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Found 43 results
  1. News Article
    A hospital trust in Bristol has been accused of risking lives after raising its patient-to-nurse ward ratio to dangerously high levels, having allegedly dismissed staff concerns and national guidance on safe staffing. University Hospitals Bristol and Weston NHS Foundation Trust (UHBW) has introduced a blanket policy across its hospitals that assigns one nurse to 10 patients (1:10) for all general adult wards. This ratio, which previously stood at 1:6 or 1:8 depending on the ward, rises to 1:12 for nights shifts. The new policy, which is applicable to Bristol Royal Infirmary (BRI) and Weston General Hospital, also extends to all specialist high-care wards, which treat patients with life-threatening conditions such as epilepsy and anaphylaxis. Nurses at the trust have expressed their anger over the decision, saying they were never fully consulted by senior officials. Many are fearful that patient safety will be compromised as the second coronavirus wave intensifies, culminating in the unnecessary loss of life. “Patients who would have extra nursing staff because they are very acutely unwell and need close observation I think are going to unnecessarily die,” one nurse at BRI told The Independent. “Or if they survive, they’ll suffer long-term conditions because things were missed as they don’t have the staff at their bed side to watch the deterioration.” Read full story Source: The Independent, 18 November 2020
  2. Content Article
    Problems related to the care home and the company were known well before the Panorama expose in 2016. When the Panorama programme was aired it resulted in immediate closure of one home and all the homes which were operated by Morleigh being transferred to new operators. The Review includes reports of abuse against residents; residents being left to lie in wet urine-soaked bedsheets; concerns from relatives about their loved ones being neglected; reports of there being insufficient food for residents, no hot water and no heating; claims that dozens of residents were sharing one bathroom. Here's a summary of the report's findings: More than 100 residents had concerns raised more than once. More than 200 safeguarding alerts were made for individuals but only 16 went through to an individual adult safeguarding conference. More than 80 whistleblower or similar reports were made concerning issues that put residents at risk. 44 inspections were undertaken at Morleigh Group homes in the three-year period, the vast majority identifying breaches. There was a period of at least 12 months when four of the homes had no registered manager in place. During the three-year period reviewed the police received 130 reports relating to the care homes. A spokesperson for Cornwall Council said: “We have different procedures and policies in place and have invested time, money and staffing into making sure that we can respond better when concerns are raised.'' “One of the problems was that all the partners had their own policies and procedures but they weren’t integrated. That is probably one of the key issues that we have now addressed.” “The assessment is so different now and the organisations are working much more closely that it reduces the risk dramatically.'' This is an important and long-awaited review. This situation echoes other care home scandals across the UK. I urge everyone to read the full report and reflect on the real root causes of the problem, which I believe go well beyond failings in inter-agency policies and communication. What would your action plan be? How would you monitor it?
  3. News Article
    A mental health unit where a patient was found dead has been placed into special measures over concerns about safety and cleanliness. Field House, in Alfreton, Derbyshire, was rated "inadequate" by the Care Quality Commission (CQC) following a visit in August. A patient died "following use of a ligature" shortly after its inspection, the CQC said. Elysium, which runs the unit for women, said it was "swiftly" making changes. The inspectors' verdict comes after the unit was ordered to make improvements, in January 2019. Dr Kevin Cleary, the CQC's mental health lead, said: "There were issues with observation of patients, a lack of cleanliness at the service and with staffing. "There were insufficient nursing staff and they did not have the skills and experience to keep patients safe from avoidable harm. Bank and agency staff were not always familiar with the observation policy." "It was also worrying that not all staff received a COVID-19 risk assessment, infection control standards were poor, and hand sanitiser was not available in the service's apartments." The CQC said a follow-up inspection on Monday had showed "areas of improvement" but it would continue to monitor the service. Read full story Source: BBC News, 22 October 2020
  4. Content Article
    On 1 October 2020, the Health and Social Care Select Committee published its inquiry report into ‘Delivering core NHS and care services during the pandemic and beyond’.[1] [2] Patient Safety Learning contributed to this inquiry earlier in the year with two formal submissions of evidence. The first focused on hospital discharge arrangements, in a joint submission with CECOPS.[3] In the second we looked at the impact of COVID-19 on patient safety, specifically considering non-COVIDcare and treatment.[4] For the latter, our insights on this were partly informed by a webinar we held with patients, healthcare professionals and patient safety experts.[5] We welcome the publication of today’s report, which sets out recommendations in five different areas where action is needed to ensure the safe and effective provision of health and social care services both during and after the pandemic. Communication with patients The report recognises the importance of clear communications with patients during the pandemic. It acknowledges that there have been shortcomings in this area, stating that: “… the patient experience for some has been unacceptably poor, leaving them feeling like they have been left in 'limbo' or 'in the lurch'. Unnecessary anxiety and stress has been caused to those patients due to poor communication not just from their local hospital about the scheduling of appointments or access to treatments, but from national bodies, and on key items of guidance such as on shielding.” The Committee calls on the NHS to review the guidance they provide to trusts on how to communicate with patients about treatment changes and medical guidance in the event of a further spike in COVID-19 cases. We agree with this recommendation and reflected concerns about this issue in our submission to the inquiry. We also believe the NHS needs to consider how it communicates with patients who are impacted by the pandemic backlog of treatment and care. There needs to be honest and transparent conversations with patients about how this may affect their personal circumstances. Managing the backlog of care and treatment Recognising the serious challenge that the NHS now faces in managing waiting times and a backlog of appointments resulting from the pandemic, the report considers this in more detail in the areas of elective surgery, mental health, cancer and dental services. This was also an area of focus in our submission to the inquiry, where we highlighted other areas of concern such as chronic disease management and postnatal support.[4] We have also subsequently looked in more detail at the backlog in elective surgery and the patient safety implications of this.[6] We welcome the Committee’s recommendations that the Department of Health and Social Care and NHS should set out plans to address the backlog, along with steps that will be taken in future to manage the overall level of demand across health services. Patient Safety Learning believes that a strategy is needed to tackle the demand on NHS services in a systemic way; a published strategy that will help to ensure that decisions regarding the priority of cases are made transparently and with patient safety at the forefront. Staff access to Personal Protective Equipment (PPE) and routine testing Another area of focus in the report is the protection of staff from infection during the pandemic. The Committee asks for assurances about future supplies of PPE and presses for routine staff testing of staff in health and social care. We completely agree on the importance of this issue and in our recent work for World Patient Safety Day made the case for staff safety being intrinsically linked with patient safety.[7] In terms of physical safety during the pandemic, the case for this is clear – ensuring sufficient suitable PPE is available and that staff have access to testing is essential in both limiting the risk of passing on infection to patients as well as protecting staff themselves. We also note that in discussing PPE requirements the report refers to a specific issue around problems with fitting PPE, particularly for staff from some ethnic groups. We note the Royal College of Nursing has called for equality impact assessments on PPE and fit testing and we think that this should form part of the Department of Health and Social Care response to this report. Burnout and staff wellbeing The report notes the significant impact that the pandemic has had on both the mental and physical wellbeing of staff, advising that the Committee also has launched a separate inquiry on this, 'Workforce burnout and resilience in the NHS and social care'. This is also an area we highlighted in our submission to the inquiry and we have been sharing and highlighting staff perspectives on this during the pandemic on the hub.[8] We are also using the hub to share and publicise tools to help support staff through this period, such as a set of wellbeing resources from the Scottish Patient Safety Programme. We welcome the report’s call on NHS to set out in more detail the steps it will take “to support the mental and physical wellbeing of all staff and a plan to deal with the specific issue of sustained workplace pressure due to the current pandemic and backlog associated with the coronavirus”. Learning lessons from the pandemic The final section of the report considers the fundamental changes that have been ushered into health and social care services by the pandemic, looking in more detail at the 111 dial service, technology and digital innovations, and the independent sector. It calls on the Department of Health and Social Care and the NHS to assess the effectiveness of such changes while also noting the need to “ensure patients’ wellbeing is not jeopardised by the risk of being digitally excluded from accessing medical treatment and advice”. Patient Safety Learning welcomes these recommendations. As we noted in our response to the inquiry, the pandemic has created the opportunity for innovations in health and social care that we should seize upon to improve future services. We also believe that this presents an opportunity to design new models of care and delivery with patient safety and staff safety at their core. References Health and Social Care Select Committee, Delivering core NHS and care services during the pandemic and beyond, 1 October 2020. UK Parliament, Delivering Core NHS and Care Services during the Pandemic and Beyond, Last Accessed 30 September 2020. Patient Safety Learning and CECOPS, Hospital Discharge Arrangements, 7 May 2020. Patient Safety Learning, Response to the Health and Social Care Select Committee Inquiry: Delivering Core NHS and Care Services during the Pandemic and Beyond, 8 May 2020. Patient Safety Learning, Your voice matters: how it is shaping out work in non Covid-19 care and patient and staff safety, 14 May 2020. Patient Safety Learning, The return of elective surgery and implications for patient safety, 15 June 2020. Patient Safety Learning, Why is staff safety a patient safety issue?, 3 September 2020. Claire Cox, “I know this is burnout. I didn’t want it to be. But it is.”, Patient Safety Learning’s the hub, 11 June 2020.
  5. News Article
    The mother of a former patient at a north Wales mental health unit has said she "couldn't let" her daughter "go back there" as new details about people being "neglected" there have emerged. ITV News has seen a leaked copy of the Robin Holden report from 2014. It was commissioned by Betsi Cadwaladr Health Board after staff on the Hergest mental health unit, which is situated within Ysbyty Gwynedd in Bangor, blew the whistle over management and patient safety concerns. It reveals details never before made public, about how staff struggled to care for patients. The document, which the health board has fought for six years to keep out of public view, gives an account of the death of a patient while no doctor was available because of rota gaps, another of a patient who tried to take their own life, again when no doctor was available, and inadequate staffing affecting patient care. Read full story Source: ITN News, 31 August 2020
  6. News Article
    The NHS will be unable to meet the needs of patients unless significant action is taken to tackle staff shortages, an unprecedented coalition of health leaders has warned. Medical royal colleges, NHS trade unions and bodies representing senior hospital managers and other health organisations have joined together to warn bosses at NHS England and the government that they must act to ensure the health service workforce is supported in the wake of coronavirus. The organisations said they were united in the belief that meaningful action on long-standing workforce issues would be the best way to repay the efforts of NHS staff during the virus outbreak – calling for a public commitment to boost numbers, increase flexible working, and improve leadership and support for staff. Professor Carrie MacEwen, chair of the Academy of Medical Royal Colleges, which organised the statement, told The Independent: “Continued staff shortages in the NHS will be hugely damaging for patients. It has long been recognised that there is a serious shortage of doctors and nurses and right now we need to keep the staff we have, who have done a brilliant job during the pandemic, as well as increase the size of the workforce." Read full story Source: The Independent, 7 July 2020
  7. Content Article
    Both the 2019/20 CCG and PSS CQUIN schemes comprise indicators, aligned to four key areas, in support of the NHS Long Term Plan. Patient safety Mental health Prevention of ill health Best practice pathways This document sets out the: Overview of quality and safety indicators CCG Scheme Specialised Services Scheme Scheme Eligibility and Value Rules and Guidance - Agreeing and Implementing a CQUIN Scheme
  8. News Article
    Patients are more likely to die on wards staffed by a high number of temporary nurses, a study has found. Researchers say the findings, published in the Journal of Nursing Scholarship, are a warning sign that the common practice by many hospitals of relying on agency nurses is not a risk-free option for patients. The University of Southampton study found that risk of death increased by 12 per cent for every day a patient experienced a high level of temporary staffing – defined as 1.5 hours of agency nursing a day per patient. For an average ward, this increased risk could apply when between a third and a half of the staff on each shift are temporary staff, according to Professor Peter Griffiths, one of the study’s authors. He told The Independent: “We know that patients are put at risk of harm when nurse staffing is lower than it should be. “One of the responses to that is to fill the gaps with temporary nursing staff, and that is an absolutely understandable thing to do, but when using a higher number of temporary staff there is an increased risk of harm. “It is not a solution to the problem.” Read full story Source: The Independent, 10 December 2019
  9. Content Article
    This report builds on those of previous years to provide analysis of longer-term trends and insights into the changing NHS staff profile. It focuses specifically on the critical NHS workforce issues that have been repeatedly identified in recent years: nursing shortages, and shortages of staff in general practice and primary care. The report also explores key pressure points: student nurses the international context and international recruitment retention. The report concludes by summarising the key workforce challenges that will need to be considered in the development of the full NHS people plan. Patient Safety Learning's repsonse to the report: This report on NHS workforce trends released by the Health Foundation today includes some really interesting findings, particularly around the changes in the skills mix between nurses and clinical support staff (including health care assistants and nursing assistants). The report states that in 2009/10 there were equal numbers of nurses and support staff, with one clinical support staff member for every FTE nurse in the NHS. In 2018/19, the number of support staff per FTE nurse had risen 10% to 1.1 FTE per nurse. Looking at the numbers, this translated to the NHS employing 6,500 more clinical support staff to doctors, nurses, and midwives, compared to 4,500 more FTE nurses. While changes to ratio of nurses to clinical support staff may reflect changing patient needs, technological advances and other factors, the report also notes concerns that these may be ‘introduced in an unplanned way in response to negative factors – such as cost pressures or recruitment difficulties – rather than positive drivers of improvement’. At Patient Safety Learning we believe to achieve a patient-safe future, patient safety must be more than a priority for an organisation. It must be core to its purpose, reflected in everything that it does. This should apply to the NHS when considering changes in workforce staffing and numbers so that the impact that these may have on patient safety is considered as an intrinsic part of the decision making process. While the report notes that in many cases decisions on skill mix changes are implemented well and evidence led, it’s not clear whether patient safety has been taken into account. Our view is that these decisions should involve a explicit, evidence-based assessment of the impact on patient safety which leads to the selection of the option that offers that safest outcome for patients.
  10. News Article
    A woman described as a "high risk" anorexia patient faced delays in treatment after moving to university, an inquest has heard. Madeline Wallace, 18, from Cambridgeshire, was told there could be a six-week delay in her seeing a specialist after moving to Edinburgh. The student "struggled" while at university and a coroner said there appeared to be a "gap" in her care. Ms Wallace died on 9 January 2018 due to complications from sepsis. A parliamentary health service ombudsman report into her death was being written at the time of Ms Wallace's treatment in 2017 and issues raised included moving from one provider to another and higher education. Coroner Sean Horstead said Ms Wallace only had one dietician meeting in three months, despite meal preparation and planning being an area of anxiety she had raised. Dr Hazel said she had tried to make arrangements with the Cullen Centre in Edinburgh in April 2017 but had been told to call back in August. The Cullen Centre said it could only accept her as a patient after she registered with a GP and that an appointment could take up to six weeks from that point. Read full story Source: BBC News, 10 February 2020
  11. News Article
    Hospital wards across the country are having to look after an unsafe number of patients, with hundreds of beds closed due to an outbreak of norovirus. NHS England has said that on average almost 900 beds were closed each day during the week to Sunday 15 December. Hospitals have reported fewer empty beds with bed-occupancy rates reaching as high as 95 per cent, 10 per cent higher than the recommended safe level. Read full story Source: The Independent, 20 December 2019
  12. News Article
    The first publication of data from the Royal College of Emergency Medicine’s 2019-20 Winter Flow Project shows that existing data does not reflect the true scale of the problem of 12 hour stays in A&E. RCEM data shows that in the first week of December over 5,000 patients waited for longer than 12 hours in the Emergency Departments of 50 Trusts and Boards across the UK. The sample of trusts and boards from across the UK is the equivalent to a third of the acute bed base in England. From the beginning of October 2019 over 38,000 patients have waited longer than 12 hours for a bed at the sampled sites across the UK – yet data from NHS England reports that in England alone a total of only 13,025 patients experienced waits over 12 hours since 2011-12. President of the Royal College of Emergency Medicine, Dr Katherine Henderson said: “In a nine-week period, at only a third of trusts across the UK, we’ve seen nearly three times the number of 12 hour waits than has been officially reported in eight years in England. This must be fixed." Read full story Source: Royal College of Emergency Medicine, 9 December 2019
  13. News Article
    Nearly 35,000 patients are overdue a follow-up appointment at North Lincolnshire and Goole Foundation Trust, HSJ has learned. Almost 20% of the 34,938 follow-up appointments are in ophthalmology. A paper from the trust’s November board meeting said the “backlog of follow-up appointments… clearly remains a risk”. The report also said the service was failing some of the quality guidelines set out by the National Institute for Health and Care Excellence (NICE). The trust told HSJ it had introduced a clinical harm review process last year to address the backlog. It has reviewed “more than 5,000 patients”, out of the 34,938 cases to date, according to Chief Operating Officer Shaun Stacey. He said the trust had initially identified 83 patients who could have come to “potential harm”. Read full story Source: HSJ, 28 January 2020
  14. News Article
    A major London hospital has declared a “critical incident” due to a surge in patients with coronavirus, with one senior director in the capital calling the development “petrifying”. In a message to staff, Northwick Park Hospital in Harrow said it has no critical care capacity left and has contacted neighbouring hospitals about transferring patients who need critical care to other sites. The message, sent last night and seen by HSJ, said: “I am writing to let you know that we have this evening declared a ‘critical incident’ in relation to our critical care capacity at Northwick Park Hospital. This is due to an increasing number of patients with Covid-19. “This means that we currently do not have enough space for patients requiring critical care. “As part of our system resilience plans, we have contacted our partners in the North West London sector this evening to assist with the safe transfer of patients off of the Northwick Park site” Read full story (paywalled) Source: HSJ, 20 March 2020
  15. Content Article
    Three NHS case studies (from acute care, primary care and commissioning) are described and reviewed in the light of evidence from successful organisational change in the US. Eight key features of successful leadership for patient and family centred care are outlined: Strong, committed senior leadership Active engagement of patients and families Clarity of goals Focus on the workforce Building staff capacity Adequate resourcing of care delivery redesign Performance measurement and feedback
  16. News Article
    Hospitals are having to redeploy nurses from wards to look after queues of patients in corridors, in a growing trend that has raised concerns about patient safety. Many hospitals have become so overcrowded that they are being forced to tell nurses to spend part of their shift working as “corridor nurses” to look after patients who are waiting for a bed. The disclosure of the rise in corridor nurses comes days after the NHS in England posted its worst-ever performance figures against the four-hour target for A&E care. They showed that last month almost 100,000 patients waited at least four hours and sometimes up to 12 or more on a trolley while hospital staff found them a bed on the ward appropriate for their condition. “Corridor nursing is happening across the NHS in England and certainly in scores of hospitals. It’s very worrying to see this,” said Dave Smith, the Chair of the Royal College of Nursing’s Emergency Care Association, which represents nurses in A&E units across the UK. "Having to provide care to patients in corridors and on trolleys in overcrowded emergency departments is not just undignified for patients, it’s also often unsafe.” A nurse in south-west England told the Guardian newspaper how nurses feared the redeployments were leaving specialist wards too short of staff, and patients without pain relief and other medication. Some wards were “dangerously understaffed” as a result, she claimed. She said: “Many nurses, including myself, dread going into work in case we’re pulled from our own patients to then care for a number of people in the queue, which is clearly unsafe. We’re being asked to choose between the safety of our patients on the wards and those in the queue." Read full story Source: The Guardian, 12 January 2020