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Found 500 results
  1. Content Article
    Each year since May 2023 the Sands & Tommy’s Joint Policy Unit have published an annual report setting out the extent of pregnancy and baby deaths across the UK. This year’s report argues that progress made to date falls short of what is needed to stop babies dying every day in the UK, and that unacceptable inequalities in pregnancy and baby loss persist despite continued calls for change. It estimates that at least 2,500 fewer babies – the equivalent of around 100 primary school classrooms - would have died since 2018 if the government had achieved its ambition of halving the 2010 rates of stillbirth, neonatal and maternal deaths in England. The report draws on the latest data from MBRRACE-UK, which shows that the gap continues to grow between neonatal death rates in the most deprived areas and those in the least deprived areas of the UK. It highlights that the stillbirth rate among babies of Asian ethnicity has risen sharply, and Black babies are still twice as likely as White babies to be stillborn. It includes 10 key actions for policymakers Renew commitments to save babies’ lives. Specifically, a stillbirth rate of 2.0 stillbirths, and a neonatal mortality rate of 0.5 neonatal deaths for babies born at 24 weeks’ gestation and over (per 1,000 live births). A preterm birth rate of 6.0%. Count miscarriages in the UK. The number and rate of miscarriages are not reported across the UK or for any individual nation. All UK governments should set up routine data collection on miscarriage. Take coordinated and meaningful action to eliminate inequalities. There are a range of policy areas where specific action is needed, including: understanding whether current efforts to reduce inequalities are working, and a comprehensive review of translation and interpreting services in maternity and neonatal care. Strengthen national leadership to make progress on the safety of maternity and neonatal services. Clarify the workforce needed to deliver safe care. Future development of the workforce must move away from a binary debate focussed on whether we do or don’t have enough staff and focus on the staffing requirements needed to deliver safe care, in line with nationally-agreed standards. Put the resources needed in place to deliver safe care. More investment is needed to improve the safety and quality of services if the government is going to deliver on its commitments to reduce rates of stillbirth and neonatal death and eliminate inequalities. Make informed choice a reality. Everyone should receive personalised care, know what they are entitled to, such as their birth choices, and services need the resources and operational capacity to provide this. Address unwarranted variation in care. Too often babies are dying because of care that is not in line with nationally-agreed standards. We need clarity on how national guidance is applied and clear national standards to improve the consistency of service provision. Ensure lessons are learned when babies die. The NHS is still not properly learning lessons when babies die or listening to the experiences of bereaved families to improve care in the future. There must be more robust oversight of the implementation of actions that are identified by reviews and investigations. Prioritise pregnancy and baby loss in research. This requires a broad range of research topics, the involvement of bereaved parents and communities, and a strong connection with policy and practice.
  2. Content Article
    The work of the Department of Health and Social Care (DHSC) and its organisations touches the lives of an average of 1.7 million patients per day and costs the UK taxpayer around £187.3 billion per year. This report presents the Public Accounts Committee’s analysis of the DHSC Accounts for 2023/24. The Public Accounts Committee is a Select Committee in the House of Commons that examines value for money of Government projects, programmes and service delivery. This report highlights a number of issues of concern, including the two areas highlighted below. Abolition of NHS England The Committee points to several issues where it believes further clarity is required from the Government in this respect: The lack of a clear plan for how DHSC and NHS England will achieve significant headcount reductions, and the costs involved. How the reductions fit in with the wider 10 Year Health Plan for the NHS. How savings made from reducing NHSE staff costs help frontline services. How the institutional knowledge of NHSE would be preserved following its abolition. The scale of headcount reductions in the DHSC, and the geographical spread of the planned 50% headcount reductions in NHSE and across local Integrated Care Boards. Clinical negligence The Committee has expressed disappointment in this area and stressed the need for significant improvements, stating that: “Both patients and public money need to be better protected by the Department. Far too many patients still suffer clinical negligence which can cause devasting harm to those affected. It also results in large sums of public money being spent on legal fees and compensation, drawing resources from the wider health service.” Concerns it highlights include: £58.2bn has been set aside to cover the potential cost of clinical negligence events in the latest accounts – the second largest liability across government after nuclear decommissioning. 19% of money awarded to claimants in 2023-24 goes to their lawyers (£536m of the total £2.8bn paid that year), on top of the fees payable for the Government Legal Team. It recommends that within six months, DHSC should set out a plan with clear actions to: Reduce tragic incidences of patient harm to as low a level as possible Manage the costs of clinical negligence more effectively, including introducing a mechanism to reduce legal fees. Improve patient safety across the NHS and in particular in maternity services
  3. Content Article
    From Autumn 2023, NHS organisations in England began to change the way they investigated cases of avoidable patient harm and near misses, introducing the Patient Safety Incident Response Framework (PSIRF). As part of PSIRF, organisations are required to create and publish a Patient Safety Incident Response Plan. This blog summarises the findings of a new report, Patient Safety Incident Response Plans: An analysis and reflection by Patient Safety Learning. Drawing from a sample of 13 Patient Safety Incident Response Plans, the report considers what they can tell us about the implementation of PSIRF. PSIRF When something goes wrong with a patient’s care or treatment that causes them harm, or has the potential to cause harm, healthcare staff are required to formally report these incidents. Subsequently, investigations take place into these events, which can act as an important source of insights and learning. These investigations provide an opportunity to identify what went wrong and the actions needed to prevent a similar incident from taking place in the future. In England, the NHS has recently introduced a new approach to these investigations called PSIRF. This represents a significant shift in the way the NHS responds to patient safety incidents and is intended to be a major step towards establishing a systems approach to patient safety in the NHS. A systems approach is one that focuses on understanding how different parts of the healthcare system interact, rather than placing blame solely on individuals when things go wrong. Patient Safety Incident Response Plans As part of PSIRF, NHS organisations in England are required to create and publish a Patient Safety Incident Response Plan. These plans should specify the methods an organisation intends to use to maximise learning and improvement, and how these will be applied to different patient safety incidents. They provide an opportunity for organisations to demonstrate to patients, staff and the wider public how they are seeking to improve patient safety through incident investigations. In our new report, we have analysed a sample of 13 Patient Safety Incident Response Plans (a sample size of 6% out of the 206 organisations included in our Patient Safety Incident Response Plan [PSIRP] Finder). Our intention has been to reflect on what these tell us about the implementation of PSIRF, identify issues that could help organisations update their plans in the future and take action to reduce avoidable harm. Report findings From the sample of Patient Safety Incident Response Plans we analysed, our new report has identified a number of key themes: Variations in approach Although NHS Trusts use a common template to create their Patient Safety Incident Response Plans, their approach to completing these has varied significantly in places. An example of this is the criteria organisations use when deciding to conduct a formal Patient Safety Incident Investigation (PSII). There are some patient safety incidents, such as those classed as a ‘Never Event’, where a PSII must be carried out. However, for incidents where there is no national requirement to do so, Trusts decide whether to carry out a PSII based on their own criteria. In our analysis, we found that in some cases Trusts provided a detailed explanation of factors that they would consider in deciding on whether to undertake a PSII; however, in other plans only a brief explanation was provided. In a few cases, there was no statement on when a PSII would be required. Differences in detail While Trusts in the sample we examined all sought to meet the requirements NHS England set them for their Patient Safety Incident Response Plans, the level of detail they have provided differs considerably. An example of this can be seen when organisations detail how they have identified local patient safety priorities. Patient Safety Incident Response Plans contain both national and local priorities. While NHS Trusts are required to adopt a standardised approach to national priorities, local priorities vary from organisation to organisation. In our analysis, we found that in some cases Trusts had provided a significant amount of detail of the sources they used to identify local priorities and also included the methodology they used in prioritising these sources. Other organisations, however, provided significantly less detail—in some cases just a brief list of priorities and data sources. Critical information gaps We also identified a range of issues that Patient Safety Incident Response Plans in our sample either covered very briefly or not at all. This included: Compassionate engagement and the involvement of those affected by patient safety incidents. Detail on this was largely absent in plans, despite this being identified as one of the four key aims of PSIRF. Evidence of the existence of robust mechanisms to ensure that safety recommendations are actioned and monitored effectively. References to sharing learning and insights from patient safety investigations more widely for system-wide improvement. Recommendations Based on the findings in our report, we have identified five recommendations for NHS England and the Department of Health and Social Care. These are intended to improve the approach to creating and implementing Patient Safety Incident Response Plans. Develop a national standardised framework for evaluating individual Patient Safety Incident Response Plans. Create a central NHS repository of Patient Safety Incident Response Plans and Policies. Consider the benefits of introducing independent external reviews of Patient Safety Incident Response Plans. Update Patient Safety Incident Response Plan guidance for NHS and Foundation Trusts so this explicitly refers to sharing insights and learning from the implementation of plans. Commission a full evaluation of Patient Safety Incident Response Plans. We also highlight some key issues that we believe NHS Trusts should consider when it comes to reviewing their Patient Safety Incident Response Plans: Transparency: Trusts should seek to ensure plans are accessible and clearly communicate how approaches are developed, how they impact patients, staff and the public, and how they address patient safety incidents. Investigation quality: To help improve the depth and rigor of investigations, there should be a greater emphasis and understanding of the contributory factors to incidents in these plans. Quality improvement: Trusts should identify issues that lead to tangible actions to enhance patient safety. Knowledge sharing: How plans can help to facilitate widespread dissemination within organisations and encourage sharing across the health system in England. Standardisation of prioritisation: Explore whether a standardised approach—such as outcome-based, contributory factor-based, or a combination of both—could provide a system-wide perspective for reporting and analysis. Commenting on the report, Patient Safety Learning's Chief Executive Helen Hughes said: “Too often in the NHS we see examples of patient safety investigations not resulting in learning and improvement. This is a theme that emerges time and time again in cases of avoidable patient harm and major patient safety inquiries. The introduction of PSIRF presents a significant opportunity to improve the approach to patient safety incident investigation in England. However, if this is to live up to its ambitions, it must have a clear focus on turning insights and learning into action and improvement. The content of early Patient Safety Incident Response Plans suggests that greater work is needed in this area. Plans should have details on how safety recommendations will be monitored and evaluated, as well as including provisions for sharing good practice as widely as possible. PSIRF is intended to be flexible, with NHS guidance on the creation of Patient Safety Incident Response Plans reflecting this. However, from our analysis we have found that the lack of uniformity in these plans has the potential to complicate cross-organisational comparisons and learning. This in turn could hinder the identification of best practices as Trusts’ approaches diverge. If we are to understand and evaluate the impact of PSIRF, we believe a standardised framework for evaluating individual Patient Safety Incident Response Plans is essential.” Share your experiences and views with us Are you involved in your NHS Trust’s plans to review its Patient Safety Incident Response Plan in the near future? What issues are you considering as part of this process? What do you think is needed to deliver this? We would welcome your reflections on the issues raised in the report and are keen to hear further insights from those involved in shaping and delivering Patient Safety Incident Response Plans. You can comment below (sign up to the hub first, for free) or email the team directly at [email protected] to share your experiences.
  4. Content Article
    This Independent Report led by Professor Mary Renfrew was commissioned in May 2023 by the Department of Health (DoH) Northern Ireland (NI). It forms part of a broad programme of work to receive assurance on the safety of maternity and neonatal services for the population of NI. It resulted from two related developments: A request from the Coroner for Northern Ireland that the Department of Health NI take action to investigate her concerns following an inquest into the death of a baby that raised questions about care in Freestanding midwifery led units (MLUs). In the inquest report the Coroner identified a number of practice and system failings and shortcomings including the management of shoulder dystocia, fetal macrosomia (the baby being large for gestational age), and raised maternal body mass index (BMI). At the time of the inquest, all Freestanding MLUs in NI were closed. The Coroner found that a comprehensive review of the number of staff, experience, training, and policies should be conducted by the DoH, in the event of these Units reopening in the future. In response to this request, the Permanent Secretary asked the Chief Nursing Officer (CNO) for NI, along with the Midwifery Officer, to instigate an inquiry into the issues highlighted by the Coroner. Several other reports, both local and national, concerning the safety of services for pregnant women, new mothers, and babies required consideration of the wider health service context that influences midwifery and maternity care and services. In summary, the report advocates for the following changes: A shared strategic vision for safe, quality midwifery and wider maternal and newborn services in Northern Ireland with a regional framework for action. A reconfigured relationship with women, families and communities, ensuring respectful personalised care for all and a genuine voice in shaping services. A consistent, region-wide, evidence-informed approach to planning, funding, standards, provision, monitoring, and review of maternity and neonatal services. Improving clinical, psychological, and cultural safety and equity for women, babies and families across the whole continuum of care and in all settings. Changing the prevailing work culture to implement an enabling environment for all staff and managers, including ensuring midwives are represented at senior management levels, tackling silo working, and developing an open learning culture at every level of the system. Supporting midwives to provide quality midwifery care and services across the whole continuum of maternal and newborn care, with investment in community as well as hospital services, and increasing midwives’ influence over the safety and quality of care and services. Better oversight through improved accountability, monitoring, evaluation, and research. A unified approach to education and training of all staff, including leadership development - especially for midwives - and capacity building for the future.
  5. Content Article
    Sir Justice O’Hara’s report raises serious concerns about the standard of healthcare delivered to five children who tragically died in Northern Ireland as a result of hyponatremia related illnesses between 1995-2001. The report also identified system failures in the investigation of the deaths. This is the joint response to the report from the Royal College of Paediatrics and Child Health, Royal College of Surgeons (England), Royal College of Surgeons (Edinburgh), Royal College of Anaesthetists and Royal College of Pathologists.
  6. News Article
    Childbirth charities are warning parents that hands-free breastfeeding or bottle feeding, when a baby is being carried in a sling, is unsafe. The National Childbirth Trust (NCT) and the Lullaby Trust say the risks are highest for premature babies and those under four months old because their airways can be easily blocked. Their updated guidance follows an inquest into the death of a six-week-old boy who was being breastfed in a baby carrier while his mother moved around their home. The baby, Jimmy Alderman, from London, was being breastfed in a sling in October 2023, but was in an unsafe position too far down the sling and lost consciousness after five minutes, the coroner found. A coroner's report to prevent future deaths like his found there was very little information on safe positioning of babies in slings or the risks of suffocation when feeding. Senior coroner for west London, Lydia Brown, issued a warning, external about the dangers of baby slings following an inquest held last year into his death. She said there appeared to be no helpful visual images of "safe" versus "unsafe" postures for babies in slings or carriers, adding that "the NHS available literature provides no guidance or advice". The NCT said it "immediately reviewed" its online information on baby slings and carriers after receiving the coroner's report and hearing feedback from Jimmy's parents. The NCT's online advice now says: "Hands-free breastfeeding or bottle feeding, where the wearer moves around and does other jobs while the baby is feeding, is unsafe. "This is especially true for babies under four months old. It also applies to babies born prematurely or those with a health condition." The charity says young babies do not have strong necks and cannot lift their heads, meaning that their airway "can easily be blocked" in baby slings and carriers. It adds that a sling's fabric or the fabric from a parent's clothes "could cause suffocation very quickly". "If the sling or carrier is not correctly fitted and adjusted, babies can experience traumatic head injuries," the charity's advice says. Read full story Source: BBC News, 26 March 2025
  7. Content Article
    A wide ranging and comprehensive independent review of emergency departments within NHS Greater Glasgow and Clyde has found a system under pressure, where unacceptable practices such as patients waiting on trolleys in corridors, have become normalised. The report published by Healthcare Improvement Scotland concludes that relationships need to be repaired between various groups of staff, supported by compassionate leadership. The poor relationships highlighted in the review are impeding the NHS board’s ability to address the problems – this was particularly prominent within the Queen Elizabeth University Hospital. The report finds that a culture of “disrespectful behaviours, poor teamwork and incivility” is having a negative impact on staff morale and wellbeing, and it is likely having a detrimental impact on patient care. The report makes 30 recommendations for NHS Greater Glasgow and Clyde, but the findings also have national implications with a further 11 recommendations for Scottish Government and national agencies. The review – chaired by experienced, independent experts Dr Pamela Johnston and Prof Hazel Borland – was carried out as a result of concerns raised by a group of emergency department clinicians at Queen Elizabeth University Hospital, who believed that patient care was being compromised and that their concerns were not being listened to. National recommendations Scottish Government Scottish Government should commission Healthcare Improvement Scotland to lead the development of a national approach to improving the quality and safety of urgent and unscheduled care in NHS Scotland, consistent with the Quality Management System, including the development of national standards in partnership with a range of agencies including the Royal Colleges. This will build on work already commenced by The Centre for Sustainable Delivery and include urgent work needed to work towards eliminating the unacceptable use of non-standard care areas given the risks to patients and the impact on staff. This will require significant national focus and support. Scottish Government should explore with Healthcare Improvement Scotland how best to gather patient views about experiences of accessing urgent and unscheduled care services and waiting in emergency departments to inform more detailed national recommendations on how to improve the patient experience and shape services for the future. Scottish Government should engage with relevant national agencies to commission a review of the national guidance for specific health and care demand, capacity escalation and business continuity, which recognises the need to ensure a credible, robust and practical whole system response. This is essential and complementary to the current Multi Agency Major Incident Guidance. Scottish Government should engage with relevant national agencies to commission a review of the professional advisory committee arrangements in NHS boards to ensure they have a transparent, independent and objective mechanism for the board to consider matters of safety and concern. There is an opportunity to refresh the previous national guidance and make these arrangements clearer and more open for all professions to understand. Public Health Scotland Reliable and comparable whole-system datasets are essential to support improvement in urgent and unscheduled care and optimise flow through the health and social care system. Public Health Scotland should be commissioned by Scottish Government to work with other national and local partners with the aim of progressing existing work and further developing datasets that are designed with, and available to NHS boards to support continuous improvement. The Centre for Sustainable Delivery The Centre for Sustainable Delivery should strengthen its collaboration with territorial and national NHS boards to engage in improvement activities aimed at: Reducing unwarranted variation in urgent and unscheduled care performance to enhance the quality and experience of care, as well as patient outcomes. Rethinking access to urgent and unscheduled care to ensure equity and that individuals are treated in the right place, the first time. • Ensuring appropriate representation, including clinical leaders, in the recently formed Strategic Delivery Groups to drive improvement, set standards, and deliver change. Participating in the acute hospital site visit process to ensure that change is driven by clinical teams and tailored to meet the needs of local communities. NHS Education for Scotland NHS Education for Scotland should strengthen and further develop structured development programmes to identify and support clinical and non-clinical leaders in NHS Scotland. These programmes will enable NHS boards to focus on developing whole system multidisciplinary working and relationships which foster innovation, improvement and inclusivity in decisions that explicitly benefit quality of care and patient safety NHS Education for Scotland should be supported by Scottish Government to explore the implications, and work towards the shift to whole time equivalent medical trainee recruitment in order to strengthen the learning experience, reduce gaps in service and build a more sustainable, effective medical workforce for the future. The review has highlighted the critical role of effective and supportive leadership by the NHS Board. It is recommended that the Scottish Government commission NHS Education for Scotland to evaluate the current national and local induction and support arrangements for NHS Non-executive Board Members. This evaluation should aim to identify and implement any necessary improvements to ensure that Non-executive Board Members can perform their roles as effectively as possible, and consistent with the requirements set out in the NHS Scotland Blueprint for Good Governance. Healthcare Improvement Scotland The review has identified that the tools for appropriate staffing levels with regard to emergency departments are not sufficiently robust. Healthcare Improvement Scotland’s Healthcare Staffing Programme should prioritise the development of new tools which reflect the current operating context and multi-disciplinary working to ensure safe and effective care. Healthcare Improvement Scotland should collaborate with the Independent National Whistleblowing Officer, and other relevant bodies, to develop clear and unambiguous guidance for staff in NHS boards on the national routes for staff to raise concerns under Whistleblowing and the Public Interest Disclosure Act. This will enable NHS boards to ensure that they have effective arrangements in place and improve staff awareness and understanding.
  8. Content Article
    The government's response to the recommendations made in the Women and Equalities Committee: Women’s reproductive health conditions report. The government agrees with the overarching aims of the findings and recommendations for improving women’s health outcomes and experiences. The government acknowledges the impact that reproductive health conditions have on women’s lives, relationships, and participation in education and the workforce.  The report acknowledges that, since the publication of the Women’s Health Strategy for England, some progress has been made, including: the appointment of the Women’s Health Ambassador work to build trust with women from marginalised groups improved research into reproductive health conditions. However, we recognise that much more needs to be done to support women with reproductive health conditions, particularly around: listening to women improving information and education improving access to healthcare services. Tackling waiting lists, including for gynaecology, is a significant part of the government’s health mission Build an NHS Fit for the Future. NHS England’s Reforming elective care for patients plan, published in January 2025, builds on the investments already made with an ambitious vision for the future of diagnostic testing to ensure that patients receive more timely, accessible and accurate diagnostic testing, including for women’s reproductive health conditions. It sets out how the NHS will: reform elective care services meet the 18-week referral-to-treatment standard, For gynaecology specifically, NHS England will support the delivery of innovative models, offering patients care closer to home and piloting gynaecology pathways in community diagnostic centres. The government is also working with NHS England and the Women’s Health Ambassador on how to take forward the Women’s Health Strategy for England, by aligning it to the government’s missions under the Plan for Change and forthcoming 10 Year Health Plan. The 10 Year Health Plan will set out how we tackle the inequities that lead to poor health, including those for women. As part of this, the government is committed to setting an explicit target to close the Black and Asian maternal mortality gaps.
  9. Content Article
    Overloaded with duplicative recommendations, the healthcare system must prioritise impactful actions, improve collaboration, and ensure meaningful implementation to enhance patient safety and restore public trust, writes Rosie Benneyworth, chief executive officer of the Health Services Safety Investigations Body (HSSIB).
  10. Content Article
    Sara Riggare has had Parkinson's disease for nearly forty years. In this BMJ blog, she highlights the importance of trust and dialogue when making treatment decisions. Sara describes a recent interaction with a doctor to illustrate why listening to patients' concerns and answering their questions is vital to building mutual trust.
  11. Content Article
    This is an Early Day Motion tabled in the House of Commons on 27 February 2025, which urges the Government to also create a national oversight mechanism to ensure that recommendations concerning deaths involving the State and corporate agencies are routinely monitored by an independent body to help enact learning and prevent future deaths. What is an Early Day Motion? Early Day Motions are motions submitted for debate in the House of Commons for which no day has been fixed, and as such very few are debated. They are used to put on record the views of individual MPs or to draw attention to specific events or campaigns. By attracting the signatures of other MPs, they can be used to demonstrate the level of parliamentary support for a particular cause or point of view. Early Day Motion 867: National oversight mechanism This Early Day Motion was sponsored by Carla Denyer MP. It reads as follows: That this House believes that the State owes it to bereaved families and victims to learn and implement lessons from deaths involving the State and corporate agencies; notes that the Grenfell Inquiry recognised a failure of the State to follow up on recommendations made by inquests and inquiries; acknowledges the Government’s commitment to a publicly available record of these recommendations as a step in the right direction; urges the Government to also create a national oversight mechanism to ensure that these recommendations are routinely monitored by an independent body to help enact learning and prevent future deaths; further notes that such a Mechanism would go beyond facilitating transparency and ensure accountability, which is desperately needed for bereaved families and for public confidence; and believes that for victims of large scale tragedies such as Hillsborough and Grenfell, as well as victims of individual state failings, the Government must ensure that lessons are learned from their deaths and the same mistakes are not repeated. Related reading Inquest - No More Deaths Campaign Patient Safety Learning - Mind the implementation gap: The persistence of avoidable harm in the NHS
  12. Content Article
    On 16 February 2024, Pamela Anne Marking – who was unable to give a complete history due to cognitive issues – was admitted to the Emergency Department at East Surrey Hospital from her home address after unknowingly vomiting blood-stained fluid, with right sided and suprapubic abdominal tenderness. She was diagnosed as having had an epistaxis (nosebleed) by a Physician Associate  and discharged home later that afternoon without a medical review or direct medical supervision of the Physician Associate who had a lack of understanding of the significance of abdominal pain and vomiting and had undertaken an incomplete abdominal examination which would have been likely to have found a right femoral hernia. Mrs Marking re-presented to the Emergency Department two days later with grossly dilated small bowel obstruction due to an incarcerated right femoral hernia containing ischaemic bowel requiring emergency surgery later that evening. Despite maximal support Mrs Marking died at East Surrey hospital on 20th February 2024. The clinical management Mrs Marking had on her first admission and thereafter during the Rapid Sequence Induction materially contributed to her death. The medical cause of death given was: 1a Respiratory failure and Sepsis   1b Aspiration of feculent gastric contents at induction of anaesthesia 1c. Strangulated femoral hernia. Coroner's concerns 1. The term ‘Physician Associate’ is misleading to the public. Mrs Marking’s son was under the mistaken belief that the Physician Associate was a doctor by this title in circumstances where no steps were taken by the Emergency Department or the Physician Associate to explain or clearly differentiate their role from that of medically qualified practitioners. 2. Lack of public understanding of the role of Physician Associate. Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety. 3. The right of patients and family to seek a second opinion. The lack of public knowledge that a Physician Associate is not medically qualified has the potential to hinder requests by patients and their relatives who would wish to seek an opinion from a medical practitioner. It also raises issues of informed consent and protection of patient rights if the public are not aware or have not been properly informed that they are being treated by a Physician Associate rather than a medically qualified doctor. 4. Lack of national and local guidelines and regulation of the scope of practice for a Physician Associate. A diagnosis of epistaxis was made by the Physician Associate without appreciating the relevance of the vomiting and lower abdominal discomfort and in the absence of understanding the need to undertake palpation of the groins in an abdominal examination in a patient who was unable to give a proper clinical history because of short term memory loss. No evidence was presented that the management of Mrs Marking was subject to a reflective practice review. Given their limited training and in the absence of any national or local recognised hospital training for Physician Associates once appointed, this gives rise to a concern they are working outside of their capabilities. 5. Lack of guidelines for direct supervision and consideration of an appropriate level of autonomy for Physician Associates. Whilst there were discussions with the ‘supervising’ consultant the Physician Associate was effectively acting independently in the diagnosis, treatment, management and discharge of Mrs Marking without independent oversight by a medical practitioner. This gives rise to a concern that inadequate supervision or excessive delegation of undifferentiated patients in the Emergency Department to Physician Associates compromises patient safety. 6. Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery. Mrs Marking required a rapid sequence induction to protect her airway from aspiration of bowel contents as a consequence of small bowel obstruction. The consultant anaesthetist gave evidence that the ‘traditional’ use of consecutive syringes of induction agent and muscle relaxant was obsolete, and it was common practice locally and nationally to routinely undertake a RSI with Total Intravenous Anaesthesia, in the absence of updated local or national guidelines to support this practice. 7. Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI. Other than empirically increasing the rate of infusion of TIVA agents (Propofol and Remifentanil) no evidence was forthcoming as to the target range required to ensure and confirm an adequate depth of anaesthesia for patients or the length of time required prior to and following the administration of a muscle relaxant (Rocuronium) to facilitate intubation. This is despite TIVA being known to provide a slower onset of anaesthesia and approximately 50% of all anaesthetic related deaths are due to aspiration (NAP 4). 8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic. Evidence was heard that as cricoid pressure was ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.
  13. Content Article
    Juvenile idiopathic arthritis (JIA) is an autoimmune disease that affects around 10,000 children aged under 16 in the UK. It is a chronic disease and many patients will continue to have JIA into adulthood. JIA causes inflammation, pain and stiffness in joints, and can be have a big impact on a child's life. This study by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) looked at the quality of care provided to patients diagnosed with JIA. Patients were randomly selected for inclusion in the peer review process if their diagnosis had been made between 1st April 2019 and 31st March 2023, and they were diagnosed or experienced symptoms before their 16th birthday. Data included 374 clinician questionnaires and the assessment of 290 sets of case notes. In addition, 122 organisational questionnaires were returned along with 130 primary care questionnaires, survey responses from 68 parents/carers and 117 healthcare professionals. The study report  includes recommendations highlighting areas that are suitable for regular local clinical audit and quality improvement initiatives. Recommendations Raise awareness of juvenile idiopathic arthritis and its symptoms with the healthcare professionals who will see this group of patients. Streamline and publicise local referral pathways with clear measurable timelines for patients with suspected juvenile idiopathic arthritis. Provide timely access to appropriately trained physiotherapy, occupational therapy, pain and psychology services at the diagnosis of juvenile idiopathic arthritis, and then as needed through adolescence and adulthood. Offer age-appropriate information about juvenile idiopathic arthritis and medication risks and benefits to patients and their parents/carers at diagnosis and on an ongoing basis. Provide training to the patient, if age-appropriate, and/or their parents/carers on how to administer subcutaneous injections for juvenile idiopathic arthritis at the point treatment is initiated. Ensure timely access to intra-articular steroid injections by staff who have been trained to deliver age-appropriate care in units where local or general anaesthesia can be delivered. Provide a holistic, developmentally appropriate rheumatology service for patients with juvenile idiopathic arthritis. Develop NICE guidance for the management of juvenile idiopathic arthritis.
  14. Content Article
    On the 13 February 2025, the Health Services Safety Investigations Body (HSSIB) published a report exploring how patient safety is managed across different organisational boundaries. This forms part of a series of reports looking at Safety Management System principles and their application to health and care. In this blog, Patient Safety Learning sets out its reflections on the findings of this investigation. HSSIB investigates patient safety concerns across the NHS in England, and in independent healthcare settings where safety learning could also help to improve NHS care. Their latest report looks at patient safety issues across organisational boundaries, by exploring the safety management activities of Integrated Care Boards (ICBs).[1] An ICB is a statutory NHS organisation responsible for bringing NHS and other partners together to plan and deliver services in an Integrated Care System (ICS). ICSs are partnerships that bring together organisations in specific geographical areas—there are currently 42 across England.[2] This HSSIB investigation focuses on the experiences of Ros and her husband and carer Norman, using their case to demonstrate the gaps in patient safety management when patients’ care is managed across multiple providers in an ICS. Reflecting on the findings of this report, in this blog we focus on four key subject areas: safety management systems reporting and learning from patient safety incidents ICBs and ICSs patients still having to join the dots of patient safety. Safety management systems The HSSIB report forms part of a series looking at the application of a safety management systems (SMSs) approach to health and care. HSSIB define this as: “A safety management system (SMS) is a proactive approach to managing safety that is used in other industries. It sets out the necessary organisational structures and accountabilities to manage safety risks. It requires safety management to be integrated into an organisation’s day-to-day activities.” There is a growing debate about the potential benefits of moving towards a SMS approach in healthcare, which is widely used to manage safety in different industries. HSSIB states that such an approach has four key components: Safety policy—establishes senior management's commitment to improve safety and outlines responsibilities; defining the way the organisation needs to be structured to meet safety goals. Safety risk management—which includes the identification of hazards (things that could cause harm) and risks (the likelihood of a hazard causing harm) and the assessment and mitigation of risks. Safety assurance—which involves the monitoring and measuring of safety performance (e.g., how effectively an organisation is managing risks), the continuous improvement of the SMS and evaluating the continued effectiveness of implemented risk controls. Safety promotion—which includes training, communication and other actions to support a positive safety culture within all levels of the workforce.[3] However, as the findings of their report highlight, we are currently a long way removed from such an approach in our health and care system. Emphasising this, it states: “There are no overarching principles that all healthcare providers and ICBs can use which enable a consistent and collaborative approach to the management of patient safety.” The report notes a particular gap around the role of ICBs, referencing the NHS Oversight Framework, which describes how oversight of NHS trusts, foundation trusts and ICBs operates. It highlights that this does not specify the day-to-day patient safety management activities to be undertaken by ICBs. The report’s key recommendation in this area is as follows: “HSSIB recommends that the Department of Health and Social Care, working with NHS England, uses the findings of this report to inform the development of the 10 Year Health Plan and NHS Quality Strategy. The intent of this recommendation is to encourage further exploration of how the safety management principles described in this report might be applied in health and care settings to improve patient safety.” Patient Safety Learning supports this recommendation. We think that a country-wide SMS would have the potential to provide a more structured and joined up approach to patient safety strategies, involving all the national bodies. We believe that integral to this is a standards-based framework to ensure safety, quality patient care, consistently delivered.[4] A patient safety standards framework helps organisations understand ‘what good looks like’ for patient safety and where more action is needed for improvement with clearly defined safety aims and goals. Such a framework will enable organisations and regulators to demonstrate a risk-based approach to patient safety and evidence achievement. It can provide assurance that patient safety sits at the organisation’s core, improves performance through increased effectiveness, and enables patients and families, staff, funders and communities to identify and differentiate good safety providers. This is a point we recently highlighted in our submission to the independent review of patient safety across the health and care landscape being led by Dr Penny Dash.[5] Reporting and learning from patient safety incidents In the last couple of years, the NHS has been transitioning to a new system for recording and analysing patient safety incidents. The former National Reporting and Learning System (NRLS) has been gradually phased out, with organisations moving onto the new Learn from Patient Safety Events (LfPSE) service.[6] This HSSIB investigation highlights a number of concerning issues relating to how effectively the LfPSE service supports the identification and management of patient safety risks across organisational boundaries. The report notes difficulties accessing and using data from the system with less analysis tools available compared to the previous NRLS. Worryingly, it states: “ICBs suggested that they needed to be building a picture of ICS risks, including those which involved cross-organisational boundaries, but they could not currently do this because of the usability of the LFPSE service and data.” The report does note that in response to these concerns some ICBs have developed local adaptations to compensate for this lack of visibility of patient safety risks within providers. It also says that NHS England has indicated it is developing a new Recorded Data Dashboard for LfPSE that will allow for greater analysis of incident records than was possible with NRLS. Considering these concerns, HSSIB makes the following safety observation: “Health and care organisations can improve patient safety by working together to identify the challenges with the practical use of the Learn from Patient Safety Events service to enable the identification of risks that span multiple providers. This is intended to identify the requirements and support needed to improve risk management.” On these issues, we feel more robust action is required. Sharing learning from patient safety incidents is a fundamental component of improving patient safety and delivering safe care. That LfPSE is not currently providing the means to analyse and share cross-organisational learning represents a significant missed opportunity. As the findings of the report demonstrate, local fixes, which may not be applied consistently across the NHS, are now required because of ICBs lack of visibility of patient safety risks within providers. At Patient Safety Learning we also have related concerns about the availability of LfPSE data beyond ICBs. Currently, individual trusts can see reports of their own data but not system-wide information to help them assess risk or engage with others. This can create a siloed approach where individual trusts or departments may benefit from their data but fail to contribute to a wider culture of safety improvement. We are also troubled that the outputs of local learning responses and safety incident investigations under the new Patient Safety Incident Response Framework (PSIRF) are not widely shared either within or across ICBs. We understand that the new initiatives, PSIRF and LfPSE, are intended to align so that there is a comprehensive and system-wide analysis with reports on the causes and contributory factors of avoidable harm and action needed to make improvement. However, this alignment is not currently reflected in practice. This is not an acceptable situation. The existing gaps in the LfPSE service are not simply a technical issue with a new digital service. They will result in missed opportunities to identify patient safety risks, learn from them and ultimately prevent avoidable harm to patients. We believe the Department of Health and Social Care and NHS England must now prioritise the development and improvement of LfPSE and its integration with PSIRF. Integrated Care Boards and Integrated Care Systems A theme that runs throughout the HSSIB report is the lack of clarity around the roles of ICBs and ICSs in patient safety. Its key findings highlight this, noting: “There is a difference in the perception of how patient safety is managed between ICBs and national health and care stakeholders, including the lines of safety accountability.” This lack of clarity can also be seen in a number of other examples in the report: Inconsistency in how ICBs have reported processes and responses when escalating safety risks to NHS England. If these do not fall within existing programmes of work, responses were described as “hit and miss”. Uncertainty about whether ICBs have oversight of provider collaboratives in relation to patient safety. This was described by an NHS England respondent as a “big black hole”. Varying approaches to safety management activities by ICBs. The report notes that while some undertake assurance visits, “these are limited by capacity and ICBs described a reliance on more reactive activities such as responding to incidents which had already occurred”. In a further example of this lack of clarity, at one point the report notes: “… a senior manager at NHS England told the investigation that while there is an expectation that ICBs will manage cross-organisational safety risks, NHS England “have not told ICBs they have to” do this or “flagged this” in planning or operational guidance. The investigation acknowledges that PSIRF guidance refers to management of cross-organisational safety risks. However, this does not direct how cross-organisational safety risks should be managed more generally outside of PSIRF.” Patient Safety Learning believes action is required to create clarity about the role of ICBs and ICSs in patient safety. We set this out previously in in our report, The elephant in the room: Patient safety and Integrated Care Systems.[7] One means of addressing this gap could be through implementing a SMS approach in health and care, with ICBs and ICSs tasked with a clear leadership role for system safety. This is another point we recently highlighted in our submission to the independent review of patient safety across the health and care landscape.[5] We believe that there is potential at an ICS level to develop an integrated and coordinated approach to safety, reflecting patient care pathways across systems and ensuring consistency and collaboration. Patients still having to join the dots of patient safety At Patient Safety Learning, we believe that patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account. We identify this as one of our six foundations of safer care in our report, A Blueprint for Action.[8] The importance of patient feedback is reflected in the HSSIB report, which notes that: “Patients and carers are an important source of feedback to ICBs about patient safety risks across organisational boundaries. However, this can create inequities as some people are more able than others to make their voice heard.” There is no doubt that insights and feedback from patients and carers can provide ICBs with valuable information on patient safety risks, within organisations and across organisational boundaries. However, this must be accompanied by a structured and resourced framework for gathering these insights otherwise the visibility of these insights are likely to favour those patients and carers who are more adept and confident at making their voices heard. As noted by Norman in his own reflections on his carer role for Ros: "Norman told the investigation that he was getting the care Ros needed through his actions and that he was aware of other patients whose families did not have as strong an advocate as him. He said this affected their ability to get the care they needed, and that 'there are a lot of us out here trying to look after patients'.” While points around safety management systems, LfPSE and ICB/ICS roles and responsibilities can appear detached from day-to-day care, ultimately their impact comes back to the patient. As noted by the First Do No Harm report of the Independent Medicines and Medical Devices Safety Review, patients impacted by avoidable harm and unsafe care often have to ‘join the dots of patient safety’ in response to systemic failures.[9] If we fail to address these systemic failures, they will result in patient safety risks that come with a very real human cost. References HSSIB. Safety management systems: accountability across organisational boundaries, 13 February 2025. NHS England. What are integrated care systems? Last accessed 10 February 2025. HSSIB. Safety management systems: an introduction for healthcare, 18 October 2023. Patient Safety Learning, Standards: What Good Looks Like, Last accessed 10 February 2025. Department of Health and Social Care, Review of patient safety across the health and care landscape: terms of reference, 15 October 2024. NHS England. Learn from patient safety events (LFPSE) service, Last accessed 10 February 2025. Patent Safety Learning. The elephant in the room: Patient safety and integrated care systems, 11 July 2023. Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019. The IMMDS Review, First Do No Harm: The report of the Independent Medicines and Medical Devices Safety Review, 8 July 2020.
  15. Content Article
    This is one of a series of Health Services Safety Investigations Body (HSSIB) investigations exploring safety management and whether the principles adopted in other industries may assist in the management of safety in health and care. The aim of the investigations is to help improve patient safety in relation to the management of patient safety risks across organisational boundaries. This has been explored through an understanding of the pathways of care for patients whose care involves engaging with providers in primary, secondary and community care and with integrated care systems (ICSs). This report makes reference to processes which exist within the health and care system relating to the management of safety. You can read Patient Safety Learning’s response to this report here. This investigation explored the experiences of Ros, and her husband and carer Norman, to demonstrate the gaps in patient safety management when patients’ care is managed across multiple providers in an ICS. The investigation engaged with patient safety and quality teams within Integrated Care Boards (ICBs) to understand how patient safety risks were managed at this level of the health and care system. The investigation also engaged with NHS England regional and national teams to understand the risks that were escalated to them and how they were managed. Findings There are no overarching principles that all healthcare providers and ICBs can use which enable a consistent and collaborative approach to the management of patient safety. There is a difference in the perception of how patient safety is managed between ICBs and national health and care stakeholders, including the lines of safety accountability. National organisations’ expectations of how ICBs manage patient safety are not in line with what ICBs can currently achieve due to challenges with resourcing and the usability of safety data. Patient safety risks may be escalated from the regional to the national level but there is variability in how these risks are managed at a national level and how responses to escalations are fed back. Cross-organisational safety risks are not always being escalated to ICBs and there may be limited resources and capability to identify, define and investigate such risks. Learn from Patient Safety Events (LFPSE) is the national learning service for the NHS; however, challenges in the usability of LFPSE data means that system level risks may not be visible to ICBs and the wider health and care system. Existing informal ‘good relationships’ between individual providers and an ICB facilitate the effective sharing and management of risks. Where these ‘good relationships’ do not exist or change, formal governance processes do not always ensure information sharing continues. Patients and carers are an important source of feedback to ICBs about patient safety risks across organisational boundaries. However, this can create inequities as some people are more able than others to make their voice heard. Recommendations, observations and suggestions HSSIB makes the following safety recommendation: Safety recommendation R/2025/057: HSSIB recommends that the Department of Health and Social Care, working with NHS England, uses the findings of this report to inform the development of the 10 Year Health Plan and NHS Quality Strategy. The intent of this recommendation is to encourage further exploration of how the safety management principles described in this report might be applied in health and care settings to improve patient safety. HSSIB makes the following safety observations: Safety observation O/2025/061: Health and care organisations can improve patient safety by working together to identify the challenges with the practical use of the Learn from Patient Safety Events service to enable the identification of risks that span multiple providers. This is intended to identify the requirements and support needed to improve risk management. Safety observation O/2025/062: Health and care organisations can improve patient safety by having clear lines of safety accountability and assurance of risk management processes. Currently patient safety risks are not managed in line with established UK government risk management principles. HSSIB makes the following safety suggestions: Safety learning for Integrated Care Boards ICB/2025/011: HSSIB suggests that integrated care boards seek assurance of how health and care providers will work together when commissioning services, so that patient safety can be managed across health and care providers. This is to help support the visibility and management of patient safety risks across an integrated care system. Safety learning for Integrated Care Boards ICB/2025/012: HSSIB suggests that integrated care boards develop their patient safety capability and expertise to ensure they can effectively analyse safety data and intelligence about patient safety risks. This would help to identify and understand patient safety risks that exist across multiple providers in order to proactively investigate and manage these risks.
  16. Content Article
    Prioritising patient safety is a new quarterly blog series from the Parliamentary Health and Service Ombudsman (PHSO). Each month, PHSO publishes between 70 to 100 of their casework decisions as a way to share learning that will help organisations improve their service and prevent mistakes happening again. Through these blog, Tony Dysart, Senior Lead Clinician, will be highlighting some of the cases PHSO publish to share good practice and findings from the casework more widely. This first blog focuses on two cases PHSO have looked into about maternity care and imaging. 
  17. News Article
    One woman who tracks preventable deaths says the failure to take action when inquests identify threats to life is ‘mind-blowing’. Thousands of deaths could be prevented every year if public bodies took action over concerns highlighted at inquests. Almost 82,000 deaths in 2022 were recorded by the Office for National Statistics in England and Wales as “preventable”, meaning they could have been avoided “through effective public health and primary prevention interventions”. Analysis by the Preventable Deaths Tracker project at King’s College London revealed that 1,495 Prevention of Future Deaths reports (28 per cent of the total) have not received any responses and another 741 (14 per cent) received only partial responses. Once reports are issued there is no official monitoring of responses or whether any action follows. Coroners have no powers to ask further questions or request progress reports on reforms. The founder of the Preventable Deaths Tracker, the epidemiologist Dr Georgia Richards, said it was “mind-blowing” there was no system to disseminate learning from inquests. “Across 5,000 reports over the last 12 years, it is impossible to know anything about what action that might or might not have been taken following a coroner’s report,” Richards said. "People think there must be a system that’s protecting us. We assume that if you were in government that you would want to know what’s happening in these death investigations. But the system doesn’t work, it’s a waste of time. There are very few PFDs that have led to meaningful change and often it’s not the PFD that triggered it. Change comes from additional factors like change in leadership of the organisation, huge media scrutiny or dedicated families.” Peter Thornton KC, chief coroner from 2012-16, said: “First, there are not enough coroners writing these reports. Secondly, they can’t force a response. Thirdly, they can’t follow up a response. Fourthly, they can’t force action — they can only suggest that an area of action is considered. And last, there’s no national follow-up, there’s no co-ordination.” Thornton urged reform through the creation of a national coroner service. The inquest system is jointly managed by the judiciary, local councils and the police. It is poorly funded and has big backlogs: 1,685 bereaved families are waiting longer than two years for hearings. Read full story Source: The Times, 14 January 2025 (paywalled) Related reading Five recommendations to prevent future deaths: Written evidence for the Parliamentary follow-up Inquiry to The Coroner Service (Georgia Richards, 9 February 2024) Patient Safety Learning - Mind the implementation gap: The persistence of avoidable harm in the NHS (7 April 2022)
  18. Content Article
    To deliver value for money over the medium to long term, a government needs to turn its objectives into outcomes in a way that delivers the best value for every pound of taxpayers’ money while managing its fiscal position. It needs to: plan and prioritise its spending (and other activities) to address those objectives. monitor and manage both costs and value delivered. evaluate the results. adjust as necessary. report to Parliament on how it has used taxpayers’ money. This report by the National Audit Office aims to provide useful insights as officials and ministers are making changes to the planning and spending framework. It will also be useful to Parliamentarians and stakeholders seeking to scrutinise government spending and delivery.
  19. Content Article
    This report presents the national state of patient safety in England in 2024. Two years on from their first report, the authors provide an updated analysis of the publicly available data. The report concludes that performance in key areas such as maternity care has deteriorated, requiring urgent attention. This report was produced by Imperial College London's Institute of Global Health Innovation in partnership with the charity Patient Safety Watch. Key figures highlighted in this report include: In 2023, the number of deaths that could have been avoided if the UK matched the top 10% of Organisation for Economic Co-operation and Development (OECD) countries was 13,495. In 2023, the UK ranked 21st out of 38 OECD countries for patient safety. Cost of harm for claims resulting from incidents in 2023/24 was £5.1 billion. Maternal deaths increased from 8.8 to 13.4 per 100,000 maternities between the 2017-2019 and 2020-2022 periods – an increase of 52.3%. In 2023, the proportion of patients who said there were enough nurses on duty to care for them was 56%. As of September 2024, the proportion of people waiting more than four hours for a treatment decision in A&E was 25%. In 2023, 65% of maternity units in England were rated as “inadequate” or “requires improvement” for safety by the Care Quality Commission. In June 2024, the number of people waiting for elective care was 7.6 million. 2 in 3 staff feel unable to carry out their jobs fully due to workforce shortages. The report sets out two recommendations to support the long-term improvement of patient safety in England: Local NHS organisations must be supported to adopt evidence-based interventions to tackle the most common safety problems causing significant harm to patients. The report’s analysis of trust patient safety plans identified six common problems that many organisations are tackling, such as pressure ulcers and patient falls. Adopting proven interventions to common problems like these would finally see the NHS truly acting like a National Health Service. The authors envisage a future where the first port of call for NHS organisations is a repository of such interventions, along with the support they need to implement them, rather than developing their own solutions from scratch. National organisations must agree on a focused set of patient safety improvement priorities for the system to rally around. The report’s analysis found a crowded landscape of patient safety bodies, an opaque process for national priority setting, and evidence that the system cannot keep pace with the volume of recommendations it receives. The authors envisage a future where patients and healthcare workers are partners in the development of these priorities, and where national organisations rationalise their own activities to ensure the NHS is supported to deliver improvements against them.
  20. Content Article
    Lord Carter’s review identifies unwarranted variation in the delivery of ambulance services, as well as the potential savings of £500 million that could be made in efficiencies by 2020/21. Following Lord Carter’s 2016 review into the operational productivity of acute non-specialists trusts, the ambulance sector requested a similar review into its services to help them understand what good looks like. As well as what improvements could be made to deliver good quality, better value services for their patients. Lord Carter has produced the report into ambulance productivity in England with nine recommendations to improve patient care, efficiency and support for frontline staff who have responded to a significant rise in demand for ambulance services in recent years. The report found that if more patients were treated at the scene by paramedics or were better assessed over the phone when dialling 999 — avoiding the need for an ambulance when it is safe to do so — the NHS could treat patients closer to home and reduce unnecessary pressure on emergency departments (EDs) and hospital beds. Offering safe and quicker care could save the NHS £300m a year by 2021, with a further £200m of savings through improvements in ambulance trusts infrastructure and staff productivity.
  21. News Article
    Bereaved parents have described maternity investigations carried out by a watchdog as “deeply flawed” after it failed to make recommendations to trusts in 182 cases of deaths and harm. The Maternity and Newborn Safety Investigations programme investigates certain cases of early neonatal deaths, stillbirths and severe brain injury in babies born at term following labour, alongside maternal deaths. Last year, it moved to the Care Quality Commission having previously been hosted by the Health Services Safety Investigation Branch. Now a Freedom of Information request has revealed a third (182) of 556 MNSI reports completed between April 2023 and March 2024 did not contain recommendations. Officials said in the 182 reports, none of the findings of the investigation contributed to the outcome for the mother or baby, and therefore no recommendations were made. However, Emily Barley, whose daughter Beatrice died during labour in 2022, said it was “very concerning” to see that so many investigations result in no safety recommendations at all. She added: “It is hard to believe that when a full-term baby dies or suffers a serious brain injury there is nothing for providers to learn. “I do not have any confidence in the MNSI, its investigations, or its conclusions. Having been through an MNSI investigation following the death of my daughter… it is clear to me the entire process is deeply flawed.” Read full story (paywalled) Source: HSJ, 25 November 2024
  22. Content Article
    Each year over 600,000 people die in the United Kingdom and many of these deaths occur in hospital, despite the majority of people saying that they would prefer not to die there. Approximately 70% of people die from long-term health conditions that often follow a predictable course, with death anticipated well in advance of the event. The annual number of deaths in the United Kingdom is predicted to rise to 736,000 by mid-2035. Therefore, the provision of care at the end of life must meet the needs of the population. NCEPOD reviewed the quality of care provided towards the end of life for adults with a diagnosis of dementia, heart failure, lung cancer or liver disease and have made a number of recommendations. Recommendations Ensure that patients with advanced chronic disease have access to palliative care alongside disease modifying treatment (parallel planning) to improve symptom control and quality of life. Normalise conversations about palliative/end of life care, advance care plans, death and dying. As a trigger to introduce a conversation which includes the patient and their family/carers, consider: The surprise question “Would you be surprised if this patient died within the next 12 months?” This can be used across all healthcare settings; and/or recurrent hospital admission of patients with advanced chronic disease. Ensure all patients with an advanced chronic disease are allocated a named care co-ordinator. Provide specialist palliative care services in hospitals and in the community, to ensure all patients, including those with non-malignant diseases receive the palliative care they need. Train patient-facing healthcare staff in palliative and end of life care. This training should be included in: undergraduate and postgraduate education; and tegular training for patient-facing healthcare staff. Ensure that existing advance care plans are shared between all providers involved in a patient’s care. Raise public awareness to increase the number of people with a registered health and welfare lasting power of attorney (LPA) well before it is needed. .
  23. Content Article
    In May 2024, Dr Penny Dash was asked by the Department of Health and Social Care (DHSC) to conduct a review into the operational effectiveness of the Care Quality Commission (CQC). An interim report of her work, providing a high-level summary of her emerging findings, was published in July 2024. This full report summarises the final findings of the review, outlining the necessary changes to start improving CQC. It makes seven recommendations and is aimed at: health and care professionals health and social care services academic and professional institutions the general public. Alongside the review’s full report, DHSC wanted to independently determine if the review’s concerns were substantiated with objective data through the consideration of a number of research questions. A second review considering the wider landscape for quality of care, with an initial focus on safety, will be published in early 2025. The conclusions of the review are summarised around 10 topics. Conclusion 1: poor operational performance There has been a stark reduction in activity with just 6,700 inspections and assessments carried out in 2023, compared with almost 15,800 in 2019. This has resulted in: a backlog in new registrations of health and care providers delays in re-inspecting after a ‘requires improvement’ or ‘inadequate’ rating increasing age of ratings The review has concluded that poor operational performance is impacting CQC’s ability to ensure that health and social care services provide people with safe, effective and compassionate care, negatively impacting the opportunity to improve health and social care services, and, in some cases, for providers to deliver services at all. Conclusion 2: significant challenges with the provider portal and regulatory platform New IT systems were introduced at CQC from 2021 onwards. However, the deployment of new systems resulted in significant problems for users and staff. The review has concluded that poorly performing IT systems are hampering CQC’s ability to roll out the SAF, and cause considerable frustration and time loss for providers and CQC staff. Conclusion 3: delays in producing reports and poor-quality reports All sectors told the review that they can wait for several months to receive reports and ratings following assessments. The review has heard multiple comments about poor-quality reports - these have come from providers and from members of the public. Poor-quality and delayed reports hamper users’ ability to access information, and limit the credibility and impact of assessments for providers. Conclusion 4: loss of credibility within the health and care sectors due to the loss of sector expertise and wider restructuring, resulting in lost opportunities for improvement CQC underwent an internal restructuring in 2023, alongside the introduction of the SAF and new IT systems. The restructuring moved operational staff from 3 directorates with a focus on specific sectors into integrated teams operating at a local level, resulting in a loss of expertise. The review has found that the current model of generalist inspectors and a lack of expertise at senior levels of CQC, combined with a loss of relationships across CQC and providers, is impacting the credibility of CQC, resulting in a lost opportunity to improve health and social care services. Conclusion 5: concerns around the single assessment framework (SAF) and its application The SAF has set out 34 areas of care quality (called ‘quality statements’) that could be applied to any provider of health or social care with a subset applied to assessments of integrated care systems (ICSs) and local authorities. These align to the 5 domains of quality used for many years and referred to as ‘key questions’ within the SAF. For each of the 34 quality statements, there are 6 ‘evidence categories’. These are: people experience, staff experience, partner experience, observations, processes and outcomes. The review has identified 7 concerns with the SAF as follows: the way in which the SAF is described is poorly laid out on the CQC website, not well communicated internally or externally, and uses vague language there is limited information available for providers and users or patients as to what care looks like under each of the ratings categories, resulting in a lack of consistency in how care is assessed and a lost opportunity for improvement there are questions about how data on user and patient experience is collected and used more could be done to support and encourage innovation in care delivery there is insufficient attention paid to the effectiveness of care and a lack of focus on outcomes (including inequalities in outcomes) there is no reference to use of resources or the efficient and economic delivery of care, which is a significant gap there is little reference to, or acknowledgement of, the challenges in balancing risk and ensuring high-quality care across an organisation or wider health and care system Conclusion 6: lack of clarity regarding how ratings are calculated and concerning use of the outcome of previous inspections (that often took place several years ago) to calculate a current rating The review has learnt that overall ratings for a provider may be calculated by aggregating the outcomes from inspections over several years. This cannot be credible or right. Furthermore, providers do not understand how ratings are calculated and, as a result, believe it is a complicated algorithm, or a “magic box”. Ratings matter - they are used by users and their friends and family, they are used by commissioning bodies (the NHS, private health insurers and local authorities), and they drive effective use of capacity in the sector. They are a significant factor in staff recruitment and retention. Conclusion 7: there are opportunities to improve CQC’s assessment of local authority Care Act duties The Health and Care Act 2022 gave powers to CQC to assess local authorities’ delivery of their adult social care duties after several reports and publications identified a gap in accountability and oversight of adult social care. The review found broad support for the overall assessment framework but also heard feedback that the assessment process and reporting could be improved. Conclusion 8: ICS assessments are in early stages of development with a number of concerns shared The Health and Care Act 2022 introduced a new duty for CQC  to review and assess ICSs. Statute sets out 3 priority areas for CQC to look at: leadership, integration and quality of care; and the Secretary of State can set priorities on other themes. CQC developed a methodology for these assessments, which was tested in pilots in Dorset and Birmingham and Solihull, but wider rollout has been paused as a result of a number of concerns shared with the review. Conclusion 9: CQC could do more to support improvements in quality across the health and care sector The review heard a consistent comment that CQC should not be an improvement body per se, but, at the same time, could do more to support the health and care sectors to improve. It could do this, for example, through the description of best practice and greater sharing of new models of care delivery, leading international examples of high-quality care and more innovative approaches - particularly the use of technology. Governance structures within organisations are crucial to improvement. A greater focus on how organisations are approaching and delivering improvement, rather than looking at input metrics, could enable more significant improvements in quality of care. Conclusion 10: there are opportunities to improve the sponsorship relationship between CQC and the Department of Health and Social Care (DHSC) DHSC’s sponsorship of CQC should promote and maintain an effective working relationship between the department and CQC, which should, in turn, facilitate high-quality, accountable, efficient and effective services to the public. The review has found that DHSC could do more to ensure that CQC is sponsored effectively, in line with the government’s Arm’s length body sponsorship code of good practice. The review’s recommendations The health and care sector is one of the most significant drivers of health, public satisfaction and economic growth. It needs - and deserves - a high-performing regulator. In order to restore confidence and credibility and support improvements in health and social care, there is a need to: rapidly improve operational performance, fix the provider portal and regulatory platform, and improve the quality of reports rebuild expertise and relationships with providers review the SAF to make it fit for purpose with clear descriptors and a far greater focus on effectiveness, outcomes and use of resources clarify how ratings are calculated and make the results more transparent continue to evolve and improve local authority assessments formally pause ICS assessments strengthen sponsorship arrangements.
  24. Content Article
    This review has been commissioned by the board of the Care Quality Commission (CQC) to complement the report by Dr Penny Dash, by looking at changes that CQC made following the publication of its new strategy in 2021 and their impact. Importantly, this review makes recommendations on solutions to CQC’s current problems. The transformation programme that followed the 2021 strategy had 3 key elements: A major organisational restructure. The introduction of a single assessment framework across all the sectors that CQC regulates (hospitals, mental health services, ambulances, primary and community care services and adult social care). The development of a new IT system, named the regulatory platform. These three initiatives are clearly interlinked, but this review has shown that all three have failed to deliver the benefits that were intended, despite being initially welcomed by providers.  Key recommendations from the review A fundamental reset of the organisation is needed. This needs to be akin to the reset in 2012/13, following the problems related to the regulator that were revealed by the report of the public inquiry into Mid Staffordshire NHS Foundation Trust (the Robert Francis inquiry) and the BBC investigation of Winterbourne View. The previous organisational structure should be re-instated as soon as reasonably possible. Chief inspectors should lead sector-based inspection teams at all levels. These teams can be brought together to assess integration of care across a local area, while retaining focus on their own specialism. The current Operations directorate should be disbanded and reformed into sector-based inspection directorates. Many of the staff currently working in the regulatory leadership directorate should be re-assigned to the relevant inspection directorate. At least three permanent Chief Inspectors should be appointed as soon as reasonably possible to lead the sector-based inspection directorates. Serious consideration should be given to the appointment of a fourth Chief Inspector to lead regulation of mental health services and to oversee inspections under the Mental health Act. Ongoing relationships between inspection staff with relevant skills and experience and providers should be re-instated as soon as possible. Regular dialogue coupled with appropriate levels of support and challenge in respect of required improvements has been sorely missed both by CQC staff and by health and social care providers. Aspects of the single assessment framework could be retained – with some modifications. Other aspects should be suspended and almost certainly scrapped, including the evidence categories and scoring system. More work needs to be done to define what good looks like in different services. Decisions on the future of the regulatory platform are outside the scope of this review. However, it is possible that simplifying the assessment framework (e.g. by scrapping evidence categories and scoring) may make it easier to resolve the problems with the IT system, but expert advice will be needed on this. The use of data to inform judgements should be given much higher priority than at present. Existing datasets already collected by NHS England and associated bodies should be incorporated into assessments of hospitals and primary care services as soon as possible. New data sharing agreements between national bodies should be instituted as soon as possible. Uniform availability of high-quality data/intelligence would reduce the burden on both CQC staff and providers. Staffing levels and pay scales within the inspection directorates should be reviewed as a matter of urgency. There are currently too few staff working in the hospital and primary care inspection programmes to undertake the duties of the regulator within reasonable timescales. The gap between NHS and CQC pay scales has almost certainly contributed to the loss of inspection staff. Priorities for inspection within the healthcare sectors need to be reviewed, given current staffing levels. Possible approaches to prioritisation are discussed in greater detail in later sections of this report. CQC should work closely in partnership with leaders of health care and adult social care to design improved approaches to assessment and inspection. This would be welcomed by those being regulated. They would also welcome a return to a larger element of peer review in the process. Further work to determine how the current backlogs in registration can be reduced or eliminated is urgently required. During the course of this review, the issue of “one-word ratings” was raised on numerous occasions by providers. Further consideration should therefore be given to this issue. In particular, the level at which ratings makes sense to people using services should be considered.
  25. Community Post
    About 1000 angry nurses and doctors have rallied outside Perth Children’s Hospital in Australia following the death of seven-year-old Aishwarya Aswath, demanding vital improvements to the state’s struggling health system. The Australian Nurses Federation was joined by the Australian Medical Association for the rally, with staff from hospitals across Perth attending. Many people held signs that read “We care about Aishwarya”, “Listen to frontline staff”, “Report the executive — not us” and “Please don’t throw me under the bus”. Aishwarya developed a fever on Good Friday and was taken to Perth Children’s Hospital the next day, but had to wait about two hours in the emergency department before she received treatment. She died soon after from a bacterial infection. An internal report into the tragedy made 11 recommendations — including improvement to the triage process, a clear way for parents to escalate concerns and a review of cultural awareness for staff — but Aishwarya’s parents said the report raised more questions than it answered. The family wants a broader independent inquiry to look at all 21 near-misses in the past 15 months – not just their daughter’s case. Some people have been referred to medical authorities, while Child and Adolescent Health Service chair Debbie Karasinski resigned after the report.' I am encouraged to see the way healthcare staff reacted to this tragedy. Imagine a similar event in England, would nurses protest outside the hospital and stand up to authority like this? I doubt it very much, which is very sad reflection on the prevailing culture and health leadership in England. What do others think? Source: The Australian. 9 July 2021 Picture: Picture: 9 News
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