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Found 94 results
  1. Content Article
    Yvonne had experienced mental health problems since childhood and was considered originally to have a personality disorder. She was treated by mental health services for many years and had several inpatient admissions, some of which were compulsory. After a period of self-neglect and refused admission, Yvonne was finally detained under the Mental Health Act on 27 January 2020 at Park House Psychiatric unit, Manchester. On admission she was found to be significantly malodorous and have several long-standing serious deep infected ulcers. She had to be transferred to the acute hospital for assess
  2. Content Article
    The report highlights that, based on analysis of NHS data, there has been a 30% increase in the number of patient safety incidents in surgery – instances that did or could have led to injury or death – since 2015. The analysis also shows that there were 407 ‘Never Events’ in the last year, with no reduction in the number of these incidents since 2015. The report includes results from a survey of 1,500 people who have had surgery in the last five years, with more than three quarters (76%) of the patients surveyed reporting safety concerns during the surgery process. Of those who were worri
  3. Content Article
    This document has been developed to support providers of mental health inpatient services that are considering, actively implementing, or who are already advanced in use of vision-based patient monitoring systems (VBPMS) to create or update their protocols, policies, and governance arrangements to support safe use for the benefit of patients and staff. Its aim is to support individual healthcare providing organisations in their current or future use of VBPMS to standardise implementation approaches across the country and provide a platform for sharing learning. Particular attention has been pa
  4. Content Article
    The report analyses responses from 955 perioperative practitioners – including Registered Nurses, Operating Department Practitioners (ODPs) and surgeons – surveyed in late 2021. Some key findings from the report include: Demand for a recognised, national training programme. 52% of perioperative practitioners have not received any education on the hazards of exposure to surgical smoke plume. However, 96% would attend training if it were made available. National guidance is needed to mandate the use of evacuation equipment during surgical procedures where surgical smoke plume
  5. News Article
    Systems and processes in place around patient safety failed in terms of the work of a Belfast-based neurologist, an inquiry has found. Dr Michael Watt was at the centre of Northern Ireland’s largest ever recall of patients, which began in 2018, after concerns were raised about his clinical work. More than 4,000 of his former patients attended recall appointments. Almost a fifth of patients who attended recall appointments were found to have received an “insecure diagnosis”. The final report following the Independent Neurology Inquiry found that problems with Dr Watt’s pract
  6. Content Article
    Key conclusions include: The Belfast Trust should have intervened earlier, but failed to do so. Systems and processes in place to assure the public about patient safety prior to November 2016 failed. The effect of numerous failures ensured problems were missed for many years and opportunities to intervene were lost. Failures not confined to Belfast Trust - information was contained in silos with communications between different organisations and management levels poor and inadequate.
  7. Content Article
    This suite of documents includes: 1. The systems thinking journey What: Weaves systems thinking throughout the policy design process. Outlines how systems thinking complements existing guidance. Who: Designed as a first step into understanding systems thinking. 2. The systems thinking toolkit What: A step-by-step guide to 11 simple and accessible systems thinking tools. Includes illustrative examples and templates for each tool. Who: Designed for those who want to use systems thinking. 3. The systems thinking case study bank What:
  8. News Article
    Contractors could be required to provide trusts with the findings of criminal records checks on their employees, an update from Michael inquiry into mortuary security has suggested. The independent inquiry, chaired by Sir Jonathan Michael, was set up to examine the implications of the sexual assaults on the bodies of women and children in hospital mortuaries by maintenance supervisor and convicted murderer David Fuller. A progress report published this month by the inquiry highlighted “responsibilities between trusts and contractors” as an area of concern. The report said expect
  9. News Article
    West Suffolk Foundation Trust’s investigation to find a whistleblower was “intimidating…flawed and not fit for purpose”, according to a damning review which is highly critical of the organisation’s leadership. The long-awaited review, published today, was triggered by ministers back in January 2020 following allegations that trust directors had ordered staff to give fingerprints and handwriting samples during a “witch hunt” for a whistleblower. The review, led by Christine Outram, has corroborated many of the allegations. It concluded trust leaders’ investigation to uncover the
  10. Content Article
    Christine Outram MBE, working to terms of reference, oversaw the investigation and assessment of the Trust’s handling and circumstances surrounding concerns raised in an anonymous letter sent to the relative of a patient who had died at the West Suffolk NHS Foundation Trust. The purpose of the Review was twofold: To consider the appropriateness of the actions taken in response to the issues raised by/ connected with the October letter by the Trust and other relevant bodies. To produce advisory recommendations and learnings. The Review did not consider the cause of deat
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