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Found 191 results
  1. News Article
    Stable coronavirus patients could be taken off ventilators in favour of those more likely to survive, it emerged on Wednesday, as another sharp rise in deaths left the UK braced for the outbreak to reach up to 1,000 deaths a day by the end of the week. In a stark new document issued by the British Medical Association (BMA), doctors set out guidelines to ration care if the NHS becomes overwhelmed with new cases as the outbreak moves towards its peak. Under the proposals, designed to provide doctors with ethical guidance on how to decide who should get life-saving care when resources are overstretched, hospitals would have to impose severe limits on who is put on a ventilator. Large numbers of patients could be denied care, with those facing a poor prognosis losing the potentially life-saving equipment even if their condition is improving. The BMA suggested that younger, healthier people could be given priority over older people and that those with an underlying illness may not get treatment that could save them, with healthier patients given priority instead. Read full story Source: The Guardian, 1 April 2020
  2. News Article
    Hospitals should allow parents to be with children who are being treated for the coronavirus, NHS England has confirmed, after a 13-year-old boy died without any family members beside him. Under its national guidance to hospitals, parents are considered essential visitors, but hospitals do have discretion to suspend visitors if it is “considered appropriate”. Anyone who has symptoms of COVID-19 should not be allowed to visit a hospital. NHS England confirmed the position after 13-year-old Ismail Mohamed Abdulwahab died at King’s College Hospital in south London in the early hours of Monday without any family members present. A statement by his family suggested he was alone because of the risk of infection. On its website the hospital repeated the guidance sent to trusts by NHS England that states children are allowed one parent or carer as a visitor, but declined to explain why his family were not with him. The end-of-life charity Marie Curie has also called on doctors to allow families to be with their loved ones, describing it as an “important part of their duty of care”. Read full story Source: The Independent, 2 April 2020
  3. News Article
    Special body recovery teams have begun work to deal with suspected coronavirus victims who die in their homes. Small units of police, fire and health service staff will confirm death and the identity of the dead and remove their bodies to a mortuary. Known as Pandemic Multi-Agency Response Teams, or PMART, they will be dispatched when victims die outside hospitals and there is a high probability they had COVID-19. The teams have been set up, initially in London, to relieve pressure on hospitals overwhelmed with coronavirus emergency cases. Read full story Source: Sky News, 1 April 2020
  4. Content Article
    Key recommendations Ask the patient if they would like to have the conversation and how much information they would want. All healthcare professionals reviewing patients with chronic conditions, patients with more than one serious medical problem or terminal illness, should initiate shared decision making including advance care planning in line with patient preferences. Conversations about the future can and should be initiated at any point. The conversation is a process not a tick-box, and does not have to reach a conclusion at one sitting. Be aware of the language you use with patients and those they have identified as being important to them, and try to involve all the relevant people in agreement with the patient.
  5. News Article
    A campaign to reduce stillbirths, brain injury, and avoidable deaths in babies has failed to have any effect in the past three years, findings from the Royal College of Obstetricians and Gynaecologists show. The president of the college, Edward Morris, has urged maternity units across the UK to learn from the latest report and act on its recommendations. “We owe it to each and every person affected to find out why these deaths and harms occur in order to prevent future cases where possible,” he said. Read full story (paywalled) Source: BMJ, 19 March 2020
  6. Content Article
    Recommendations Human factors and behaviour: Each Baby Counts has demonstrated that human factors are recurrent themes that need to be urgently addressed at a systemic level. Research is required to establish how to operationalise learning from this report into practice with improved clinical outcomes. Workload and workforce challenges: Develop and fund an appropriate tool to record current workload and anticipate the obstetric care required for the population. This tool should complement the midwifery acuity tools currently implemented nationally. Research is required to identify safe obstetric staffing standards for the workload and acuity, to guide policy-level changes for the workforce. Communication: All staff must be familiar with using their unit emergency communication and escalation protocols, in particular where emergency buzzers are located and how to activate a switchboard emergency call. This should be mandatory in departmental induction and included in simulated escalation calls during local multidisciplinary team training.
  7. News Article
    A “collective failure” to appreciate the enormity of the coronavirus pandemic and enact swift measures to protect the public will lead to unnecessary deaths, according to a leading doctor who says the UK ignored clear warning signs from China. Richard Horton, the Editor-in-Chief of the Lancet, rounded on politicians and their expert advisers for failing to act when Chinese researchers first warned about a devastating new virus that was killing people in Hubei eight weeks ago. The team from Wuhan and Beijing reported in January that the number of deaths was rising quickly as the virus spread in China. They urged the global community to launch “careful surveillance” in view of the pathogen’s “pandemic potential”. Horton said nothing in the science had changed since January. “The UK’s best scientists have known since that first report from China that Covid-19 was a lethal illness. Yet they did too little, too late,” he said. While the UK was now taking the right actions to quell the outbreak, Horton said, in due course “there must be a reckoning” where difficult questions would have to be asked and answered. “We have lost valuable time. There will be deaths that were preventable. The system failed,” he said. Read full story Source: The Guardian, 18 March 2020
  8. News Article
    Great Ormond Street Hospital (GOSH) failed to properly investigate child deaths, suggests evidence uncovered by the BBC. The source of one fatal infection was never examined and in another case GOSH concealed internal doubts over care. Amid claims GOSH put reputation above patient care, former Health Secretary Jeremy Hunt urged it to consider a possible "profound cultural problem". Responding, the central London hospital said it rejected all suggestions that it treated any child's death lightly. BBC Radio 4's File on 4 programme has spoken to several families whose children were treated at the world-famous hospital. All said that while care at one point had been excellent, when things went wrong GOSH appeared to have little interest in fully understanding what had happened. The concerns over how Great Ormond Street is run are shared by staff. A staff survey, published last month, made grim reading for management. On two aspects, including whether there is a safety culture, it received the lowest score of all trusts in its category, while on three other questions, including how bad bullying and harassment were, and how good the quality of care was, its own staff rated it as among the worst. "If we want the NHS to offer the highest quality care in the world, then we have to change a blame culture and sometimes a bullying culture, for a learning and an improvement culture," the former Health Secretary Jeremy Hunt told File on 4. "That staff survey would indicate they don't have that culture at Great Ormond Street." Read full story Source: BBC News, 17 March 2020 Read Joanne Hughes' response to this news in her blog shared on the hub.
  9. News Article
    The mother of a student, who took his own life, said today she felt 'sick to her stomach' after an NHS communications manager labelled a media report on her son's suicide a 'malarkey'. Pippa Travis-Williams, whose son Henry was found dead days after leaving a mental health unit run by the Norfolk and Suffolk Foundation Trust (NSFT) in 2016, said an email sent by NSFT communications manager Mark Prentice to his boss was 'disgusting'. It comes weeks after Mr Prentice gloated in another email to his boss that the NSFT had 'got away (again)' with media coverage of the death of a dementia patient. In an email to his boss, explaining why NSFT chief executive, Jonathan Warren, was going on BBC Look East, Mr Prentice said the NSFT might look 'uncaring' if Mr Warren did not appear and then described the coverage of Mr Curtis-Williams' suicide as a 'malarkey'. Read full story Source: Ipswich Star, 10 March 2020
  10. News Article
    At least 20 maternity deaths or serious harm cases have been linked to a Devon hospital since 2008, according to NHS reports obtained by the BBC. A 2017 review which was never released raised "serious questions" about maternity care at North Devon District Hospital. The BBC spent two years trying to obtain the report and won access to it at a tribunal earlier this year. Northern Devon Healthcare NHS Trust (NDHT) said the unit was "completely different" after recommended reforms. A 2013 review by the Royal College of Obstetricians and Gynaecologists (RCOG) investigated 11 serious clinical incidents at the unit, dating back as far as 2008. The report identified failings in the working relationships at the unit, finding some midwives were working autonomously and some senior doctors failed to give guidance to junior colleagues. Despite the identified problems with "morale", the subsequent investigation by RCOG in 2017 expressed concerns with the "decision-making and clinical competency" of senior doctors and their co-operation with midwives. An independent review into midwifery in October 2017 noted "poor communication" between medical staff on the ward for more than a decade. The report identified a "lack of trust and respect" between staff and "anxiety" among senior midwives at the quality of care. Read full story Source: BBC News, 16 March 2020
  11. Community Post
    Hi The new Patient Safety Incident Response Framework is due for publication this month for early adopters and as 'introductory guidance' for everyone else: https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/ I wondered if there is anyone who is involved in an organisation that is an early adopter who can share what has happened so far and also would be willing to share any local learning as the new framework is implemented? Also, more generally wondered if anyone has any initial comments on the proposals which were mentioned in the NHS patient safety strategy and any things in particular which they think will bring benefit or could represent significant challenges or issues?
  12. News Article
    The parents of a baby who nearly died after a series of failings during his birth said they were "heartbroken" mistakes continued to be made East Kent Hospitals told Harry Halligan's parents they would learn lessons from his delivery in 2012. But similar failings recently came to light after the death of Harry Richford in 2017 and the trust is now being probed over up to 15 baby deaths. The trust said it made "many changes to the maternity service" after 2012. Parents Dan and Alison Halligan, from New Romney, said watching news coverage of an inquest into Harry Richford's death earlier this year, which laid bare the failings, had brought back stressful memories. Mr Halligan said the trust "clearly haven't learned from [the] mistakes" made in his son's care, adding that it was "heartbreaking" to see "the same mistakes being repeated". Read full story Source: BBC News, 5 March 2020
  13. News Article
    Northern Ireland's infant mortality rate remains the highest of any UK region although it has decreased, according to a new report. Infant mortality is a measure of deaths of children under one year of age. The report from the Royal College of Paediatrics and Child Health (RCPCH) shows the current rate is 4.2 deaths per 1,000 live births. In 2017, the figure stood at 4.8 deaths. Infant mortality rates decreased in Northern Ireland, Scotland and Wales but remained unchanged in England, which has the second highest rate of 3.9 deaths per 1,000. The report also highlights an increase in the suicide rate among young people aged 15–24 years. Responding to the figures, Health Minister Robin Swann said the physical and mental health of children and young people was a "priority" for the for the Northern Ireland Executive. "My department is already investing in a number of programmes and strategies which seek to address child health inequalities and improve the wellbeing of our children." Dr Ray Nethercott, RCPCH officer for Ireland acknowledged the current healthcare crisis as well as concerns about waiting lists and standard of care but added that "children's health and wellbeing should not be seen as being in competition with adult services or health provision". "Acting early to treat and prevent conditions, and reducing the impact of factors such as poverty, can really improve health outcomes. A healthier population of children and young people will reduce many of the pressures on adult services in the long term." Read full story Source: BBC News, 4 March 2020
  14. News Article
    Neglect and serious failures by the Home Office and multiple other agencies contributed to the death of a vulnerable man who died from hypothermia, dehydration and malnutrition in an immigration removal centre, an inquest has found. Prince Fosu, a 31-year-old Ghanaian national, died in October 2012 when his naked body was found on the concrete floor of his cell in Harmondsworth, a detention centre near Heathrow. He had been experiencing a psychotic episode but he was not referred for a mental health assessment due to “gross failures” by all agencies to recognise the need to provide appropriate care to a person unable to look after himself. Four GPs, two nurses, two Home Office contract monitors, three members of the Independent Monitoring Board (IMB) and countless detention custody officers and managers who visited him failed to take any meaningful steps, the inquest found. Three doctors have since been referred to the UK’s medical watchdog for their alleged failures relating to the death of Mr Fosu on recommendation of the Prison and Probation Ombudsman (PPO), who said the care he received fell “considerably below acceptable standards”. Read full story Source: The Independent, 3 March 2020
  15. News Article
    An 87-year-old woman died after her carers gave her the wrong medication, a coroner was told. Heather Planner, from Butler's Cross in Buckinghamshire, died at Wycombe Hospital on 1 April from a stroke. Senior coroner Crispin Butler heard three staff from Carewatch Mid Bucks had failed to spot tablets handed over by the pharmacy were for a male patient. Mr Butler said action should be taken to prevent similar deaths. A hearing in Beaconsfield on Thursday, where he issued a Prevention of Future Deaths report, followed an inquest in November. In the report he said he was told at the inquest that the carers from Carewatch Mid Bucks gave widow Mrs Planner the wrong medication four times a day for two and a half days. She suffered a fatal stroke because she did not receive her proper apixaban anticoagulation medication. Mr Butler said he would send his concerns to the chief coroner and the Care Quality Commission. He said there was no procedure in place to ensure individual carers read and specifically acknowledged any medication changes. Read full story Source: BBC News, 27 February 2020
  16. Content Article
    Summary of findings and recommendations People living in the poorest neighbourhoods in England will on average die seven years earlier than people living in the richest neighbourhoods. People living in poorer areas not only die sooner, but spend more of their lives with disability – an average total difference of 17 years. The Review highlights the social gradient of health inequalities - put simply, the lower one's social and economic status, the poorer one's health is likely to be. Health inequalities arise from a complex interaction of many factors – housing, income, education, social isolation, disability - all of which are strongly affected by one's economic and social status. Health inequalities are largely preventable. Not only is there a strong social justice case for addressing health inequalities, there is also a pressing economic case. It is estimated that the annual cost of health inequalities is between £36 billion to £40 billion through lost taxes, welfare payments and costs to the NHS. Action on health inequalities requires action across all the social determinants of health, including education, occupation, income, home and community.
  17. Content Article
    What are PFD reports? There is a statutory duty for coroners to issue a PFD report to any person or organisation where, in the coroner’s opinion, action should be taken to prevent future deaths. These reports are made publicly available on the Coroners Tribunals and Judiciary website with the organisations involved having a duty to respond within 56 days. When serious incidents occur in healthcare that result in the death of a patient, PFD reports play a key role in identifying what went wrong and the actions needed to prevent this reoccurring. These crucial insights may often be applicable beyond the organisation in which this took place and provide a point of wider system learning. Implementing actions and sharing learning While these reports provide a wealth of information, the key challenge is ensuring that we utilise these to their full extent to improve patient safety and care. At Patient Safety Learning while we recognise the important role these reports have to play, we have some concerns about how they are currently acted on. Implementing actions When actions are requested by the coroner, it is not clear under the current system whether there is a structured process, either at a national or individual organisation level, for monitoring the actions implemented in response to the PFD report. There is also an open question about who is held accountable if the actions requested are not fully implemented, or if the response taken is ineffective. It is difficult to assess how healthcare providers go about this as there appears to be no specific system of monitoring this at a national level. Sharing learning As noted earlier, often the learnings from PFD reports may be applicable beyond the organisation involved. However, at present there appears to be no clear system of sharing these outcomes more widely. Although these reports are published online, they are not in an easily searchable or shareable format and it is difficult to draw out common themes, actions and responses. Furthermore, it is not clear whether NHS England and NHS Improvement undertake any central trend analysis or review to draw out common themes that may be applicable to all organisations, in the same way that the Healthcare Safety Investigation Branch does when it publishes its investigation reports. What do we want to see? We have recently written to the Chief Coroner, Judge Mark Lucraft QC, to raise these issues. We have also drawn this to the attention of Dr Alan Fletcher, the National Medical Examiner. As the new National Medical Examiner system is currently being rolled out across England and Wales, their role in ‘ensuring proper scrutiny of all non-coronial deaths’ will be complementary to the current PFD system. We feel it is important that coroners and medical examiners take a consistent approach to reporting and sharing learnings as widely as possible. When we receive responses, we will take this up directly with NHS England and NHS Improvement, and other national bodies with responsibility for patient safety, along with our ideas of actions that we feel could help to address the current gaps in the system: Implementing actions 1) Analyse reports – Sustainability and transformation partnerships (STPs)/Integrated Care Systems (ICSs) to carry out annual thematic reviews of all PFD reports, Serious Incident (SI) reports and associated safety action plans. These plans can inform future commissioning, safety action plans and Care Quality Commission oversight. 2) National oversight – put in place a clear system of national oversight. Shared learning 3) Increase transparency – make all PFD reports, SI reports and their associated safety action plans available in the public domain. 4) Improve accessibility – create a central repository for all PFD reports, SI reports and associated safety action plans in one database searchable by actions and themes. 5) Standards – put in place patient safety standards for each STP and ICS, with requirements on individual trusts, primary care networks and service providers to share learning from these reports. 6) Publish an annual report – on PFD reports and SI reports including themes for learning and action.