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Found 86 results
  1. News Article
    Parents affected by serious failings in maternity units at a Welsh health board will be told of the findings of an independent investigation this autumn. Ten more cases at units run by Cwm Taf Morgannwg in the south Wales valleys have been found by a review, bringing the total number to 160. Maternity services at hospitals in Merthyr Tydfil and Llantrisant were placed in special measures last year. Failings at the maternity units were discovered after an investigation by two Royal Colleges, which found mothers faced "distressing experiences and poor care" between 2016 and 2018. The services at the Royal Glamorgan Hospital in Llantrisant and Prince Charles Hospital in Merthyr Tydfil were also found to be "extremely dysfunctional" and under extreme pressure. A number of recommendations were set to make the service safe for pregnant women and those giving birth at the hospitals. The Welsh Government then appointed the Independent Maternity Services Oversight Panel (IMSOP) to look back at cases, including neonatal deaths. Mick Giannasi, the chairman of IMSOP, said: "In the early autumn, we will start writing to mothers to say we have reviewed your care and this is what we found. "That will be quite distressing for the women because they will have to revisit all those things again. "But it's going to be a difficult period for staff as well because we know that the Royal Colleges review was very difficult for staff - some of the messages that they had to hear were very challenging and those things may be played out again." Read full story Source: BBC News, 28 September 2020
  2. Content Article
    This resource covers: leadership culture resources improvement approaches safety, clinical audit and clinical governance during major change digitalisation innovation trust improvement stories.
  3. Content Article
    This leaflet includes patient information on: why is patient safety important how you can help your medicine recognising acute illness what happens if your Early Warning Score increases? what should relatives or friends do if they are worried that your health is worsening or not improving? blood clots safe surgery infections falls prevention advice preventing pressure ulcers.
  4. Content Article
    Why is Advance Care Planning Important? What is Advance Care Planning? Who can undertake Advance Care Planning and when should it occur? When should Advance Care Planning take place? Identify ways of promoting positive communication around ACP Recognise barriers to communication Promoting opportunities for discussion and responding to 'cues' Time and place Communicate and Listen Documenting References.
  5. Content Article
    General information about the NHS Who does what? How is the NHS regulated? Why do we need to think about how people with a learning disability access the NHS? How does The Equality Act 2010 ensure people with a learning disability have equal access to healthcare? What are reasonable adjustments? The Mental Capacity Act 2005 and access to healthcare What to do if things do not go well: The NHS Complaints process Top Tips to involve someone you support in their health care In Summary.
  6. News Article
    Across 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
  7. News Article
    A 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
  8. Content Article
    This 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.
  9. Content Article
    The 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.
  10. Content Article
    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.
  11. Content Article
    This 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.
  12. News Article
    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
  13. Content Article
    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.