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Found 152 results
  1. Content Article
    In high-income countries, critical illness in children is rare, and often difficult for physicians to distinguish from common minor illness until late in the disease. Parents or caregivers are well positioned to detect early and subtle signs of deterioration, but the relationship between their concerns and patient outcomes is unknown. This study examined the relationship between documented caregiver concern about clinical deterioration and critical illness in children presenting to hospital. It found that caregiver concern for clinical deterioration is associated with critical illness in paediatric patients and, after adjusting for variables including abnormal vital signs, had a strong association with ICU admission and mechanical ventilation. Rapid response systems should incorporate proactive assessment of parent or caregiver concerns for deterioration.
  2. Content Article
    Research led by Lancaster University has revealed that the exceptional circumstances early in the Covid-19 pandemic led to distressing experiences of death and dying in care homes. Not only did care homes suffer significantly high death rates amongst residents , but this was compounded by the impact of social distancing restrictions on family visiting and external support from palliative care teams for some care home residents dying in the early months of the pandemic. The study was led by Lancaster Professor Nancy Preston of the International Observatory on End-of-Life Care with colleagues from Newcastle University and the University of Sheffield. The research explored the impact on care homes of the early waves of the pandemic between Autumn 2020 and Summer 2021. Interviews were conducted with 16 UK care home staff , three residents , five family members and health service staff working with ten care homes , exploring their experiences of death and dying. Experiences of death and dying in care homes were particularly distressing for staff and families at this time for a number of reasons. Preparing for large scale deaths The findings suggest that care home staff found the prospect of preparing for, and managing a large number of deaths particularly difficult, with one care home manager telling researchers that “Just before lockdown we had a nurse came to the home and said to us, ‘Right you need to be prepared to hold bodies in the care home. Do you have any cold bedrooms where you can hold bodies?’ … and I think that kind of hit us.” Policing family visiting due to social distancing restrictions Care home staff also found it very distressing enforcing strict social distancing restrictions on family visits when a care home resident was dying, which often brought them into conflict with their personal and professional instincts for supporting residents and families at these times. One care home worker said: “It’s just an awful position to be in because who are we to say they can’t say their goodbyes and for how long. That’s the bit that I find difficult.” Distress surrounding deaths for all involved Social distancing regulations were clearly also very distressing for families. As well as time restrictions on visits, they also had to choose a single family member to visit, which was difficult for all involved, and could cause family conflict. The findings suggest that the impact of these factors continued to affect families some months after their bereavement, with one telling researchers: “To end his life without having anyone there with him that he knows. That is just a terrible way to go and I don’t think we’ll ever forgive that really.” Staff also found resident deaths extremely distressing, particularly witnessing the rapid decline of residents whom they had often known and worked with for months or years. They reported not being able to offer the type of end-of-life care that they would wish to, and some felt they had limited external support in managing end-of-life care. Professor Nancy Preston said: “We don’t yet know the long-term impact of this distress for care home staff and families, but planning for future crises should have clear policies for end-of-life care, including prioritising family visiting and ensuring consistent access to external support services including specialist palliative care.”
  3. News Article
    Families of the victims of Nottingham knife killer Valdo Calocane have urged NHS England to rethink a decision not to publish a report into the care he received in full. Calocane was sentenced to an indefinite hospital order after killing 19-year-old students Barnaby Webber and Grace O'Malley-Kumar, and 65-year-old caretaker Ian Coates, before attempting to kill three others, in a spate of attacks in Nottingham in June 2023. Prosecutors accepted his not guilty pleas to murder after medical evidence showed he had paranoid schizophrenia. He was later sentenced for manslaughter by reason of diminished responsibility and attempted murder. A summary of the independent mental health homicide report is due to be made publicly available later this week, but the full version will be kept confidential due to “data protection legislation relating to patient information”. Speaking on behalf of the families ahead of the NHS England (NHSE) report's publication, adviser Radd Seiger said: “The families have already reached out to NHSE to strongly urge them to publish the findings in full. “They believe it is very much in the public interest and in the interests of safety to do so. NHSE have thus far refused.” An NHS England spokesperson said: “Independent mental health homicide reports are commissioned by NHS England and published in line with the requirements of confidentiality and data protection legislation relating to patient information.” In August, a damning report by the Care Quality Commission into the care previously received by Calocane found the trust’s mental health unit “minimised or omitted” key details of the serious risk he posed to others. The watchdog laid out “gross, systematic failures”. It found that risk assessments had played down Calocane’s refusal to take his medication and his persistent symptoms of psychosis, and that he was released after undergoing eight separate risk assessments. Read full story Source: The Independent, 4 February 2025
  4. News Article
    Parents are trusting ChatGPT for medical advice over actual doctors and nurses, a new study found. Researchers at the University of Kansas also found that parents also say AI-generated text is credible, trustworthy and moral. “When we began this research, it was right after ChatGPT first launched — we had concerns about how parents would use this new, easy method to gather health information for their children,” lead author and doctoral student Calissa Leslie-Miller said in a release. “Parents often turn to the internet for advice, so we wanted to understand what using ChatGPT would look like and what we should be worried about.” Participants in the study were given health-related text, reviewing content generated by healthcare professionals and the OpenAI chatbot ChatGPT. They were not told who, or what, authored the texts. They were asked to rate the texts based on five criteria - perceived morality, trustworthiness, expertise, accuracy and how likely they would be to rely on the information. In many cases, parents couldn’t tell which content was generated by ChatGPT or by the experts. When there were significant differences in ratings, ChatGPT was rated to be more trustworthy, accurate and reliable than the expert-generated content. Read full story Source: The Independent, 30 October 2024
  5. Content Article
    ChatGPT and other large language models have the potential to transform the health information landscape online. However, lack of domain-specific expertise and known errors in large language models raise concerns about the widespread adoption of content generated by these tools for parents making healthcare decisions for their children. The aim of this study is to determine if health-related text generated by ChatGPT under the supervision of an expert is comparable to that generated by an expert regarding persuasiveness and credibility from the perspective of a parent. Results indicate that prompt engineered ChatGPT is capable of impacting behavioural intentions for medication, sleep, and diet decision-making. Additionally, there was little distinction between prompt engineered ChatGPT and content experts on perceived morality, trustworthiness, expertise, accuracy, and reliance. Notably, when differences were present, prompt engineered ChatGPT was rated as higher in trustworthiness and accuracy, and participants indicated they would be more likely to rely on the information presented by prompt engineered ChatGPT compared to the expert.
  6. Content Article
    Two years after his 13-year-old child died needlessly in hospital, Paul Laity reflects on life without her. Martha Mills died of septic shock due to a series of serious failures in her care after she injured her pancreas in a cycling accident. Her father Paul talks about the ongoing pain of grief, and the additional burden of knowing that Martha's death was preventable, caused by the complacency of her doctors and a culture in the hospital that meant consultants were reluctant to ask expert advice from paediatric ICU. "Martha’s avoidable death was unusual in that the prime causes weren’t overwork or a lack of resources, but complacency, overconfidence and the culture on the ward. What upsets me most was that the consultants – a different one most days – took a punt that she was going to be OK over the weekend. No one assumed responsibility; they hoped for the best rather than playing safe. Was everything done for Martha that could have been done? Emphatically not. It’s very hard to live with this knowledge. But just as hard is the recognition that I, too, didn’t do enough." Further reading ‘We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death (The Guardian, 3 September 2022) Prevention of Future Deaths Report: Martha Mills (28 February 2022)
  7. Content Article
    More information about "Patient Safety Partners - A workshop at Kingston Hospital"
    Melanie Whitfield, Associate Director of Patient Safety at Kingston NHS Foundation Trust, and Helen Hughes, Chief Executive of Patient Safety Learning, recently ran a workshop for Patient Safety Partners (PSPs) at the Kingston Trust. Here is a summary of the workshop. PSPs are vital in bridging the gap between healthcare providers in the UK and the patients who use these services. They are the patient’s voice and enable us, as providers, to ensure we are putting our patients first, challenging us when things go wrong and asking the difficult questions. But what is their role and why are they so important? In July 2019, the NHS Patient Safety Strategy was released with a framework for PSP involvement in healthcare organisational safety. This relates to the role that patients, carers and other lay people can play in supporting and contributing to a healthcare organisations’ governance and management processes for enhancing and improving patient safety. This is a voluntary role with the official allocated time given to PSPs to complete their work at Kingston being 1.5 days per month. The role for PSP’s was outlined as follows: Membership of safety and quality committees whose responsibilities include the review and analysis of safety data. Involvement in patient safety improvement projects. Working with organisation boards to consider how to improve safety. Involvement in staff patient safety training. Participation of investigation oversight groups. We know that the opportunity and benefit of PSPs is so much more than this. So Melanie and Helen developed the idea of a workshop for PSPs, the patient safety team, the staff wellbeing chaplain and PEPI lead to share experiences of the first year of PSPs, to learn from each other from this experience, celebrate achievements and impact, and to discuss opportunities to promote listening and learning from patients to shape the future journey. Helen facilitated the workshop and the discussions and outcomes of this are outlined below. The session started with what do we want from PSPs. Reflections included: Take us out of our comfort zone; challenge us on our actions and evidence and ‘bring us back to reality’ of what it’s like to be a patient or family member. Help us look at systems and culture and for PSPs to ask difficult/challenging questions – ‘lift the rocks and see what’s underneath’. Remind us that following up when things go wrong isn’t just about incident reviews and report writing, there are patients involved. Help us close the gap between patients and staff and build the interaction between patients, staff and patient and staff safety. Bridging the gap between patients and clinicians responsible for them. Leadership and insight by doing together. Patient safety improvement and prevention by providing information to patients sooner. Improving communication by being more visible. Raising PSP profile for staff and patients. Access to networks within the community. Real time listening rather than delayed Duty of Candour. Usefulness of speaking up and the consequences of not wanting to. Everyone agreed this is a huge and challenging agenda but it’s what’s needed. There was huge energy in the room and motivation to work collaboratively to address these issues. During the workshop Three of the PSPs were then asked for an insight into their role, what they want to achieve from the role and what barriers they face. This was a rich session with much insight, including these issues highlighted by PSP colleagues: We’re all passionate about patient’s voice being heard; what can we do to help the NHS and give back. There’s a real desire to fix things and it make better and to implement ideas that can be easily rolled out. It’s still an evolving role – by the time we’ve got the skills and knowledge to do a good job our time in the role may be at an end, so we need to create longevity in the role, including succession planning. There are huge amounts of learning to be done. Opportunity to be more effective by being project based and utilising volunteers. Feeling really welcomed and accepted; feeling lucky to be a part of the team. The value of PSPs being outside ‘experts’ who may have access to other networks, e.g. in voluntary sector, children’s services How do we best use PSP individual experience and knowledge? Awareness of staff pressures. There’s a huge opportunity for PSPs but do we have sufficient numbers and time? Opportunity to demonstrate value and create the business case for more resourcing. Meetings are often fast paced meetings with no time to ask questions; if decisions are already made, what’s the value that PSPs can bring? And it’s a real struggle to understand NHS terminology and jargon. There is a need for improved visibility of PSPs, with staff and patients; comms and engagement strategies needed. Demonstrate the credibility of the role. Difficulties of families having their voice heard. How can patients be signposted, what are the communication pathways? “I’ve attended meetings where Trust colleagues didn’t understand who we were or what our role entailed. We need clear guidance on our job description and need better visibility to Trust colleagues, so they know who we are. I would love for us to be involved in policy writing and attend formative discussions on major transformation project with high impact on patient safety.” Michelle Deans – Hounslow and Richmond Community Healthcare. “Patients need to have their voices heard; therefore, a clear communication pathway is essential. The language used by clinicians in incident reports is far too complex for the average reader to understand and often implies negative connotations. We need to be fully visible for both staff and patients, but we only have so much time.” Sue Strudwick – Kingston Hospital Foundation Trust. “I’ve struggled with understanding NHS terminology having had no clinical or NHS experience in my life. The meetings we are asked to attend can often be fast paced with no time to ask questions. I would love this role to be more project based utilising hospital volunteers.” Chloe Scott – Hounslow and Richmond Community Healthcare. As you can see, the PSPs have challenges within their roles which is no doubt reflected across the country. The workshop provided an opportunity for the PSPs and staff to come up with ways to work together to improve patient safety. Everyone agreed the biggest opportunities would come from visibility, education and direct engagement with patients. Here are some of the ideas that came up: Use of social media channels to publicise the role of the PSP at the Trust, including visibility on our internet and intranet page. Frontline patient engagement, including ward walkabouts, pop-up desks and drop-in sessions. PSPs to hold us to account when things have gone wrong ensuring constructive follow up on action plans and improvements. Spreading the word through patient stories and experiences. PSPs to have regular interaction/involvement with quality improvement to influence what projects are completed and how the patients are involved. Collaborative/cross organisational working. More thinking is needed on how we recruit PSPs that reflect the diversity of the community we serve. Involvement in the new Patient Safety Incident Response Framework (PSIRF) and patient safety incident investigations (PSIIs). It is important we highlight to the staff and patients that patients and families need to be able to speak to the right people in real time. We don’t want something to go wrong and then people pick up on it afterwards; we want to encourage staff and patients to speak up when they have questions that need answering and to be able to be listened to when they recognise that something is about to go wrong. We know we can’t stop things from going wrong, but prevention and learning from incidents is well within our control. With the help of our PSPs and educating patients and staff, we can make the necessary improvements to ensure our patient’s safety is always our priority. We hope that by sharing this blog with colleagues in the NHS in England, others can learn from the ambition, excitement and opportunity at Kingston for the PSP role. As we develop, we’re keen to share our journey and collaborate with colleagues, through the newly established Patient Safety Partnership Network and with Dr Henrietta Hughes, the Patient Safety Commissioner.
  8. Content Article
    Visits from loved ones are vital to the health and wellbeing of people receiving care in care homes, hospitals and hospices. There have been concerns about visiting restrictions in health and care settings for several years, and the restrictions introduced in response to the COVID-19 pandemic exacerbated these concerns. While those restrictions were in place at the time to control the risk of transmission and keep people safe, it was detrimental for loved ones to have been kept apart or not to have had someone supporting them in hospital. Guidance is now clear that visiting should be encouraged and facilitated in all circumstances. This consultation seeks views on introducing secondary legislation to protect visiting as a fundamental standard across CQC-registered settings so that no one is denied reasonable access to visitors while they are resident in a care home, or a patient in hospital or a hospice. This includes accompanying people to hospital appointments (outpatients or diagnostic visits). Related reading on the hub: Visiting restrictions and the impact on patients and their families: a relative's perspective It’s time to rename the ‘visitor’: reflections from a relative
  9. News Article
    Top boss of NHS complaints in England has told the BBC he wants Martha's rule to be introduced to give patients the power to get an automatic second medical opinion about hospital care, when they think things are going wrong. Rob Behrens said he had been moved by the plea of Merope Mills, who shared the story of her daughter's death. Martha was 13 when she died from sepsis. Merope Mills wants hospitals around the country to bring in Martha's rule, which would give parents, carers and patients the right to call for an urgent second clinical opinion from other experts at the same hospital, if they have concerns about their current care. It is something that Parliamentary and Health Service Ombudsman Rob Behrens fully supports. He told BBC Radio 4's Today programme: "Along with many others, I was moved and in great admiration for what Merope has said and done and I give unambiguous support. "Unfortunately, as tragic as this case is, it's not the first and there have been many cases where patients have been failed by their doctors because they haven't been listened to." Read full story Source: BBC News, 5 September 2023
  10. News Article
    Soaring numbers of families struggling to care for someone with dementia have hit a “crisis point” with nowhere to turn for help when their loved one puts themselves or others at risk of harm, a charity has said. More than 700,000 people in the UK look after a relative with dementia. Many feel they can no longer cope with alarming situations where they or their relative are at immediate risk of being harmed, according to Dementia UK. Dementia can affect a person’s ability to manage their reactions to difficult thoughts and feelings. This can lead to them experiencing such intense states of distress that they become verbally or physically aggressive, putting themselves and those around them at risk of harm. The charity says carers and their loved ones are being failed because health and social care support services are already stretched to their limit, which has led to a surge in calls to its helpline. Sheridan Coker, the deputy clinical lead at Dementia UK, said: “We’re increasingly being contacted by families who are at risk of harm with no one to turn to. We receive calls where the person with dementia has become so distressed that they have physically assaulted the person caring for them, often a family member." Read full story Source: The Guardian, 31 July 2023
  11. Content Article
    Clinicians in emergency departments (EDs) will see babies and young children with injuries that may be non-accidental. If the cause of such injuries is missed, there is a risk of further harm to the child. However, making a judgement about whether an injury might be accidental or not is complex and difficult. This Healthcare Safety Investigation Branch (HSIB) investigation explores the issues that influence the diagnosis of non-accidental injuries in infants (children under 1 year of age) who visit an ED. Specifically, it explores the information and support available to ED clinicians to help them to make such a diagnosis. Due to the nature of the subject matter no specific incident was used to explore this area of care. Instead, the investigation analysed 10 serious incident reports (reports written by NHS trusts when a serious patient safety incident occurs) to identify the factors that contribute to non-accidental injuries not being diagnosed. These factors were grouped into themes, which informed the terms of reference for the investigation. Findings There is no specific guidance for ED clinicians on the identification of suspected non-accidental injuries and what to do if they suspect an infant has a non-accidental injury. There may be barriers to routinely escalating cases of children with a potential non-accidental injury to paediatric (child specialist) and safeguarding teams. Delays in the availability of information about potential safeguarding concerns add to the pressures on ED staff when making decisions about infants with potential non-accidental injuries. There remain concerns about, and an inconsistent approach to, sharing safeguarding information between organisations. The Emergency Care Data Set (ECDS) gathers information about ED attendances and includes a field for when such attendances are related to safeguarding. The ECDS safeguarding information collected is not currently utilised within the NHS and there is minimal quality assurance in place to ensure that it is reliable. Risk factors for non-accidental injuries which do not meet the criteria to be included on the Child Protection – Information Sharing system (the electronic system designed for information sharing between the NHS and social services) are not included in a patient’s summary care record and may therefore remain unknown to clinicians. The investigation identified mechanisms which could enable safeguarding information that is not currently available to ED clinicians, to be made available through existing national and regional digital systems. Safeguarding teams are often located physically distant from EDs. This can create a barrier to communication and liaison with the team. Safety recommendations HSIB recommends that the Royal College of Emergency Medicine, working with relevant stakeholders, develops guidance to support clinicians in the diagnosis and management of non-accidental injuries. HSIB recommends that NHS England, working with relevant stakeholders, reviews the utility of the safeguarding data in the Emergency Care Data Set and agrees a process for assuring the quality of any data to be captured. Safety observations HSIB makes the following safety recommendations: It may be beneficial if there was an electronic system available for clinicians to view any safeguarding information to assist in decision making. It would be beneficial if the safeguarding operating model, to be tested through pathfinders, included a response time for advice when sought by professionals such as emergency department clinicians It may be beneficial if safeguarding teams are either physically located near to, or make efforts to promote their visibility in, emergency departments.
  12. Content Article
    Cincinnati Children’s Hospital Medical Center believes all patients and their families have a right to receive medical information in their preferred language. Andy Schwieter from Cincinnati Children’s shares how his organisation supports the diverse languages of the community they serve through improved communication.
  13. News Article
    “I’ve seen patients take swings at doctors because they’re not happy with the time it’s taken or the doctor’s diagnosis. I’ve seen fire extinguishers set off and thrown at people, computers lifted and thrown across the emergency department and people run out of cubicles and punch other patients – people they don’t know – for no reason.” Roger Webb, a security supervisor at the Queen’s Medical Centre hospital in Nottingham, is recalling some of the more unsavoury incidents he has witnessed in the course of his work. “I’ve been struck in the groin, had scratches all over my arms where people have dug their nails in. I’ve been bitten and I’ve been spat at while trying to deal with situations. The spitting is the most depressing of those, though, because it’s so contemptuous and so horrible. And legally it’s assault.” Like staff across the NHS, those at the QMC have seen a rise in abusive, threatening and intimidatory behaviour by patients and their relatives in recent years. In 2021-22, Nottingham University hospitals (NUH), the NHS trust that runs the QMC and its sister City hospital, recorded 1,237 incidents of aggression, violence and harassment. But it had many more – 1,806 – during the following year, 2022-23. Last year brought another increase. In the six months between April to September alone, NUH recorded another 1,167 incidents, leaving 2023-24 likely to be the worst ever on record. Staff have been hit, spat at, threatened, verbally abused and racially abused during this roll call of unpleasant incidents. Racially aggravated harassment has increased notably. Some of the incidents have led to perpetrators being charged and convicted. Worryingly, in a growing number of cases, the patient has been responsible for several incidents while receiving one single episode of care. Care delays are the main trigger for abuse at the QMC. But such incidents also arise when staff are treating drunks, rival gangs, people who are high on drugs and those with mental health problems. Read full story Source: The Guardian, 25 February 2024
  14. News Article
    The head of the NHS has today announced the rollout of ‘Martha’s Rule’ in hospitals across England from April, enabling patients and families to seek an urgent review if their condition deteriorates. The patient safety initiative is set to be rolled out to at least 100 NHS sites and will give patients and their families round-the-clock access to a rapid review from an independent critical care team if they are worried about their or a loved one’s condition. This escalation process will be available 24/7 to patients, families and NHS staff, and will be advertised throughout hospitals, making it quickly and easily accessible. NHS chief Amanda Pritchard said the programme had the potential to “save many lives in the future” and thanked Martha’s family for their important campaigning and collaboration to help the NHS improve the care of patients experiencing acute deterioration. Thirteen-year-old Martha Mills died from sepsis at King’s College Hospital, London, in 2021, due to a failure to escalate her to intensive care and after her family’s concerns about her deteriorating condition were not responded to promptly. Extensive campaigning by her parents Merope and Paul, supported by the cross-party think tank Demos, has seen widespread support for a single system that allows patients or their families to trigger an urgent clinical review from a different team in the hospital if the patient’s condition is rapidly worsening and they feel they are not getting the care they need. Merope Mills and Paul Laity, Martha’s parents, said: “We are pleased that the implementation of Martha’s Rule will begin in April. We want it to be in place as quickly and as widely as possible, to prevent what happened to our daughter from happening to other patients in hospital. “We believe Martha’s Rule will save lives. In cases of deterioration, families and carers by the bedside can be aware of changes busy clinicians can’t; their knowledge should be recognised as a resource. We also look to Martha’s Rule to alter medical culture: to give patients a little more power, to encourage listening on the part of medical professionals, and to normalise the idea that even the grandest of doctors should welcome being challenged. We call on all NHS clinicians to back the initiative: we know that the large majority do listen, are open with patients and never complacent – but Martha’s doctors worked in a different culture, so some situations need to change. “Our daughter was quite something: fun and determined, with a vast appetite for life and so many plans and ambitions – we’ll never know what she would have achieved with all her talents. Hers was a preventable death, but Martha’s Rule will mean that she didn’t die completely in vain.” Read full story Source: NHS England, 21 February 2024
  15. News Article
    More than 100 families looking after severely disabled adults and children outside hospital, have told the BBC that the NHS is failing to provide enough vital support. The NHS says help is based on individual needs and guidelines ensure consistency across England and Wales. However, some families describe the system as adversarial. Only those living outside hospital with life-limiting conditions, or at risk of severe harm if they don't have significant support, get this help from the NHS. It is provided through a scheme called Continuing Healthcare (CHC) for adults, and its equivalent for under-18s, Children and Young People's Continuing Care. Cases in England are decided by NHS Integrated Care Boards (ICBs) - panels responsible for planning local health and care services. In Wales, they are overseen by local health boards. The BBC has heard from 105 families who described serious concerns with how the two schemes are working - with most calling for reform. One young man with 24-hour needs hasn't received any CHC help despite being eligible since February 2023 - his parents, who first applied for support on his behalf nearly two years ago, currently provide round-the-clock care Another family were told overnight care for their teenage child - who is non-verbal, has severe mobility issues and requires 24/7 support - would be reduced from seven down to three nights a week, without a reason being given. Read full story Source: BBC News, 14 February 2024
  16. News Article
    Jason Watkins, a British actor, has urged A&E units to look again at procedures surrounding infants as he has channels his anger at his young daughter’s death from sepsis into trying to “improve the system”. The actor said that his fury at the death of Maude aged two on New Year’s Day 2011 led him to smash up his shower. “It wasn’t anger at any individual, it was anger at fate. Why should we deserve this?” he told Andy Coulson’s Crisis What Crisis? podcast. “You feel really vulnerable and there’s a sort of rage against that. And there are all these different ways of resolving and wrestling out of this horrible dark pit that you’re in." He now campaigns for the UK Sepsis Trust. “I was never angry at any individual,” he said. “My anger was fuelled into trying to work out better ways of dealing with sepsis, or even more than that, the way that we look at infants in A&E. Because you know, it’s a funding issue, it’s an organisational issue. It’s another conversation. “Because I had identified that there wasn’t an individual at fault in the hospital, it has to be the system. So we’ve got to improve it. My anger is fuelled into that. There’s no bitterness. Nobody made a technical mistake, it’s just nobody really thought of the possibilities of what could be happening. “For me the whole of looking at infants arriving at A&E needs to be looked at again. Because if I say that Maude died twelve years ago, and that the ombudsman report about sepsis a couple of months ago said that nothing had changed about sepsis, now, that was like a body-blow, that makes me feel sick even thinking about it now, because we’ve worked so hard over that time.” Read full story Source: The Times, 1 February 2024
  17. Event
    Panelists will provide a robust overview of the challenges that accompany medical care and propose actionable recommendations for patients, family members, and carers to balance life demands for patients with complex medical needs. Register
  18. Event
    Join the Patient Safety Movement for a unique opportunity to view the award-winning HBO hit film Bleed Out and talk with the filmmaker, Steve Burrows afterwards. Bleed Out is the harrowing HBO feature documentary film that explores how an American family deals with the effects of medical malpractice. After Judie Burrows goes in for a routine partial hip replacement and comes out in a coma with permanent brain damage, her son, Steve Burrows, sets out to investigate the truth about what really happened. The documentary film takes place in real time over a span of ten years. Tickets
  19. Community Post
    What training have you had to have that crucial end of life conversation with a patient and their relatives? What has helped you have those conversations?
  20. Community Post
    Hello everyone, We know there is much learning to be gained from listening to patient and families. This is particularly true when it comes to patient safety. Have you had an experience that you'd like to share with us? Maybe you identified a risk or shared a concern and were listened to and unsafe care was avoided? Maybe you weren't listenied to or you didn't realise what was going on and you or your family member were harmed? How did you find out about the patient safety incident? Was information shared with you that you needed to know? Were you supported? Was there an invetsigation into the incident and were you invited to contributed to it? Were lessona learned and acted upon? Have others learned from this experience, do you know?
  21. Community Post
    Call 4 Concern is an initiative started by Critical Care Outreach Nurse Consultant, Mandy Odell. Relatives/carers know our patients best - they notice the subtle signs of deterioration in their loved one. Families and carers are now able to refer straight to the Critical care outreach team directly if they feel that care has not been escalated. Want to set up a call for concern initiative in your Trust? Need some support? Are you a relative that would like it in your Trust? Leave comments below -
  22. News Article
    A London acute trust is planning to provide staff working in frailty units with body cameras and those in antenatal clinics with additional security, as violence and aggression against them goes ‘through the roof’. Matthew Trainer, chief executive of Barking, Havering and Redbridge University Hospitals Trust in north east London, described the measures the trust is planning to take in response to growing staff concerns about their safety. Speaking at a King’s Fund event about making NHS careers more attractive, Mr Trainer said: “We need to understand the impact of violence and aggression against the workforce and that’s going through the roof just now. “Our ultrasound technicians have now asked for help as their antenatal scans are becoming so fraught. We are about to introduce body cameras in our frailty wards to help with the increase in violence and aggression against staff there.” Mr Trainer – who joined BHRUT in 2021 from Oxleas Foundation Trust – said a long-running problem with violence and aggression in emergency departments was spreading to other departments. Mr Trainer stressed the main problem, particularly in frailty units, was not patients’ own behaviour, but that of family and friends visiting them. Read full story (paywalled) Source: HSJ, 13 December 2023
  23. News Article
    The government is facing criticism over its guidance on safe visits to care homes in England. Labour and a number of charities have described the suggestions, including floor-to-ceiling screens, designated visitor pods and window visits, as impractical. Alzheimer's Society has said it "completely misses the point". Justice Secretary Robert Buckland told BBC Radio 4's Today programme the guidance was "non-exhaustive". The updated government advice, which came into effect on Thursday, says care homes - especially those which have not allowed visits since March - "will be encouraged and supported to provide safe visiting opportunities". Labour's shadow care minister Liz Kendall said many care homes would not be able to comply with the government's requirements which meant "in reality thousands of families are likely to be banned from visiting their loved ones". She said instead of suggesting measures such as screens, the government should "designate a single family member as a key worker - making them a priority for weekly testing and proper PPE". Kate Lee, chief executive at Alzheimer's Society, said: "We're devastated by today's new care home visitor guidance - it completely misses the point: this attempt to protect people will kill them." She said the pandemic had left people with dementia isolated and thousands had died. The guidelines "completely ignore the vital role of family carers in providing the care for their loved ones with dementia that no one else can", she added. She said the "prison-style screens" proposed by the government with people speaking through phones were "frankly ridiculous when you consider someone with advanced dementia can often be bed-bound and struggling to speak". That view was echoed by Caroline Abrahams, charity director at Age UK, who said she was "acutely aware" that the methods being sanctioned were "unlikely to be useable by many older people with dementia, or indeed sensory loss". Read full story Source: BBC News, 5 November 2020
  24. News Article
    A woman has been arrested after attempting to take her 97-year-old mother out of a care home for lockdown. Qualified nurse Ylenia Angeli, 73, wanted to care for her mother, who has dementia, at home. But when she told staff at the care home, they called the police who then briefly arrested Ms Angeli. The family have not been able to see their elderly relative for nine months, and decided to act ahead of the second national lockdown. Assistant Chief Constable Chris Noble, from Humberside Police, said: "These are incredibly difficult circumstances and we sympathise with all families who are in this position." "We responded to a report of an assault at the care home, who are legally responsible for the woman's care and were concerned for her wellbeing. We understand that this is an emotional and difficult situation for all those involved and will continue to provide whatever support we can to both parties." The incident came to light on the day the government announced new rules for families wishing to visit their loved ones in care homes. Under the guidance, issued hours before lockdown, families can meet relatives through a window or in a secure outdoor setting. Visits will need to be booked in advance, but the Department of Health and Social Care advice said care homes "will be encouraged and supported to provide safe visiting opportunities". All care home residents are allowed to receive visits from friends and family during the second national lockdown. Read full story Source: Sky News, 5 November 2020
  25. News Article
    A senior judge has said friends and family can legally visit their loved ones in care homes, in an apparent challenge to recent government policy that has in effect banned routine visits in areas of high COVID-19 infection. Mr Justice Hayden, vice-president of the court of protection which makes decisions for people who lack mental capacity, said courts are concerned about the impact on elderly people of lockdowns. He has circulated a memo that sets out his analysis that regulations do “permit contact with relatives” and friends and visits are “lawful”. He was responding to guidance from the Department of Health and Social Care (DHSC) last month telling thousands of care homes in England that visiting should be stopped in areas with tier 2 and tier 3 lock down restrictions, apart from in exceptional circumstances such as the end of life. It triggered blanket prohibitions by some councils and sparked anguish from relatives who warn a lack of contact is leading to misery and early death in some cases. Within a week, Gloucestershire county council told care homes in its area to stop visits until next spring. With the England-wide lockdown starting on Thursday, care home providers, families and groups including Age UK and Alzheimer’s Society, have called on ministers to this time make clearer provisions for visiting. Hayden said exceptions in the existing regulations mean contact with residents staying in care homes is lawful for close family members and friends. He said the court of protection was concerned about “the impact the present arrangements may have on elderly people living in care homes,” citing their suffering. Read full story Source: The Guardian, 2 November 2020

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