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Patients that I care for remain the same. Medically they are the same as they ever were. They have bowel obstructions, they have heart attacks, they have infections, they break bones, and there will always be a constant flow of patients that need the services of the NHS. One day it will be you and it will be me, at some point we will rely on NHS care. However, the way that care is organised and delivered around us will change. We have no idea what it will look like in the future, but it will be different to what we knew before the pandemic hit. At the moment we are all working in a state of flux. I work part time as a critical care outreach nurse, so there are times when I am not at the hospital for a few days in a row. When I am due back at work, I get what I call the ‘Sunday night fear’. I used to get this every Sunday night before I had to go to school. I would worry about fitting in, had I done my homework, have I got all my books together and whether I was going to have a good hair day. Now I find myself worrying about what new protocols I need to follow, what briefings have I missed, which wards are green, which are red. Now I have a new habit of looking through work emails to find out if I need to do anything different when I come to work. I’m not enjoying this habit one bit. I feel like I am starting a new job every time I turn up after two or three days. One of the roles of the critical care outreach nurse is to provide role modelling and support to staff on the wards. More often than not I have no idea what the ‘rules’ are now. Every decision is difficult. My patient needs to go to theatre urgently; they are slowly occluding their airway. Before the theatre will take them, they need a covid swab result. How do I get a swab result quickly? A new rapid test is now available (I only find this out by someone telling me this as they were passing). How do I get this swab? Does it look different? How do you perform the swab? How do I send it? How quick does it come back? How do I find the result? How reliable is it (at this point, I’m not bothered – just get it done, tick that box). Next call – cardiac arrest on one of the wards. Pre-covid we have been taught "Good chest compressions are linked with better outcomes for patients. Keep time off the chest to a minimum". This has been drummed in to us for years. It is now second nature to make sure that chest compressions are given as soon as we confirm cardiac arrest. But now we are advised by our Trust resuscitation team and the Resuscitation Council UK that performing chest compressions is an aerosol generating procedure (AGP), despite the advice from Public Health England who state that chest compressions is not classed as an AGP. There are a few issues here... As frontline healthcare staff we want to do the best for our patients, and we want to be kept safe by our employers. We need clarity on what we are supposed to be doing; this lack of clarity and standard guidance leads us into different interpretations of the rules and a lack of trust in our leaders. I recently taught on an Advanced Life Support Course. Here, I was teaching a range of healthcare professionals from differing hospitals from inner and outer London. I was amazed at the different practices that were going on. Some were wearing full personal protective equipment (PPE) for cardiac arrests despite covid status, some were not. The lack of clarity here made teaching very difficult as they were not sure who was right and who was wrong. They were then worrying if they had been exposed and are now losing trust in their leaders. In the NHS we use guidance that is evidence based. At present we have such a small evidence base, if any, on how we should treat patients during the pandemic. This is leading to differing local policies of which no one knows which is best. This lack of clarity and guidance also has an impact on the patient. If we are to wear full PPE for AGPs (in the cardiac arrest situation) there will be a delay in performing chest compressions; this has a negative impact on patient outcomes. Cardiac arrests are stressful; donning PPE at breakneck speed so that you can treat your patient is compounding the anxiety. It made me question – if covid is here to stay, should we be rewriting the resuscitation guidelines? Then I thought, how can you rewrite guidance in a time of flux? Things change all the time; nothing is the same from 48 hours ago – so how can meaningful standards and guidance be written if they will be out of date before they get uploaded? And re-writing guidance with consensus from experts and professional bodies takes time. What do we do in the meantime? At this stage we need guidance, we need clarity and we need to feel we can trust in those that lead us through. Call for action We need evidenced-based guidance, we need clarity and we need to feel we can trust in those that lead us through. How are leaders communicating best practice and updated relevant guidance to staff and instilling trust that patient and staff safety is a core priority?

It's been a busy few months to say the least. Preparing for the pandemic, sourcing correct personal protective equipment (PPE), redeploying staff, acquiring new staff, making ventilators, redesigning how we work around the constraints, writing new policies, new guidance, surge plans, and then the complex part… caring for patients. If I am honest, when this all started it felt exciting. Adrenaline was high, motivation was high, we felt somewhat ready. There was a sense of real comradeship. It felt like we were all working for one purpose; to safely care for any patient that presented to us in hospital. We were a little behind London by about 2–3 weeks, so we could watch from afar on how they were coping, what they were seeing and adapting our plans as they changed theirs. Communication through the ITU networks was crucial. Clinical work has been difficult at times. The initial confusion on what the right PPE to wear for each area added to the stress of hearing that our colleagues in other places were dying through lack of PPE. The early days for me were emotionally draining. However, this new way of dressing and level of precaution is now a way of life for us. I have come to terms that I am working in a high-risk area and I may become unwell, but following guidance and being fastidious with donning and doffing helps with ‘controlling’ my anxieties in catching the virus. Some parts of the hospital remained quiet. Staff had been redeployed, elective surgery cancelled and the flow of patients in the emergency department (ED) almost stopped. I remember walking through ED and thinking: where are the people who have had strokes? Have people stopped having heart attacks? Are perforated bowels not happening anymore? The corridor in ED is usually full. Ambulances queuing up outside, but for a good few weeks the ambulance bays were deserted. The news says over and over again "we must not overwhelm the NHS". I always have a chuckle to myself as the NHS has been overwhelmed for years, and each year it gets more overwhelmed but little is done to prevent winter surges, although it's not just winter. The surge is like a huge tidal wave that we almost meet the crest of, but never get there, and emerge out the other side. I sit in the early morning ITU meeting. We discuss any problems overnight, clinical issues, staffing and beds. We have seen a steady decline in the number of ITU patients with COVID over the last week or so. The number of beds free for COVID patients were plentiful. We have enough ventilators and staff for them. This is encouraging news. I take a sigh, thinking we may have overcome the peak. In the next breath, the consultant states that we don’t have any non COVID ITU beds. We have already spread over four different areas and are utilising over 50 staff to man these beds (usually we have 25 staff). So that’s where the perforated bowels, heart attacks and strokes are. The patients we are caring for had stayed at home too long. So long, that they now have poorer outcomes and complications from their initial complaint. These patients are sick. Some of the nurses who are looking after them are redeployed from other areas; these nurses have ITU experience, but have moved to other roles within the hospital. This wasn’t what they had signed up for. They were signed up for the surge of COVID positive patients. I’m not sure how they feel about this. As the hospital is ‘quiet’ and surgical beds are left empty, there is a mention of starting some elective surgery. This would be great. It would improve patient outcomes, patients wouldn’t have to wait too long, so long that they might die as a consequence. However, we don’t have the capacity. We have no high dependency/ITU beds or nurses to recover them. We would also have to give back the nurses and the doctors we have borrowed from the surgical wards and outpatients to staff ‘work as normal’, depleting our staff numbers further. Add to the fact that lockdown has been lifted ever so slightly, the public are confused, I’m confused. With confusion will come complacency, with complacency will come transmission of the virus and we will end up with a second peak. If we end up with a second peak on top of an already stretched ITU and reduced staffing due to the secondary impact on non COVID care, the NHS will be overwhelmed. This time we will topple off that tidal wave. It’s a viscious cycle that I’m not sure how we can reverse. My plea, however, is to ensure we transition out of this weird world we have found ourselves in together. We usually look for guidance from NHS England/Improvement, but no one knows how best to do this. The people who will figure this out is you. If your Trust is doing something that is working to get out of this difficult situation, please tell others. We are all riding the same storm but in different boats. I would say that I am looking forward to ‘business as usual’ – but I can’t bare that expression. Now would be a great time to redesign our services to meet demand, to involve patients and families in the redesign – to suit their needs. We have closer relationships now with community care, social care and primary care, we have an engaged public all wanting to play their part. Surely now is the time we can plan for what the future could look like together? The Government has announced that Ministers are to set up a ‘dedicated team’ to aid NHS recovery. We need to ensure that patient and staff safety is a core purpose of that team’s remit and the redesign of health and social care. Would you be interested in being on our panel for our next Patient Safety Learning webinar on transitioning into the new normal? If so, please leave a comment below.

The Committee identified the following health-related objectives of the lockdown withdrawal strategy: 1. Reduce spread of the COVID-19 virus. 2. Minimise loss of healthcare professionals and maximise their safety and availability to continue the work. 3. Increase case management capacity in existing hospitals and new hospitals. 4. Increase testing to eliminate community spread. 5. Ensure access to normal healthcare requirements of the population. 6. Maintain normal healthcare capacity during the coronavirus period. 7. Maintain public health initiatives (vaccinations, food/nutrition of children and pregnant/feeding mothers.

Key points Incubation period = maximum 14 days. Symptomatic individuals stay in self isolation for 7 days from becoming ill (having symptoms). Day 1 is first day of symptoms. Household members who remain well stay in self isolation for 14 days due to maximum incubation period, calculated from day 1 of first symptomatic person. Household members do not need to restart the clock if other members become symptomatic during the 14 days self-isolation.

It includes information on: symptoms advice on staying at home when and how to contact 111 advice on your immigration status how to stop the spread of the virus.

This review was carried out in response to the very low numbers of investigations or reviews of deaths at Southern Health NHS Foundation Trust. Over a four-year period, fewer than 1% of deaths in Southern Health’s learning disability services and 0.3% of deaths in their mental health services for older people were investigated as a serious incident requiring investigation. Throughout this review, families and carers have told the CQC that they often have a poor experience of investigations and are not always treated with kindness, respect and honesty. This was particularly the case for families and carers of people with a mental health problem or learning disability. However, there is currently no single framework for NHS trusts that sets out what they need to do to maximise the learning from deaths that may be the result of problems in care. This means that there are a range of systems and processes in place, and that practice varies widely across providers. As a result, learning from deaths is not being given enough consideration in the NHS and opportunities to improve care for future patients are being missed. This reports sets out the next steps.

The Yorkshire Contributory Factors Framework (YCFF) is a tool which has an evidence base for optimising learning and addressing causes of patient safety incidents by helping clinicians, risk managers and patient safety officers identify contributory factors of PSIs. Incidents that occur in a hospital setting have been well studied and all contributory factors have been mapped. Based on this research, a team of practicing clinicians with human factors experts has adapted the evidence to a two page framework. The YCFF includes all sixteen domains of the evidence-based domains. The document suggests questions that you might want to ask of those involved in the incident. The underlying aim of this tool is not to ignore individual accountability for unsafe care, but to try to develop a more sophisticated understanding of the factors that cause incidents.

This policy covers how Dorset Healthcare (DHC) University NHS Foundation Trust responds to patient deaths in care generally, not just those amounting to 'serious incidents', which will continue to be dealt with under the existing NHS Improvement’s 2015 'Serious Incident Framework'.

High level findings There is an opportune ‘policy window’ for change in patient safety. The burden of unsafe care is clear and evidence-based both locally and globally. Momentum towards safer care is building at local, national and international levels. Culture is equal to policy and public momentum in order for safety innovations to land, take root and flourish. In order for safety opportunities to materialise, they require a concerted effort towards collaboration, innovation and education. Agreed actions Create national learning systems. Ensure meaningful collection and responses to patient feedback. Develop curricula for patient safety including curricula for investigations. Develop local and global portals for sharing ideas and best practice. Design systems to prevent harm with aligned priorities. Collect data about impact and evaluation. Harness existing digital innovations to improve patient safety. Wilton Park is an Executive Agency of the Foreign and Commonwealth Office.