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Found 505 results
  1. Content Article
    This US study looked at how critical care doctors approach shared decision-making with Black compared with White caregivers of critically ill patients. The authors found that racial disparities exist in critical care clinicians' approaches to shared decision-making and suggest potential areas for future interventions aimed at promoting equity.
  2. News Article
    It is still unclear how unauthorised metal parts came to be implanted in a number of the 19 children with spina bifida who suffered significant complications after spinal surgery. But it has emerged that one child died and 18 others suffered a range of complications after surgery at Temple Street Children’s Hospital – with several needing further surgery, including the removal of metal parts which were not authorised for use. Parents of the children undergoing complex surgery were left distraught by the disclosures that emerged yesterday, after campaigning for years while the young patients in need of operations deteriorated on waiting lists. Gerry Maguire, of Spina Bifida Hydrocephalus Ireland, said “absolute horror is being visited on parents and their advocates”. He condemned as disturbing the information which is “being drip-fed to his group and “more alarmingly the families concerned”. One mother expressed concern about further delays in surgery and said children are too complex to be taken for care abroad. Read full story Source: Irish Independent, 19 September 2023
  3. Content Article
    On 8 February 2024, Ombudsman, Rob Behrens and Patient Safety Commissioner, Henrietta Hughes, wrote a joint letter to government. Both have regulatory roles to play in improving patient safety and both are struggling to gain headway with the recalcitrant NHS. Supposedly independent of government, this correspondence shows they are in fact totally dependent on government, due to their limited powers writes Della Reynolds in this blog.
  4. News Article
    Mothers of babies who died or suffered brain damage from a Group B Strep (GBS) infection say routine screening is needed. Oliver Plumb, from the charity Group B Strep Support, said it was a "small number of babies" exposed to the bacteria that developed a serious and potentially fatal infection. He said around 800 babies a year developed the infection - which is about two babies a day - and about one a week will die, while another a week will be left with a lifelong disability. "It's a heart-breaking start to life for families and that often the first they hear of Group B Strep is when their baby is sick or in intensive care". The charity has called for GBS to be a notifiable disease to make it a legal responsibility for infections to be reported. It added that current figures could be "missing around one fifth of the infections". There was a "postcode lottery" in terms of how many families will hear about GBS, he said. The charity also backed calls for screening. "In the UK we don't sadly have a routine testing programme, that's at odds with much of the rest of the high-income world. " A DHSC spokesperson said a public consultation on the notifiable diseases list was carried out last year. "DHSC and UKHSA are considering the responses and confirmation of any changes will be published in due course," they said. Several reasons for not recommending routine screening have been given by the committee, including that results can change in the last few weeks of labour, and that GBS does not cause infection in every baby. Read full story Source: BBC News, 26 February 2024 Further reading on the hub: Leading for safety: A conversation with Jane Plumb, Founder of Group B Strep Support
  5. Content Article
    Wellcome Collection long read on two women who battled through decades of medical paternalism: Marie Lyon, who took Primodos, and Dr Isabel Gal, the scientist who first raised the alarm.
  6. Content Article
    This animation aims to help staff and employers across health and social care understand Oliver's Training and why it is so vitally important. It was co-designed and co-produced with autistic people and people with a learning disability. Oliver McGowan died aged 18 in 2017 after being given antipsychotic medication to which he had a fatal reaction. He was given the medication despite his own and his family's assertions that he could not be given antipsychotics, and the fact that this was recorded in his medical records. The animation tells his story and highlights the increased risks facing people with learning disabilities and autism when accessing healthcare.
  7. News Article
    Doctors tore down posters offering patients a secondary care review if they were worried about their condition in hospital, the mother of a teenager who died of sepsis claimed. Merope Mills, who has campaigned for a similar policy called “Martha’s Rule” named after her 13-year-old daughter, claimed a small minority of “bad actors” in hospitals risked slowing down the initiative. It comes as NHS England announced 100 hospitals with critical care units will be invited to sign up for the policy, which will be rolled out from April this year. Martha died from sepsis in 2021 after staff at King’s College Hospital failed to move her to intensive care despite her family warning them her condition had deteriorated. “When something similar to Martha’s Rule was introduced to Royal Berkshire Hospital, doctors actually pulled down the posters advertising the service to patients because they hated the idea of giving patients this kind of power,” Mrs Mills told the Today Programme. “A small minority of bad actors whose arrogance, complacency or pride stops them listening and doing the right thing and that is what we are trying to challenge with Martha’s Rule. There are pockets of damaging cultures in hospitals around the country. Sometimes it is not a whole hospital, sometimes it is just a ward in a hospital, sometimes it is just a particular individual on a ward in a hospital.” Read full story Source: The Independent, 21 February 2024
  8. News Article
    In 2009, Emma Murphy took a phone call from her sister that changed her life. “At first, I couldn’t make out what she was saying; she was crying so much,” Murphy says. “All I could hear was ‘Epilim’.” This was a brand name for sodium valproate, the medication Murphy had been taking since she was 12 to manage her epilepsy. Her sister explained that a woman, Janet Williams, on the local news had claimed that taking the drug during her pregnancies had harmed her children. She was appealing for other women who might have experienced this to come forward. Murphy found the news segment that evening and watched it. “I was just stunned,” she says. “Watching that, I knew. I knew there and then that my children had been affected.” At that point, Murphy was a mother to five children, all under six, and married to Joe, a taxi driver in Manchester. “My kids are fabulous, all of them, but I’d known for years that something was wrong,” she says. “They weren’t meeting milestones. There was delayed speech, slowness to crawl, not walking. There was a lot of drooling – that was really apparent. They were poorly, with constant infections. I was always at the doctors with one of them." A call between Murphy and Janet Williams was the start of an incredible partnership. It led to the report published this month by England’s patient safety commissioner, Dr Henrietta Hughes, which recommended a compensation scheme for families of children harmed by valproate taken in pregnancy. Hughes has suggested initial payments of £100,000 and described the damage caused by the drug as “a bigger scandal than thalidomide”. It is estimated that 20,000 British children have been exposed to the drug while in the womb. Williams and Murphy have campaigned relentlessly to reach this point. It is by no means the endpoint – even now, an estimated three babies are born each month having been exposed to the drug. Together, the women formed In-Fact (the Independent Fetal Anti Convulsant Trust) to find and support families like theirs. They were instrumental in the creation of an all-party parliamentary group to raise awareness in government. Read full story Source: The Guardian, 22 February 2024
  9. News Article
    The head of the NHS has today announced the rollout of ‘Martha’s Rule’ in hospitals across England from April, enabling patients and families to seek an urgent review if their condition deteriorates. The patient safety initiative is set to be rolled out to at least 100 NHS sites and will give patients and their families round-the-clock access to a rapid review from an independent critical care team if they are worried about their or a loved one’s condition. This escalation process will be available 24/7 to patients, families and NHS staff, and will be advertised throughout hospitals, making it quickly and easily accessible. NHS chief Amanda Pritchard said the programme had the potential to “save many lives in the future” and thanked Martha’s family for their important campaigning and collaboration to help the NHS improve the care of patients experiencing acute deterioration. Thirteen-year-old Martha Mills died from sepsis at King’s College Hospital, London, in 2021, due to a failure to escalate her to intensive care and after her family’s concerns about her deteriorating condition were not responded to promptly. Extensive campaigning by her parents Merope and Paul, supported by the cross-party think tank Demos, has seen widespread support for a single system that allows patients or their families to trigger an urgent clinical review from a different team in the hospital if the patient’s condition is rapidly worsening and they feel they are not getting the care they need. Merope Mills and Paul Laity, Martha’s parents, said: “We are pleased that the implementation of Martha’s Rule will begin in April. We want it to be in place as quickly and as widely as possible, to prevent what happened to our daughter from happening to other patients in hospital. “We believe Martha’s Rule will save lives. In cases of deterioration, families and carers by the bedside can be aware of changes busy clinicians can’t; their knowledge should be recognised as a resource. We also look to Martha’s Rule to alter medical culture: to give patients a little more power, to encourage listening on the part of medical professionals, and to normalise the idea that even the grandest of doctors should welcome being challenged. We call on all NHS clinicians to back the initiative: we know that the large majority do listen, are open with patients and never complacent – but Martha’s doctors worked in a different culture, so some situations need to change. “Our daughter was quite something: fun and determined, with a vast appetite for life and so many plans and ambitions – we’ll never know what she would have achieved with all her talents. Hers was a preventable death, but Martha’s Rule will mean that she didn’t die completely in vain.” Read full story Source: NHS England, 21 February 2024
  10. Content Article
    Decisions to admit older, frail patients to critical care must pay particular attention to quality of life and the potential burden of care on patients. This burden may extend beyond surviving a critical illness. These decisions are not easy and require careful thought, clinical judgment, and communication write Daniele Bryden and colleagues in this BMJ opinion piece. 
  11. Content Article
    On 29 December 2022, Shahzadi Khan was detained under section 2 of the Mental Health Act due to her mental state and the risks she presented. She was found to have had a manic episode with psychotic symptoms. Due to a lack of beds, she was placed in a privately-run mental health hospital in Norfolk. She remained there until her discharge to the family home on 26 January 2023. She was commenced on Olanzapine and Zopiclone for her mental health whilst an inpatient.   Her diagnosis on discharge was mania with psychotic symptoms. She was to remain on olanzapine in the community. Her placement out of area contributed to disjointed and inadequate discharge planning to support her in the community and was exacerbated by poor communication between the team managing out of area placements and the local team. As a consequence, the aftercare planning did not take place in accordance with S117 Mental Health Act.   This was exacerbated by a failure by all health professionals involved in her care within the mental health trust to recognise that she needed to be referred on to the Trafford Shared Care pathway. A referral would have ensured she received support and care for at least 12 weeks when she returned to the community. There is no clear reason for this failure. She was seen by the Home-Based Treatment Team (HBTT) on 28 January and 2 February, then discharged back to her GP. Within a week of that discharge from HBTT, which meant she had been left with no mental health support, she had deteriorated significantly. On 9 February her GP sent her to hospital for emergency assessment due to her presentation. She was discharged home to be seen by the Home- Based Treatment Team on 11th February. She was seen by that team on 11, 12, and 13 February. There was still no recognition of the fact that the Trafford policy was not being followed. She had indicated her lack of compliance with olanzapine, suicidal thoughts and her behaviour on 13th February was erratic. On 14 February 2023 she took a fatal overdose of prescribed zopiclone at her home address.
  12. News Article
    Italy will carry out an inquiry into its handling of the coronavirus pandemic in a move hailed as “a great victory” by the relatives of people killed by the virus but criticised by those who were in power at the time. Italy was the first western country to report an outbreak and has the second highest Covid-related death toll to date in Europe, at more than 196,000. Only the UK’s death toll is higher. The creation of a commission to examine “the government’s actions and the measures adopted by it to prevent and address the Covid-19 epidemiological emergency” was approved by the lower house of parliament after passing in the senate. Consuelo Locati, a lawyer representing hundreds of families who brought legal proceedings against former leaders, said: “The families were the first to ask for a commission and so for us this is a great victory. The commission is important because it has the task, at least on paper, to analyse what went wrong and the errors committed so as not to repeat the massacre we all suffered.” Read full story Source: The Guardian, 15 February 2024
  13. Event
    6th International Symposium: sharing experience and expertise on how patients and those close to them can improve safety of care today. The Symposium will hear from researchers and patients about their experience of complex modern healthcare. It will explore how to spot that things are going wrong, witness amazing new technology and map-out the ethical and legal implications of increased control of healthcare by patients. The event is in Bangor but will also broadcast content online on the day. Key topics for the 2024 event will be: Patient safety from the patient's (and family's) perspective. Patient Activated Critical Care & the policy discussion about Martha's rule. Patients held technology - empowering or distracting? Register
  14. Content Article
    A common theme of recent international inquiries is that well intentioned investigations often make things worse. Harm is compounded when we fail to listen, validate and respond to the rights and needs of all the people involved. When lengthy processes do not result in meaningful action, suffering can be exacerbated and result in further damage to wellbeing, relationships, and trust. At its worst, compounded harm produces undesirable outcomes such as a community believing an essential service is unsafe, or a clinician leaving their profession. In considering how best to respond, it is important to remember that health systems are comprised of people and relationships, as well as rules and processes. Once we think about safety as a human and relational approach, rather than one that only seeks to lessen risk and enforce regulation, we can consider how to best proceed. Whether an act is intentional or not, a dignifying approach involves working together to repair the harm involved. Restorative responses are ideal for this purpose, as Jo Wailling, Co-chair of the National Collaborative for Restorative Initiatives in Health Aotearoa New Zealand, explains in this blog on the Patient Safety Commissioner website.
  15. Content Article
    The Academy of Medical Sciences has released a stark report highlighting wide-ranging evidence of declining health among children under five in the UK and calls on policymakers to take urgent action to address the situation.It warns Government that major health issues like infant mortality, obesity and tooth decay are not only damaging the nation’s youngest citizens and their future, but also its economic prosperity, with the cost of inaction estimated to be at least £16 billion a year. In recent years, progress on child health in the UK has stalled. Infant survival rates are worse than in 60% of similar countries and the number of children living in extreme poverty tripled between 2019 and 2022. Demand for children’s mental health services surge and over a fifth of five-year-old children are overweight or obese, with those living in the most deprived areas twice as likely to be obese than in affluent areas. One-in-four is affected by tooth decay. Vaccination rates have plunged below World Health Organization safety thresholds, threatening outbreaks. Issues such as the COVID-19 pandemic, increased cost of living and climate change compound widespread inequality and are likely to make early years health in the UK even worse. 
  16. Content Article
    Traditionally, recommendations regarding responding to medical errors focused mostly on whether to disclose mistakes to patients. Over time, empirical research, ethical analyses and stakeholder engagement began to inform expectations — which are now embodied in communication and resolution programmes (CRPs) — for how healthcare professionals and organisations should respond not just to errors but any time patients have been harmed by medical care (adverse events). CRPs require several steps: quickly detecting adverse events, communicating openly and empathetically with patients and families about the event, apologising and taking responsibility for errors, analysing events and redesigning processes to prevent recurrences, supporting patients and clinicians, and proactively working with patients toward reconciliation. In this modern ethical paradigm, any time harm occurs, clinicians and health care organisations are accountable for minimising suffering and promoting learning. However, implementing this ethical paradigm is challenging, especially when the harm was due to an error.
  17. News Article
    Campaigners have said that more lives would be lost unless mental health services were reformed. Figures show 120 people each year are killed by people with mental illnesses. Julian Hendy, whose father was killed by a psychotic man with a long history of mental ill health 17 years ago, said health professionals must be “more assertive” and work better with other agencies such as the police. Valdo Calocane, who was sentenced on Thursday to an indefinite hospital order after being convicted of manslaughter of three people in Nottingham, had fallen off the radar of mental health services, which allowed him to avoid taking his medicine. Hendy accused Nottinghamshire Healthcare NHS Foundation Trust, which was responsible for Calocane’s care, of “washing their hands” of him. He said: “It’s not responsible and it’s not safe. It doesn’t look after people properly … That hasn’t helped him at all, or protected his rights at all, because he has now committed this terrible offence.” Read full story (paywalled) Source: The Times, 26 January 2024
  18. Content Article
    Poor health literacy can inhibit patient or caregiver understanding of care instructions and threaten patient safety. This cross-sectional study from Selzer et al. of medically complex children treated at one academic hospital in Austria reveals that despite high levels of satisfaction with care, many caregivers do not understand medication management instructions at discharge. Misunderstandings were more likely to occur with higher numbers and/or new prescriptions, poor medication-related communication, and language or literacy barriers.
  19. Content Article
    Richard von Abendorff, an outgoing member of the Advisory Panel of the Healthcare Safety Investigation Branch (HSIB), has written an open letter to incoming Directors on what the new Health Services Safety Investigations Body (HSSIB) needs to address urgently and openly to become an exemplary investigatory safety learning service and, more vitally, how it must not contribute to compounded harm to patients and families. The full letter is attached at the end of this page.
  20. Event
    The Patients Association and NHS England’s Worry and Concern Group is holding a webinar on pilot studies testing ways to incorporate inpatients’ views of their illness and worries and concerns in the assessment and recognition of acute illness and risk of deterioration. The webinar brings together patients and clinicians to review: The work done during the Worry and Concern pilots The experience of patients and clinicians who took part in the pilot studies How to ensure patient involvement in the design of a nationwide worry and concern programme. The panel is: John Bamford, Patient Safety Partner Kayleigh Griffiths MBE, member of National Worry and Concern Steering Group Jane Murkin, Deputy Director Safety & Improvement – Nursing, NHS England Prof Damian Roland , Honorary Professor of Paediatric Emergency Medicine, University of Leicester John Welch, Consultant Nurse, Critical Care & Critical Care Outreach, University College London Hospitals NHS Foundation Trust. Prof Roland will review experiences with the new national Paediatric Early Warning System (PEWS). The webinar is free and on Zoom. Register online
  21. Content Article
    The early recognition and treatment of deterioration in patients in clinical settings can help reduce avoidable deaths. NHS England commissioned Florence Nightingale Foundation (FNF) to examine the barriers which prevent worries and concerns being raised about a deteriorating patient. Evidence suggests that organisational culture, professional hierarchies, and the nature of leadership in healthcare environments are the three key factors behind this reluctance. The findings highlight the importance of psychological safety which is highly influenced by authentic leadership in overcoming these barriers.
  22. Content Article
    In this infographic, the Patient Safety Commissioner for England, Dr Henrietta Hughes, sets out her strategy for supporting the development of a new culture for the health system centred on listening to patients.
  23. News Article
    The Campaign to Save Mental Health Services in Norfolk and Suffolk is calling for a criminal investigation into an apparent scandal that decisively surfaced over the summer, centred on the Norfolk and Suffolk NHS foundation trust (or NSFT), which sees to mental health provision across those two very large English counties. It is centred on the “unexpected” deaths of 8,440 people between April 2019 and October 2022, all of whom were either under the care of the trust, or had been up to six months before they died. The story of the failures that led to that statistic date back at least a decade; the campaign says it amounts to nothing less than “the largest deaths crisis in the history of the NHS”. The figure of 8,440 was the key finding of a report by the accounting and consultancy firm Grant Thornton – commissioned by the trust, ironically enough, to respond to anxious claims by campaigners, disputed by the trust, that there had been 1,000 unexpected deaths over nine years. There are no consistent national statistics for such deaths, and no universal definition of “unexpected”: in Norfolk and Suffolk, a death will be recorded as such if the person concerned was not identified by NHS staff as critically or terminally ill; the term includes deaths from natural causes as well as suicide, homicide, abuse and neglect. The period in question includes the worst of the pandemic, although the trust’s own annual deaths figures did not reach a peak until 2022-23. But the numbers still seem jaw-dropping: they represent an average of about 45 deaths a week. To put that in some kind of perspective, earlier reports about the trust’s deaths record had raised the alarm about a similar number of people dying every month. And the Grant Thornton report included another key revelation: the fact that the trust’s record-keeping was so chaotic that in about three-quarters of cases, it did not know the specifics of how or why the people concerned had died. After its publication, moreover, there were more revelations about the trust, and its culture and practices. Read full story Source: The Guardian, 21 January 2024
  24. Content Article
    Sharing his own personal experiences of harm, Richard highlights four routes where patients and families can report patient safety incidents to ensure patients' voices can be heard and, most importantly, acted upon.
  25. Content Article
    This constructive commentary reflects on two recent related publications, the Healthcare Safety Investigation Branch (HSIB) report, Variations in the delivery of palliative care services to adults, and an article from Sarcoma UK, Family insights from Dermot’s experience of sarcoma care. Drawing from these publications, Richard, brother-in-law of Dermot, gives a family perspective, calling for a more open discussion around how we can improve palliative care and sarcoma services, and why we must listen and act upon family and patient experience and insight.
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