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Found 473 results
  1. Content Article
    This is an independent review commissioned by NHS England, chaired by Siobhan Melia, Chief Executive, Sussex Community NHS Foundation Trust, to support the improvement of the culture within the ambulance service. The review considers the prevailing culture within ambulance trusts in England. It considers the core factors impacting cultural norms and offers actionable recommendations for improvement. Based on insights from key stakeholders, this review has identified six key recommendations to improve the culture in ambulance trusts.
  2. Content Article
    This national learning report (NLR) draws on findings from investigation reports completed by the Healthcare Safety Investigation Branch (HSIB) that considered the risks associated with patient identification. ‘Positive patient identification’ is correctly identifying a patient to ensure that the right person receives their intended care. To support patient identification in England, the patient’s NHS number should be used alongside other identifiers, such as their name, date of birth and address. Patient misidentification is where a patient is identified as someone else. This may mean that a patient does not receive the care meant for them, or that they receive the care meant for someone else. Patient misidentification was highlighted as a risk to patient safety by the National Patient Safety Agency in the early 2000s. Despite the time that has passed, patient misidentification remains a persistent risk to patient safety that can result in significant harm. The aim of this NLR was to combine and analyse HSIB’s previous investigations and relevant international research literature, with the goal of informing national learning and influencing national actions to help reduce the risk of patient misidentification.
  3. Content Article
    Set up in January 2023, the Times Health Commission was a year-long projected established to consider the future of health and social care in England in the light of the pandemic, the growing pressure on budgets, the A&E crisis, rising waiting lists, health inequalities, obesity and the ageing population. Its recommendations are intended to be pragmatic, practical, deliverable and able to be potentially taken up by any political party or government, present or future. 
  4. Content Article
    On the 24 October 2023 the Health and Social Care Select Committee announced that its independent Expert Panel would be undertaking an evaluation of government progress on implementing accepted recommendations to improve patient safety. As part of this review, the Committee wrote to the Secretary of State for Health and Social Care requesting a list of key independent public inquiry and review recommendations pertaining to patient safety and whistleblowing in the NHS that that the Government has accepted since 2010. This letter sets out the response to this request from Maria Caulfield MP, Parliamentary Under Secretary of State.
  5. Content Article
    In 2021 in New South Wales (NSW) there were 41,619 people over 65 who were hospitalised due to a fall at home or in the community. This number increased by 60% in a decade from 25,982 in 2010 and the incidence of falls is set to increase further as the population ages. In 2021 the cost to the NSW health system from falls by older people in the community was around $752 million. These costs are projected to grow to $1.09 billion by 2041 – the result of around 60,300 hospitalised falls projected for that year. There is robust evidence that falls can be prevented. Fall prevention is a complex area as there are multiple risk factors that may contribute as to why a person may fall. A systems thinking approach acknowledges the complexity of fall prevention, seeks to understand the interactions between components, and identifies what interventions work best.
  6. Content Article
    The Health Services Safety Investigations Body (HSSIB) Senior Safety Investigator, Helen Jones, blogs about some of the key benefits and risks of electronic patient record (EPR) systems used in healthcare, sharing what we are learning from our safety investigations.
  7. Content Article
    The helicopter, G-MCGY, was engaged on a Search and Rescue mission to extract a casualty near Tintagel, Cornwall and fly them to hospital for emergency treatment. The helicopter flew to Derriford Hospital (DH), Plymouth which has a Helicopter Landing Site (HLS) located in a secured area within one of its public car parks. During the approach and landing, several members of the public in the car park were subjected to high levels of downwash from the landing helicopter. One person suffered fatal injuries, and another was seriously injured. The investigation carried out by the Air Accidents Investigation Branch identified the following causal factors: The persons that suffered fatal and serious injuries were blown over by high levels of downwash from a landing helicopter when in publicly accessible locations near the DH HLS. Whilst helicopters were landing or taking off, uninvolved persons were not prevented from being present in the area around the DH HLS that was subject to high levels of downwash. Helicopters used for Search and Rescue and Helicopter Emergency Medical Services (HEMS) perform a vital role in the UK and, although the operators of these are regulated by the UK Civil Aviation Authority, the many helicopter landing sites provided by hospitals are not. It is essential that the risks associated with helicopter operations into areas accessible by members of the public are fully understood by the HLS Site Keepers, and that effective communication between all the stakeholders involved is established and maintained. Therefore, nine Safety Recommendations have been made to address these issues.  
  8. Content Article
    Patients who visit their GP practice with an ongoing health problem may see several different GPs about the same symptoms. To make sure they receive safe and efficient care, there needs to be a system in place to ensure continuity of care. In the context of this report, continuity of care is where a patient has an ongoing relationship with a specific doctor, or when information is managed in a way that allows any doctor to care for a patient. While some GP practices in England operate a formalised system of continuity of care, many do not. This investigation explored the safety risk associated with the lack of a system of continuity of care within GP practices. The investigation focused on: How GP practices manage continuity of care. This includes how electronic record systems alert GPs to repeat attendances for symptoms that are not resolving and how information is shared across the healthcare system. Workload pressures that affect the ability of GP practices to deliver continuity of care. This investigation’s findings, safety recommendations and safety observations aim to prevent the delayed diagnosis of serious health conditions caused by a lack of continuity of care and to improve care for patients across the NHS.
  9. News Article
    At least 20,000 cancer deaths a year could be avoided in the UK with a national commitment to invest in research and innovation, and fix the NHS, says Cancer Research UK. Progress is being made in finding new treatments for the condition that affects 50% of people at some point. But the charity says the UK lags behind comparable countries for survival. It has launched a manifesto of priorities for this government and the next, ahead of a general election. The document sets out what the charity says needs to change - and fast. Whoever is running the country must commit to developing a 10-year cancer plan, spearheaded by a National Cancer Council accountable to the prime minister to bring government, charities, industry and scientific experts together, it says. Key areas to focus on include: More investment in research to close an estimated £1bn funding gap. Greater disease prevention - banishing smoking to the history books, for example. Earlier diagnosis, through screening. Better tests and treatments, as well as cutting NHS waiting lists and investing in more staff. Read full story Source: BBC News, 28 November 2023
  10. Content Article
    Cancer Research UK has set out how the next UK Government could dramatically improve cancer outcomes and prevent 20,000 cancer deaths a year by 2040.  'Longer better lives: A manifesto for cancer research and care' has been developed with the insights of cancer patients and experts from across health, life sciences, government and academic sectors.   The charity said that huge strides have been made in beating cancer – with survival in the UK doubling over the last 50 years.  But it warned that with NHS cancer services in crisis and around half a million new cancer cases each year expected by 2040 – this hard-won progress is at risk of stalling.    With the UK lagging behind comparable countries when it comes to cancer survival, the charity is calling on all political parties to make cancer a top priority in their party manifestos. 
  11. Content Article
    Homecare medicines services deliver medicines and provide medicine-related care to patients in their homes, for example, teaching them to self-inject, and delivering medicine that might need special transport. In this report, the House of Lords Public Services Committee highlights concerns about multiple reports of delays and errors by homecare providers, resulting in patients receiving care later than scheduled. The report states that this key service is not working the way it should and, in some cases, is causing patients serious harm.
  12. Content Article
    Christina Ruse was admitted to the Spire Hospital on 14 December 2021 and underwent a total left hip replacement. Her condition deteriorated and observations were commenced at five minute intervals. Mrs Ruse was reviewed and on further deterioration in her condition it was decided to transfer her to the High Dependency Unit, Norfolk and Norwich University Hospital. On arrival of the ambulance Mrs Ruse was undergoing a further investigatory procedure. On this being completed Mrs Ruse was taken to the Norfolk and Norwich University Hospital, where her condition continued to deteriorate and she died on 15 December 2021.
  13. Content Article
    Barbara Hollis underwent a total left knee replacement operation on 22 February 2022. The surgery was uneventful with no complications, however after her return to the ward Mrs Hollis became restless and confused. Following a review of her deteriorating condition the decision was made to transfer her to the High Dependency Unit at the Norfolk and Norwich University Hospital. Arrangements were made for the transfer and the ambulance service was called at 19.51 and were told that immediate clinical intervention was needed, but the agreed hospital to hospital transfer pathway was not followed. There was a two hour delay in ambulance attendance, during which time Mrs Hollis continued to deteriorate. Mrs Hollis was subsequently taken to the High Dependency Unit at the Norfolk and Norwich University Hospital where her condition continued to deteriorate and she died in the early hours of the 23 February 2022.
  14. Content Article
    In late 2015, the National Advisory Group on Health Information Technology in England was formed to advise the Department of Health and NHS England on its efforts to digitise the secondary care system. Our recommendations fall into two broad categories: 10 overall findings and principles, followed by 10 implementation recommendations.
  15. News Article
    The Health and Social Care Select Committee have commissioned an Expert Panel to consider the Government’s progress against accepted recommendations from public inquiries and reviews on patient safety. The Panel will consider a range of recommendations made by public inquiries and reviews on both patient safety and whistleblowing and subsequently select a number of these for evaluation. The Panel will in its final report provide a rating of the Government’s progress against each of these recommendations. Panel members are: Professor Dame Jane Dacre (Chair). Sir Robert Francis KC Anita Charlesworth Professor Stephen Peckham Sir David Pearson Professor Emma Cave Read full story Source: House of Commons Health and Social Care Select Committee, 24 October 2023
  16. News Article
    A London coroner has warned the health secretary that preventable child suicides are likely to increase unless the government provides more funding for mental health services. Nadia Persaud, the east London area coroner, told Steve Barclay that the suicide of Allison Aules, 12, in July 2022 highlighted the risk of similar deaths “unless action is taken”. In a damning prevention of future deaths report addressed to Barclay, NHS England and two royal colleges, Persaud said the “under-resourcing of CAMHS [child and adolescent mental health services] contributed to delays in Allison being assessed by the mental health team”. An inquest into Allison’s death last month found that a series of failures by North East London NHS foundation trust (NELFT) contributed to her death. In her report, Persaud said delays and errors that emerged in the inquest exposed wider concerns about funding and recruitment problems in mental health services. “The failings occurred with a children and adolescent mental health service which was significantly under-resourced. Under-resourcing of CAMHS services is not confined to this local trust but is a matter of national concern,” she said. Read full story Source: The Guardian, 14 September 2023
  17. Content Article
    This is the first report of a national confidential enquiry specifically focussed on child deaths. Confidential enquiries have already contributed to major improvements in obstetrics, neonatal, and perioperative care in the UK. However they are time consuming and require extensive collaboration between various professional groups as well as the attention of a dedicated full-time research team. Hence, when planning a confidential enquiry in a new patient group, it is pertinent to investigate both feasibility and utility at its outset. The aim of this enquiry was to evaluate the feasibility of using this methodology to reduce the number of child deaths and make a significant contribution to child health in the UK. The basic functions of a confidential enquiry are: To develop and maintain a register of the cases under scrutiny. To subject cases in the register (or a specific sample of them) to review by a panel of experts with a focus on identifying avoidable factors where there have been adverse outcomes. Subsequent recommendations are then derived from both the analysis of the register and the conclusions of the expert review panels. This report presents the findings of a feasibility study “The Child Death Review” in which confidential enquiry methodology was applied to child deaths (28 days to 17 years 364 days) occurring in three regions of England, all of Wales and Northern Ireland in the calendar year 2006. A surveillance programme was mounted in order to determine where and when deaths occurred. A comprehensive core dataset was developed and then collected on all deaths. A sample, designed to have an even spread across age groups and the geographical areas involved, was then subjected to more detailed enquiry. This involved scrutiny of the available records by a multidisciplinary panel in each case.
  18. Content Article
    In a recent report, the Professional Standards Authority (PSA) for Health and Social Care sets out its view on the biggest challenges affecting the quality and safety of health and social care. In this blog, Alan Clamp, PSA's chief executive, summarises these challenges and the possible solutions. You can also read Patient Safety Learning's reflections on the PSA report here.
  19. Content Article
    Safety Management Systems (SMSs) are an organised approach to managing safety which are widely used in different industries. In this report, the Health Services Safety Investigations Body (HSSIB) identifies the requirements for effective SMSs, how these are used in other safety-critical industries and considers the potential of application of this approach in healthcare. It makes safety recommendations for NHS England and the Care Quality Commission in relation to this. See also HSSIB's video Introduction to safety management systems.
  20. Content Article
    Incident investigation remains a cornerstone of patient safety management and improvement, with recommendations meant to drive action and improvement. However, there is little empirical evidence about how—in real-world hospital settings—recommendations are generated or judged for effectiveness.
  21. News Article
    More than half of staff at a hospital trust that has been under fire for its "toxic culture" have said they felt bullied or harassed. The findings come from an independent review commissioned by University Hospitals Birmingham (UHB) NHS Trust. It has been at the centre of NHS scrutiny after a culture of fear was uncovered in a BBC Newsnight investigation. UHB has apologised for "unacceptable behaviours". It added it was committed to changing the working environment. Of 2,884 respondents to a staff survey, 53% said they had felt bullied or harassed at work, while only 16% believed their concerns would be taken up by their employer. Many said they were fearful to complain "as they believed it could worsen the situation," the review team found. Read full story Source: BBC News, 27 September 2023
  22. Content Article
    The Culture Review report was published following an independent external review of the organisational culture at University Hospitals Birmingham Trust. The external review was carried out by consultancy firm The Value Circle following a series of investigations into problems at University Hospitals Birmingham Foundation Trust over the last year.
  23. Content Article
    Mental health in the UK is getting worse. Sickness absence due to mental illness is soaring, rates of mental health difficulties are increasing at an alarming rate, and already overstretched services are struggling to meet rising demands. Along with over 30 organisations with an interest in mental health, the Centre for Mental Health has developed a plan to address this and build a mentally healthier nation.
  24. Content Article
     On 3 August 2022, Geoffrey Hoad underwent a total hip replacement at The Spire Hospital. On 5 August 2022, Mr Hoad was diagnosed with a paralytic ileus and some respiratory compromise with gradually deteriorating renal function. On 6 August 2022, Mr Hoad’s transfer to Norfolk and Norwich University Hospital was agreed due to possible bowel obstruction, possible pulmonary infection and deteriorating renal function.   Ambulance service was called at 18:16 hours and again at 23.45. On 7 August 2022, the ambulance service was called again at 07.38 hours. The ambulance was on scene at 08:26 hours.         The medical cause of death was: 1a) Sub Acute Myocardial Infarction 1b)  Coronary Artery Atherosclerosis 2) Hospital Admission for Post Operative lieus.
  25. Content Article
    Dementia remains the biggest killer in the UK and is on track to be the nation’s most expensive health condition by 2030. This report by the charity Alzheimer's Research UK sets out a series of calls for party leaders ahead of the next general election, all of which are underpinned by an urgent recommendation for greater investment in dementia research.
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