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Content ArticleThis research presents a number of factors contributing to poor reporting in healthcare as well as suggestions for system improvement drawn from the car industry. Amongst these, an increase in specificity of reporting method, need for long term data and recognition of behavioural differences between different sources could lead to better reporting methods and potentially reduce existing levels of underreporting. It also considers that bringing device performance reporting outside the context of incidents only would lead to improved knowledge and learning for all stakeholders. Thus, a diff
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News ArticleNew data indicates the dental crisis shows no signs of slowing, with four in five people (80%) struggling to access timely care during the last COVID-19 lockdown. Access to NHS dental care continues to be a problem for people across England, with Healthwatch recording a 22% rise in calls and complaints about dentistry between January and March 2021. A review of 1,375 people’s experiences shared with Healthwatch found a lack of consistency across the country when it comes to accessing a dental appointment. Whilst some people were asked to wait an unreasonable time of up to three ye
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News Article
People in England ‘face three-year waits for dentist appointments’
Patient Safety Learning posted a news article in News
People are being told to wait until 2024 for dentist appointments while others are being removed from their practice lists for not making appointments sooner, according to a damning report into the state of dentistry. Dental surgeries have reported that they have thousands of people on their waiting lists, while patients are unable to access care after ringing round numerous dental surgeries, a watchdog has warned. Delays have resulted in the worsening of painful symptoms and in one instance even led to a patient needing hospital treatment after overdosing on painkillers, it said. -
News Article
Patients harmed after roll-out of new IT system
Patient Safety Learning posted a news article in News
Patients have come to avoidable harm after a large private provider failed to deliver thousands of medicine prescriptions, according to a report from the Care Quality Commission. Healthcare at Home, which is based in Staffordshire but provides NHS-funded care and medicine supplies to patients’ homes across the country, has been rated “inadequate” and placed in special measures. A report published today said inspectors found more than 10,000 patients missed a dose of their medicine between October and December 2020 due to problems caused by the introduction of a new information system -
News ArticleA private healthcare provider has been ordered to pay £20,000 after failing to disclose errors in the treatment of patients under the care of a surgeon. Spire Healthcare was prosecuted today in what the Care Quality Commission (CQC) said was “the first prosecution of its kind against an independent provider of healthcare”. The CQC said concerns around the treatment of four patients were initially raised by Leeds Clinical Commissioning Group, several physiotherapists at the hospital and another surgeon. The patients had surgical procedures carried out by Michael Walsh, a shoulder
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Content ArticleThe gap was illustrated through an investigation that focused on a case of wrong tooth extraction. Wrong tooth extraction was categorised as a Never Event and therefore HSIB sought to understand the ‘barriers’ that exist in the pathway of care for wrong tooth extraction. The report identifies that while there are controls in place to prevent wrong tooth extraction, they invariably rely on staff to be effective and should not be regarded as ‘strong systemic protective’ barriers. The investigation went further to examine the differences in how the NHS defines and assures barriers in compari
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Content ArticleThere has been a history of collaboration between the NHS and independent hospitals when delivering care to patients. This has included NHS patients undergoing care for certain conditions in independent hospitals. Recently, COVID-19 has placed increased pressure on the NHS. This has resulted in independent hospitals providing more care for NHS patients including urgent NHS elective surgical care and delivery of cancer pathways. This HSIB investigation will consider the safe provision of surgical care, with reference to a specific incident, and how decisions are made around which patients are
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Content Article
Fatigue and alertness: Keeping the rail industry alert
Patient Safety Learning posted an article in Techniques
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News ArticleNearly 30 patients suffered severe or moderate harm due to quality issues with ultrasounds carried out by an independent provider, a review has found. Scans of 1,800 patients carried out by two sonographers employed by Bestcare Diagnostics were examined as part of a clinical harm review initiated by Coastal West Sussex Clinical Commissioning Group in 2019. Papers for next week’s governing body meeting of West Sussex CCG — which has absorbed Coastal West Sussex CCG — reveal the review found 29 cases of severe or moderate harm. According to the NHS’ National Recording and Learni
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Content ArticleThe Paterson Inquiry The Independent Inquiry into the Issues raised by Paterson, published on 4 February 2020, was prompted by the case of Ian Paterson, a breast surgeon who was convicted of wounding with intent some of the 11,000 patients he treated and jailed for 20 years in 2017. More than 200 patients and family members gave evidence as part of the Inquiry and it is estimated that he could have harmed more than 1000 patients.[2] The scale of his malpractice is truly shocking, and it served to highlight a range of serious patient safety concerns in both the NHS and the independent
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News Article
PHIN responds to Government update on the Paterson Inquiry
Patient Safety Learning posted a news article in News
Following the statement from Nadine Dorries MP, Minister for Patient Safety, providing an update on the Paterson Inquiry, Matt James, Chief Executive of the Private Healthcare Information Network, said: “Although we were expecting the Government’s full response by now, it’s reassuring to know that this is still firmly on the agenda. The updates provided today are all welcome, but perhaps most telling is what remains to be addressed – most notably whole-practice information and better information for patients (recommendations one and three). “While it’s disappointing not to see more -
News ArticleMinisters have been accused of “knowingly exposing” NHS and private patients to safety risks after delaying again a full response to the inquiry into the Ian Paterson scandal. Victims of rogue surgeon Ian Paterson, who was jailed in 2017 for carrying out unnecessary surgery on patients, told The Independent there was a “clear and present danger” of similar crimes being committed without urgent action being taken. On Tuesday, the government released a partial response to an independent inquiry, led by Reverend Graham James, which reported in February last year. It revealed Paterson wa
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News ArticlePatients with learning disabilities were pushed and dragged across the floor while others had their arms trapped in doors by staff working at a private hospital, the care watchdog has found. The Care Quality Commission said instances of abuse caught on CCTV had now been reported to police and staff working at St John’s House, near Diss in Norfolk, have been suspended. Police have said no further action will be taken. The regulator has rated the home, part of The Priory Group, inadequate and put it into special measures after inspectors found a string of failures at the 49-bed home du
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News ArticleSome NHS dental patients have been asked to pay for private care "if they want any treatment", according to a watchdog. Others are facing waits of up to two years for an NHS appointment, Healthwatch England has warned. One patient was in so much pain he decided to extract his own teeth, said its chairman Sir Robert Francis QC. The NHS said over 650 urgent dental hubs have been set up so patients can access a dentist. Hundreds of people contacted Healthwatch England between October and December last year complaining about dentistry issues. A briefing document from the watchd
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News Article
Fears of 'two-tier' system as NHS waiting lists prompt more people to go private
Patient Safety Learning posted a news article in News
Concerns are growing that long NHS waiting times caused by the coronavirus crisis are exacerbating pre-existing health inequalities and creating a “two-tier” system, as more people turn to the private sector for quicker treatment. As leading doctors warn mass cancellations of NHS operations in England are inevitable this winter after waiting times reached the highest levels on record this summer, data shows a rise in the number of people self-funding treatment or investing in private health insurance. “COVID-19 has not impacted everyone equally, and there is clearly a risk that the b -
News ArticleA UK oncologist with a world reputation is facing allegations by the General Medical Council that he provided medication inappropriately in an attempt to keep terminally ill patients alive. Justin Stebbing, professor of cancer medicine and oncology at Imperial College London, who has a private practice in Harley Street, faces allegations at a medical practitioners tribunal of failing to provide good clinical care to 11 patients between March 2014 and March 2017. Read full story (paywalled) Source: BMJ, 15 September 2020
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News Article
Surgeon suspended over treatment concerns
Patient Safety Learning posted a news article in News
A doctor who worked at the same private healthcare firm as rogue breast surgeon Ian Paterson has been suspended, it has emerged. Spire Healthcare said Mike Walsh – a specialist in trauma and orthopaedic surgery – was suspended in April 2018 over concerns about patient treatment. Almost 50 of his patients from its Leeds hospital had been recalled. The details emerged following an independent inquiry into Paterson, who is serving a 20-year jail sentence. Earlier this month, an inquiry into the breast surgeon found that a culture of "avoidance and denial" had allowed him to perform -
News Article
‘Plug-and-play’ regtech solution enhances patient safety
Patient Safety Learning posted a news article in News
With a focus on pharmaceutical supply chain regulation, Bonafi is one of the latest companies to launch within the regtech startup sector. “Companies operating in the global pharma industry must verify that those they are buying from and selling to are authorised to handle medicinal products for human use in their own countries,” explains its founder, Katarina Antill. “At present, this verification process is manual. Companies are using screenshots as proof and relying on spreadsheets to track verification activities, which increases the risk of errors.” “Manual processes are very la -
News Article
Paterson scandal: Is the NHS learning from mistakes?
Patient Safety Learning posted a news article in News
Shipman, Mid Staffordshire, Morecambe Bay, and now Ian Paterson, the breast surgeon that performed botched and unnecessary operations on hundreds of women. The list of NHS-related scandals has got longer. It's tempting to say the health service has not learned lessons even after a string of revelations and reviews. But is that fair? asks BBC Health Editor Hugh Pym. The inquiry, chaired by Bishop Graham James, makes clear there were failings at every level of a dysfunctional health system when it came to patient safety. The public and private health systems did not compare notes about -
News Article
Inquiry into rogue breast surgeon to call for changes to private hospital safety
Patient Safety Learning posted a news article in News
An independent inquiry is expected to call for major changes in the way private hospitals supervise doctors after hundreds of women were put through unnecessary operations by a rogue breast surgeon. Ian Paterson was jailed for 20 years in 2017 after being convicted of 13 counts of wounding with intent and three counts of unlawful wounding. But his surgical malpractice may have harmed more than 750 women over more than a decade. He carried out unnecessary surgery for breast cancer on women who did not have the disease, and put other women who did at risk by using his own unofficial te -
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