed to help peri-operative physicians and allied health professionals provide multidisciplinary, peri-operative care for people with dementia and mild cognitive impairment. They include information on: involving carers and relatives in all stages of the peri-operative process administering anaesthesia with the aim of minimising peri-operative cognitive changes training in the assessment and treatment of pain in people with cognitive impairment. -
Content ArticleThis guide from the US Betsy Lehman Center for Patient Safety was created to help organisations include the voices of those who use the healthcare system in their work and advisory groups including: expert panels, quality improvement committees, task forces, and Patient and Family Advisory Councils. The Six Essential Elements in this guide were gleaned from a number of reputable sources, as well as from recent experiences by the Betsy Lehman Center, including members of the public in our expert panels and other convening activities.
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Review launched into East Kent NHS trust after baby deaths
Patient Safety Learning posted a news article in News
The government has announced an independent review into maternity services at an NHS trust where a number of babies have died. “Immediate actions” have also been promised and an independent clinical team has been placed “at the heart” of East Kent Hospitals University NHS Foundation Trust. It comes amid reports that at least seven preventable baby deaths may have occurred at the trust since 2016, including that of Harry Richford. Harry died seven days after his emergency delivery in a “wholly avoidable” tragedy, contributed to by neglect, in November 2017, an inquest found. Speaking in the House of Commons, the health minister Nadine Dorries confirmed the independent review would be carried out by Dr Bill Kirkup, who led the investigation into serious maternity failings at Morecambe Bay. It will look at preventable and avoidable deaths of newborns to ensure the trust learns lessons from each case and will put in place appropriate processes to safeguard families. The review is expected to begin shortly and work in partnership with affected families. Read full story Source: 13 February 2020 -
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The BAPEN self-screening tool for malnutrition
Claire Cox posted an article in Keeping patients safe
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. -
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Malnutrition Task Force case study: Lyn's story
Claire Cox posted an article in Community care
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Content ArticleThe presentation covered: Family liaison within the NHS. The role of family liaison. Supporting and working with families and/or carers-what do they want and/or need? What type of cases can family liaison handle and where they can’t support a family/carer. A case study.
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Content ArticleThe patient leaflet explains about the Call 4 Care service to patients, carers and families and contains information that may be helpful during their hospital stay. This template can be adapted and used by any trust in any setting.
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Justice is being denied to too many families
Patient Safety Learning posted a news article in News
Harry Richford's death underlines the need for the health secretary to bring back the national maternity safety training fund – and there are other issues that require urgent attention – The Independent reports. Harry Richford had not even been born before the NHS failed him. An inquest has concluded he was neglected by East Kent University Hospitals Trust in yet another maternity scandal to rock the NHS. His parents and grandparents have fought a tireless campaign against a wall of obfuscation and indifference from the NHS. In their pursuit of the truth they have exposed a maternity service that did not just fail Harry, but may have failed dozens of other families. As with the family of baby Kate Stanton-Davies at Shrewsbury and Telford Hospitals Trust, or Joshua Titcombe at the University Hospitals of Morecambe Bay Trust, it has taken a family rather than the system to expose what was going wrong. It is known that there are about 1,000 cases a year of safety incidents in the NHS across England, including baby deaths, stillbirths and children left brain damaged by mistakes. Last week, the charity Baby Lifeline, joined The Independent to call on the Department of Health and Social Care (DHSC) to reinstate the axed maternity safety training fund. This small fund was used to train maternity staff across the country. Despite being shown to be effective, it was inexplicably scrapped after just one year. There are other issues that also need urgent attention. The inquest into Harry’s death, which concluded on Friday, lasted for almost three weeks. Without pro bono lawyers from Advocate, Brick Court Chambers and Arnold & Porter law firm, the family would have faced an uphill struggle. At present, families are not automatically entitled to legal aid at an inquest, yet the NHS employs its own army of lawyers who attend many inquests and can overwhelm bereaved families in a legal battle they are ill-equipped to fight. Even the chief coroner, Mark Lucraft QC, has called for this inequality of legal backing to end, but the government has yet to take action. Read full story Source: The Independent, 26 January 2020 -
Content ArticleVanessa Sweeney, Deputy Chief Nurse and Head of Nursing – Surgery and Cancer Board at University College London Hospitals NHS FT decided to share a example of positive feedback from a patient with staff. The impact on the staff was immediate and Vanessa decided to share their reaction with the patient who provided the feedback. The letter she sent, and the patient’s response are reproduced here: Dear XXXXX, Thank you for your kind and thoughtful letter, it has been shared widely with the teams and the named individuals and has had such a positive impact. I’m the head of nursing for the Surgery and Cancer Board and the wards and departments where you received care. I’m also one of the four deputy chief nurses for UCLH and one of my responsibilities is to lead the trust-wide Sisters Forum. It is attended by more than 40 senior nurses and midwives every month who lead wards and departments across our various sites. Last week I took your letter to this forum and shared it with the sisters and charge nurses. I removed your name but kept the details about the staff. I read your letter verbatim and then gave the sisters and charge nurses the opportunity in groups to discuss in more detail. I asked them to think about the words you used, the impact of care, their reflections and how it will influence their practice. Your letter had a very powerful impact on us as a group and really made us think about how we pay attention to compliments but especially the detail of your experience and what really matters. I should also share that this large room of ward sisters were so moved by your kindness, compassion and thoughtfulness for others. We are now making this a regular feature of our Trust Sisters Forum and will be introducing this to the Matrons Forum – sharing a compliment letter and paying attention to the narrative, what matters most to a person. Thank you again for taking the time to write this letter and by doing so, having such a wide lasting impact on the teams, individuals and now senior nurses from across UCLH. We have taken a lot from it and will have a lasting impact on the care we give. The patient replied: Thank you so much for your email and feedback. As a family we were truly moved on hearing what impact the compliment has had. My son said – “really uplifting”. I would just like to add that if you ever need any input from a user of your services please do not hesitate to contact me again
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