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Showing results for tags 'Skills gap'.
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News Article
Managers are being ‘re-educated’ after losing skills, says Mackey
Patient Safety Learning posted a news article in News
Managers are having to be “re-educated” after losing skills in recent years, the chief executive of NHS England has said. Speaking at the Medical Journalists’ Association’s annual lecture on Thursday, Sir Jim Mackey was asked whether he was satisfied with the calibre of managers in the NHS. He said “generally people that work in the NHS really care about what they do” and that managers were working in highly challenging circumstances, and often in “really horrible jobs where all the risk is managed”. But he also acknowledged a concern expressed by other NHS leaders that many managers had become “deskilled at some things”, in part due to the coronavirus pandemic and how systems have worked in the recovery period since then. Sir Jim said: “We are having to re-skill [and] train people again in things like waiting list management, some stuff on flow and ED management, those sorts of things. “So, they are being rebuilt, and people are being re-coached and re-educated.” Read full story (paywalled) Source: HSJ, 9 May 2025- Posted
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The NHS workforce has gone through shifts and rebalances of roles since the service began. In recent years there has been a rebalancing through expanding other roles, such as advanced practitioners and physician associates. This report, commissioned by NHS Employers, reviews the evidence around introducing these new roles and offers lessons for implementation.- Posted
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In 2012, I could not have imagined that the greatest threat my husband faced in the hospital was not the brain bleed we came in to treat — but one of the most common post-surgical complications, venous thromboembolism (VTE). This deadly blood clot was growing in my husband, and no one on his care team knew it. In a few days, it would travel to his lungs and kill him. Simple steps, like a risk assessment and monitoring, could have been taken. However, these proven preventative measures were not taken. Vonda Vaden Bates, a patient safety advocate, shares her story.- Posted
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News Article
Plea to blur line between doctors and nurses amid NHS staff crisis
Patient Safety Learning posted a news article in News
The NHS staffing crisis will be solved only if doctors and nurses get more flexible about their job descriptions and break down barriers between roles, according to Rishi Sunak’s health adviser. Bill Morgan argues that training times for doctors and nurses may have to be reduced, and suggests developing “sub-consultants” and entirely new medical professions, He wants ministers to create an Office for Budget Responsibility-style body to predict future workforce needs. The Treasury has held down the numbers of doctors and nurses Britain trains to prevent “supply-induced demand”, which encourages people to seek appointments that are not needed, Morgan argues. Chronic shortages of qualified staff are the biggest problem facing the health service, which has more than 130,000 vacancies. Morgan acknowledges that this means “some of the government’s key manifesto commitments will not be met”, citing the promise of 6,000 extra GPs. Sunak said this week that the government was “thinking creatively about what new roles and capabilities we need in the healthcare workforce of the future”. He urged the NHS to shed “conventional wisdom”. Read full story (paywalled) Source: The Times, 24 November 2022 -
News Article
Almost 38,000 mental health appointments miss vital 72-hour window
Patient Safety Learning posted a news article in News
Nearly 38,000 vital follow-up appointments with mental health patients were missed at the time when they were most at risk of suicide, the Royal College of Psychiatrists has said. The medical body has called for “urgent action” to ensure more people are seen for follow-ups within 72 hours of their discharge from inpatient care, to prevent them from falling “through the cracks when they are so vulnerable”. The risk of suicide is highest on the second and third days after leaving a mental health ward, but 37,999 follow-up appointments with patients were not made within this timeframe in England between April 2020 and May 2022. According to NHS data, of the 160,430 instances when patients were eligible for follow-up care within 72 hours after discharge from acute adult mental health care, only three-quarters (76%) took place within that period. The Royal College of Psychiatrists is calling for more trained specialists to check on those perceived to be at risk, which they say requires more staffing and funding. The president of the Royal College of Psychiatrists, Dr Adrian James, said: “We simply can’t afford to let people fall through the cracks at a time when they are so vulnerable. It’s vital that our mental health services are properly staffed and funded to offer proper follow-up care and help prevent suicides. “Staff are working as hard as they can to provide high-quality care, but it’s clear that current resources are not enough to meet these targets. We need urgent action to tackle the workforce crisis and achieve the suicide prevention goals set out in the NHS long-term plan.” Read full story Source: The Guardian, 22 August 2022- Posted
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News Article
One in 25 heart attack deaths in north-east of England ‘preventable in London’
Patient Safety Learning posted a news article in News
One in 25 people who die of a heart attack in the north-east of England could have survived if the average cardiologist effectiveness was raised to the London level, research shows. The research, undertaken by the Institute for Fiscal Studies (IFS), looked at the record of over 500,000 NHS patients in the UK, over 13 years. It highlights the stark “postcode lottery” of how people living in some parts of the country have access to lower quality healthcare. The results found that while cardiologists treating patients in London and the south-east had the best survival rates among heart attack patients, patients being treated in the north-east and east of England had the worst. Among 100 otherwise identical patients, an additional six patients living in the north-east and east of England would have survived for at least a year if they had instead been treated by a similar doctor in London. Furthermore, if the effectiveness of doctors treating heart attacks in these areas of the country were just as effective as the cardiologists in London, an additional 80 people a year in each region would survive a heart attack. The research also revealed a divide between rural and urban areas of England, with patients living in the former typically receiving treatment from less effective doctors compared with those in more urban areas. Read full story Source: The Guardian, 9 August 2022- Posted
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News Article
Over 47,000 stroke patients to ‘miss out on a miracle treatment’
Patient Safety Learning posted a news article in News
A new report by the Stroke Association released today warns that, if the thrombectomy rate stays at 2020/21 levels, 47,112 stroke patients in England would miss out on the game changing acute stroke treatment, mechanical thrombectomy, over the length of the newly revised NHS Long Term Plan. This year, NHS England missed its original target to make mechanical thrombectomy available to all patients for whom it would benefit – only delivering to 28% of all suitable patients by December 20212. The Stroke Association’s ‘Saving Brains’ report calls for a 24/7 thrombectomy service, which could cost up to £400 million. But treating all suitable strokes with thrombectomy would save the NHS £73 million per year. Stroke professionals quoted in the report cite insufficient bi-plane suites, containing radiology equipment, as a barrier to a 24/7 service. The Stroke Association is calling for: The Treasury to provide urgent funding for thrombectomy in the Autumn Budget 2022, for infrastructure, equipment, workforce training and support, targeting both thrombectomy centres and referring stroke units. Department of Health and Social Care to develop a sustainable workforce plan to fill the gaps in qualified staff. NHS England to address challenges in transfer to and between hospitals in its upcoming Urgent & Emergency Care Plan. Putting innovation - such as artificial intelligence (AI) imaging software and video triage in ambulances - into practice. Juliet Bouverie, Chief Executive of the Stroke Association said: “Thrombectomy is a miracle treatment that pulls patients back from near-death and alleviates the worst effects of stroke. It’s shocking that so many patients are missing out and being saddled with unnecessary disability. Plus, the lack of understanding from government, the NHS and local health leaders about the brain saving potential thrombectomy is putting lives at risk. There are hard-working clinicians across the stroke pathway facing an uphill struggle to provide this treatment and it’s time they got the support they need to make this happen. It really is simple. Thrombectomy saves brains, saves money and changes lives; now is the time for real action, so that nobody has to live with avoidable disability ever again." Read full story Source: The Stroke Association, 28 July 2022 -
News Article
Watchdog warns over medication risk to vulnerable
Patient Safety Learning posted a news article in News
Vulnerable patients cared for in secure mental health units across England could miss out on vital medications due to a shortage of learning disability nurses, the Healthcare Safety Investigation Branch (HSIB) has warned. The report into medication omissions in learning disability secure units across the country highlights problems with retaining learning disability nurses, with the number recruited each year matching those leaving. Figures quoted in the report suggest the number of learning disability nurses in the NHS nearly halved from 5,500 in 2016 to 3,000 in 2020. The HSIB launched a national investigation after being alerted to the case of Luke, who spent time in NHS secure learning disability units but was not administered prescribed medication for diabetes and high cholesterol on several occasions. At Luke’s facility, which included low and medium secure wards, HSIB investigators considered that the quality and style of care provided to patients had been directly impacted by a lack of nurses with required skill sets. Findings from HSIB’s wider national investigation link a shortfall of learning disability nurses to instances of patients missing their medication, with the report’s authors describing a “system in which medicines omissions were too common and prevention, identification and escalation processes were not robust”. Read full story (paywalled) Source: HSJ, 23 June 2022- Posted
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Only half of healthcare professionals feel they have sufficient tools to manage the long-term damage that sickle cell disease brings, new research has revealed. The in-depth study by Global Blood Therapeutics - carried out across 10 countries including the UK, US and Canada - shows that patients living with the illness remain dramatically underserved by healthcare systems, while healthcare professionals don’t feel like they have the knowledge of the disease or their patients, to properly treat them. More than two in five (43%) doctors and nurses cited difficulties due to having different ethnic backgrounds from their patients, it was revealed, while almost three quarters (73%) stated patients of lower economic status can be more difficult to treat. Almost a third of healthcare professionals (31%) found it challenging to understand their patients’ needs. Sebastian Stachowiak, Head of Europe and GCC at Global Blood Therapeutics, told The Independent that the survey “confirms the lack of options for physicians” and expressed hope that, with recent advances in available treatment, patients can be better served in the future. The study also found that almost half (46%) of patients say that emergency room healthcare providers did not believe them about their symptoms, while 48% said that they have been treated like a drug seeker in the emergency room. Read full story Source: The Independent, 14 June 2022- Posted
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News Article
Two health watchdogs have issued safety warnings after junior staff were left to work unsupervised on maternity wards previously criticised after a baby’s death. Training regulator, Health Education England (HEE), criticised the “unacceptable” behaviour of consultants who left junior doctors to work without any superiors at South Devon and Torbay Hospital Foundation Trust’s wards. The maternity safety watchdog Healthcare Safety Investigation Branch (HSIB) also raised “urgent concerns” over student midwives and “unregistered midwives” providing care without supervision. The latest criticism comes after the trust was condemned over the death of Arabella Sparkes, who lived just 17 days in May 2020 after she was starved of oxygen. According to a report from December 2022, seen by The Independent, the HEE was forced to review how trainees were working at the trust’s maternity department after concerns were raised to the regulator. It was the second visit carried out following concerns about the department, and reviewers found there had been “slow progress” against concerns raised a year earlier. Read full story Source: The Independent, 16 February 2023- Posted
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Content Article
Pulmonary embolism is the third most common cause of cardiovascular death worldwide after stroke and heart attack. Although life-threatening, when diagnosed promptly survival rates are good. This report, authored by risk expert Tim Edwards and published by Patient Safety Learning, highlights serious and widespread patient safety concerns relating to the misdiagnosis of pulmonary embolisms. Drawing on existing data, freedom of information requests and his mother’s case, he outlines nine calls for action to improve pulmonary embolism care. Key findings from the report: There were 400 excess deaths attributable to pulmonary embolism misdiagnosis from March 2021 to April 2022 in England and Wales. In parts of England and Wales the number of deaths due to pulmonary embolism were almost 3 times the national average. The clinical guidelines and diagnostic processes used in England and Wales are out of step with our European counterparts and, in Jenny’s case, were not used correctly. Clinical teams too often lack the training, expertise and/or equipment to deliver safe and effective pulmonary embolism care. Commenting on the report, Tim Edwards said: "My research found that there are hundreds of people who, like my mother Jenny, died from pulmonary embolism following misdiagnosis. It's vital we learn from these deaths, and the errors that have occurred, so we can take action to improve pulmonary embolism care. By publishing this report, I hope to start a dialogue that leads to positive change, so others do not suffer the loss of a loved one as we have." Helen Hughes, Chief Executive of Patient Safety Learning said: “This new report highlights serious patient safety concerns relating to the diagnosis of pulmonary embolisms. Urgent action is now needed to ensure that guidelines and diagnostic processes are up to date and that clinicians have the resources they need to deliver safe and effective care. It is also vital that we increase awareness of the key symptoms of pulmonary embolisms among both healthcare professionals and the wider public. Patient Safety Learning are proud to be supporting Tim and his campaign for improvement in pulmonary embolism care and to reduce avoidable deaths.” Calls for action The report includes nine calls for action to improve pulmonary embolism care: 1 Raise the level of suspicion for pulmonary embolism – given a surge in PE-related deaths, greater awareness amongst frontline emergency department and other clinicians of the importance of considering the possibility of PE during their diagnostic decision-making. More general training alongside specialisms and simulation to support practice and development of decision-making skills. Could the NEWS scoring system be calibrated to consider the aggregate of scores over a 5-6 hour period is one area for further discussion. 2 Buy-in for clinical guidelines - clinical guidance is only as valuable as, firstly, its validity and there is evidence that the NHS is not applying pulmonary embolism guidance considered best practice in comparable European countries and, secondly, adherence, which is evidenced as inconsistent at best and worst, ignored. This report calls for a change, not just a review, of NICE clinical guideline NG158 covering pulmonary embolism diagnosis. 3 Avoidance of high-risk appetite - to achieve operating standards and meet financial incentives, risk appetite should not be a variable that can be compromised or amended. A compliance metric tracking whether clinical guidelines were successfully followed could be included as a diagnostic tool used as part of the Get it Right First Time (GIRFT) initiative 8 to ensure CTPA scanning for pulmonary embolism is not under-used. 4 Ensure radiology departments have the appropriate resources - so they can deliver a safe and effective service. Currently 41% of clinical radiologists do not have the right equipment 3 and the levels of scanners is less than half that in France and a quarter of that in Germany. There are also personnel shortages. There needs to be a plan in place to address these shortages. 5 National consistency, compliance and risk management - exploration of the underlying causes of regional variation, whether from differentials in resources or processes. Ensure oversight approaches/audits are suitably embedded within existing clinical governance systems. 6 Patient engagement - meaningful engagement with those affected when carrying out an incident investigation to ensure family members’ expertise is harnessed and that they are treated as partners in the learning response (where they so wish), not just in setting the terms of reference. 7 Independence - while independent authors may contribute to investigations, independent subject-matter experts are not always involved therefore undermining the integrity of any report conclusions. NHS England’s 2015 Serious Incident Framework guidelines require independent contributors to ensure objectivity and so clearly there may need to be a review of how 'contributors' is defined and how this process may better ensure lessons are being suitably learnt. 8 Knowledge sharing – effective, timely dissemination of learning from a serious incident investigation carried out in one organisation across the NHS to other organisations which may experience a similar type of PE misdiagnosis incident in the future. Ensure Clinical Knowledge Summaries providing the latest research and clinical findings are sufficiently disseminated and actioned by frontline emergency department and clinical staff in a timely fashion. 9 Public awareness – extension of existing awareness campaign advising those at risk of the symptoms to look out for and when to seek medical attention You can access the report in full via the attached PDF document below. Further reading House of Commons Debate - Pulmonary Embolisms: Diagnosis (30 November 2022) Royal College of Radiologists: Briefing for pulmonary embolism debate (November 2022) HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments (24 March 2022)- Posted
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Content Article
On 24 October 2019 coroner Lydia Brown commenced an investigation into the death of Asher William Robert Sinclair, age 3. The investigation concluded at the end of the inquest on 24 January 2022. The conclusion of the inquest was: His medical cause of death was: 1a Hypoxic ischaemic brain injury 1b out of hospital cardiac arrest 1c displaced tracheal tube (trachael tube dependant) II Neonatal enterviral myocarditis and encephalitis (trachael ventilator dependant and cardiac pacemaker). Asher died on 8th October 2019 in Great Ormond Street hospital when his life support mechanisms were withdrawn. Coroner's concerns Asher was entirely dependent upon a complex package of care as a highly vulnerable ventilator dependent child. Evidence at inquest was that on numerous occasions he was not provided with the prescribed 2:1 care. The care package, despite being described as one of the most complex and most expensive was not appropriately reviewed and there was no mandatory system of quality checks or formal review when there was a significant change in family circumstances. Quarterly reviews were not carried out without explanation. The primary responsibility fell upon the family members, namely Asher’s parents, who were also responsible for other children in the family and employed as teachers. Concerns raised by the parents were not taken for discussion to case conference or professional’s meetings and essentially not followed up at all, leaving the situation in the house dangerous with an ultimately calamitous outcome. There was a lack of scrutiny or reconciliation of Asher’s care package, which could have identified gaps that needed to be addressed. Training for the staff involved was unclear to the court and seemingly not in place or inadequate. A high turnover of staff was cited as one of the reasons, but this should have highlighted a need for increased training and scrutiny. The court was advised that new structures would be in place by July 2022. The production of this report therefore has been delayed to give the opportunity for those systems to be in place and reported to the court.- Posted
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This report details the findings of a thematic review of Safe and wellbeing reviews (SWRs) between October 2021 and May 2022. SWRs are undertaken for children, young people and adults that are autistic and/or have a learning disability who are being cared for in a mental health inpatient setting. SWRs are part of the NHS response to the safeguarding adults review concerning the tragic deaths of Joanna, Jon, and Ben at Cawston Park Hospital, who were each detained for a long period of time and did not receive appropriate care. The review found that while in many cases care and treatment were appropriate, there were a number of cases that raised specific patient safety concerns. Below is a summary of key themes from this report: Out of area placements An out of area placement occurs when a person with acute mental health needs who requires inpatient care is admitted to a unit that does not form part of the usual local network of services. This review found that there was significant variation for people who are autistic and/or have a learning disability in this regard. This was most striking in the South West of England and Midlands regions, where 73% and 68% of all placements, respectively, were out of area compared to the national average of 57%. The report notes this can have significant impacts on the person affected by this, making it more difficult for them to maintain links with family, local services, communities and clinical/social work professionals. Hospital rather than community care It found that a significant number of patients covered by SWRs did not need to be in a hospital setting to receive the right care and treatment. The national average was 41%, while in the South West of England 53% of individuals did not need to be in hospital settings. The report linked this figure to delays in discharge processes, with patients staying in hospital settings for longer than needed as a result. Concerns about the involvement of family members and carers Concerningly, the report notes that examples of poor communication with family members and carers ‘far outweighed’ examples of effective communication, including: Being excluded from planning and decisions about their loved ones. Not being provided with basic information such as how to contact family members and visiting times. Not being listened to in relation to the care and treatment of their family member, or decisions about their care and wellbeing. There was regional variation in these figures, with one particularly striking case being an Integrated Care System stating that in 39% of their safe and wellbeing reviews, family representatives either could not be contacted for the purposes of the review, they did not want to be contacted or the individual did not want them to be contacted. Advocacy Another area of concern cited was the availability and quality of advocacy for people in hospital, which the report describes as generally inconsistent. Concerns included: Family members having to step into the role of advocates in place of professional advocacy, though they are generally not trained to do so, may not know all the options available and cannot be fully independent. Some provides being resistance to creating a “culture of importance” around advocacy. Poor advocacy awareness in places, which extended to limited attempts by providers to contact advocates and proactively involve them in processes and decisions relating to individuals. Safeguarding In the 3% of cases where safeguarding concerns were raised (50 out of 1,770), serious concerns noted by the report included: Inconsistent and/or high levels of restraint, seclusion and segregation. Patients not being assessed appropriately under the Mental Capacity Act or assessments not being completed in a timely way Harms associated with weight gain during admission (increasing the likelihood of health problems and premature mortality) and long lengths of stay. Issues associated with individuals being placed in inappropriate settings (for example, mixed-gender wards), the absence of CCTV in inpatient settings, issues with staff attitudes and relationships. Low quality and inconsistent of incident reporting. Inappropriate and inconsistent use of medication. The review also said that one region noted that safeguarding referrals were not always made appropriately, and plans were not always implemented to prevent the incidents from happening again. Physical health The report notes that it found multiple references to individuals with a high body mass index and significant weight gain following people being admitted to hospital, including instances where this led to people developing diabetes. This was a key area of concern also raised in the Cawston Park safeguarding adults review. Individual wellbeing and positive mental health The report noted that in many mental health inpatient settings there were not enough activities for people to do and not enough done to help maintain social connections. It noted that meaningful activities were not consistently available and, where they were, were not always age-appropriate, co-planned and person-centred. Workforce The report noted a number of workforce issues, including: Families and advocates raised concerns about whether wards were unsafe when there were significant staff shortages on them. Staff burnout. Heavy reliance on agency and/or temporary staff which can have negative impacts on patients being able to access regular activities and on patient-staff relationships. Reports of staff not having the appropriate training or skillset to effectively meet the needs of individuals. Conclusions and next steps Throughout the report there are a number of sections detailing ‘key considerations’ for providers and Integrated Care Systems, though no specific actions. It notes towards the end of the report that following on from this, NHS England, on a national and regional footprint, working with people with lived experience, family carers, integrated care boards, providers and commissioners, will bring partners together to look at specific actions that will address the challenges and themes highlighted through this thematic review over the next 12 months.- Posted
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In a blog for National Voices, the leading coalition of health and social care charities in England, Patient Safety Learning’s Chief Executive Helen Hughes discusses an independent report written by risk expert Tim Edwards that highlights serious and widespread safety concerns around the misdiagnosis of pulmonary embolism. In this blog Helen discusses how Patient Safety Learning is working with Tim Edwards to raise awareness of the findings of his report, and its associated nine calls for action, to help improve pulmonary embolism outcomes. Read the full blog on the National Voices website. Related reading Independent review of pulmonary embolism fatalities in England & Wales – recent trends, excess deaths, their causes and risk management concerns (December 2022, Tim Edwards) Jenny, and why we must learn from her misdiagnosis of pulmonary embolism Pulmonary embolism misdiagnosis – a systemic problem (Tim Edwards, 4 January 2023) House of Commons Debate - Pulmonary Embolisms: Diagnosis (30 November 2022) Royal College of Radiologists: Briefing for pulmonary embolism debate (November 2022) HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments (24 March 2022)- Posted
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Jenny Edwards died in February 2022 from pulmonary embolism, following misdiagnosis. In this blog, her son Tim introduces us to Jenny, illustrating the deep loss felt following her premature passing. He talks about the care she received and argues that there were multiple points at which pulmonary embolism should have been suspected. Tim found the investigation that followed Jenny’s death to be lacking in objectivity and assurance that any learning could be taken forward. He has since produced an independent report, drawing on existing data, freedom of information requests and his mother’s case, to highlight broader safety issues. Jenny, my mother Jenny was a much-admired mother, grandmother and friend. She had a strong determination and an uplifting zest for life; she was loyal and we, her family, miss her. Her passions were many, from her love of travel to places of geographic interest, to line-dancing and amassing a curious Tupperware collection. Jenny attended university in the 1960s, a time when women from her background were discouraged from attending further education. Having graduated, Jenny then worked for British Leyland and later moved to Germany with my father where she taught English. During which time she had me. Jenny returned alone with me to England in 1985, to no home or job. Her ability and determination ensured she quickly got a teaching role, then a home – she subsequently taught GCSE and A-Level for 27 years at Lewes Old Grammar School, living in the Brighton area that she called home. Unfortunately, my mother, Jenny, passed away prematurely from a pulmonary embolism in February 2022 following misdiagnosis. I am seeking to help derive a positive learning from her death and, unfortunately, many other similar recent cases. While she was 74, an extra 5 or 10 years would have made a great difference to our family – it has deprived my mother of time with her first grandchild, my daughter, who was born just weeks earlier in January 2022. A catalogue of errors taking away valuable years’ left of life Jenny, my mum, should likely not, medically speaking, have passed away on Sunday 27 February 2022 of a pulmonary embolism – a blood clot in her vein passing to her lung causing heart failure. Studies indicate that the death rate for diagnosed and treated pulmonary embolism is 8%.[1] She had never smoked in her life, exercised regularly and all had appeared well with her health at the start of 2022. She had received a letter from her GP granting her travel insurance that would have allowed her to travel to the Greek Islands and, later in the year, to the Baltic countries. In early February, despite exhibiting risk factors and sudden symptoms, including fainting and collapse, my mother was wrongly misdiagnosed in the care of an emergency department as having had a heart attack. She was then needlessly fitted with a stent. Upon her discharge from hospital her condition got worse again at home – she was dying – and yet she was reassured by a cardiac nurse who, over the phone, missed the signs of shortness of breath, chest pain (in the centre of the chest) and of fainting. The nurse advised that if the symptoms continued that my mother should call her GP. My mother never made her GP appointment. I don’t want this to continue to happen to other family’s loved ones. This was entirely avoidable. Jenny was waiting in A&E for over 12 hours and there were nine independent decision-making points where at any one of these, pulmonary embolism could and should, in totality, have been diagnosed. Pulmonary embolism was only discovered in an autopsy, and yet she exhibited symptoms consistent with 90% of pulmonary embolism patients.[2] A lack of learning forcing me to act Upon my complaint to the NHS trust that oversaw my mother’s care, a Serious Incident Report was commissioned by the trust and an inquest set up. However, in my opinion, the NHS trust appears to have exhibited a ‘shrug of the shoulders, these things happen conclusion’, inhibiting sufficient learning from my mother’s case. NHS England’s 2015 Serious Incident Framework was in operation at the time of the trust’s Serious Incident Report,[3] encouraging hospital trusts to appoint independent reviewers to ensure objectivity. However, the subject-matter experts chosen to contribute to the report were all involved with the original care of my mother and, hence, objectivity of the report was lost. The frustration I feel at the loss of my mother has then been compounded by the intransigence of the NHS trust that oversaw my mother’s case, and then the discovery that my mother’s case was not alone. Indeed, far from it. Image: Tim with his wife and little girl. References Belohlavek J, Dytrych V, Linhart A. Pulmonary Embolism, Part I: Epidemiology, Risk Factors and Risk Stratification, Pathophysiology, Clinical Presentation, Diagnosis and Nonthrombotic Pulmonary Embolism. Experimental and Clinical Cardiology 2013: 18; 129-138. The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC), 2008. NHS England. Serious Incident Report Framework, 2015. Read the recently published, independent report Tim authored: Independent Review of Pulmonary Embolism fatalities in England & Wales - recent trends, excess deaths, their causes and risk management concerns Further reading Press release (Patient Safety Learning) House of Commons Debate - Pulmonary Embolisms: Diagnosis (30 November 2022) Royal College of Radiologists: Briefing for pulmonary embolism debate (November 2022) HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments (24 March 2022)- Posted
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This article by Katherine Virkstis, Managing Director of the US health thinktank Advisory Board, looks at the growing problem of a nursing 'skills gap' in the US. She argues that this area is often overlooked, but needs to be tackled to ensure patients are safe. A recent boom in new nurses graduating means that the balance of the nursing workforce is now less experienced than it has previously been. The growing complexity of patients and care approaches in healthcare systems also means that the demand for highly-trained nurses with specific skills has increased. The author explains this as a widening 'experience-complexity gap' and suggests four strategies to close the gap: Bolster emotional support and show staff your own vulnerability as a leader Dramatically scope the first year of practise Differentiate practice for experienced nurses Reinforce experienced nurses' identity as system citizens- Posted
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News Article
Blackpool death: Abortion sepsis risk training inadequate
Patient Safety Learning posted a news article in News
Doctors are receiving "inadequate" training about the risk of sepsis after a mother-of-five died following an abortion, a coroner has warned. Sarah Dunn, 31, died of "natural causes contributed to by neglect" in hospital on 11 April 2020, an inquest found. Assistant coroner for Blackpool and Fylde, Louise Rae, said Ms Dunn had been treated as a Covid patient even though the "signs of sepsis were apparent". Her cause of death was recorded as "streptococcus sepsis following medical termination of pregnancy". In her record of inquest, the coroner noted Ms Dunn was admitted to Blackpool Victoria Hospital in Lancashire on 10 April 2020. She was suffering from a streptococcus infection caused by an early medical abortion on 23 March, which had produced sepsis and toxic shock by the time she was admitted to hospital. The coroner said "signs of sepsis were apparent" before and at the time of Ms Dunn's hospital admission but she was instead treated as a Covid-19 patient. "Sepsis was not recognised or treated by the GP surgery, emergency department or acute medical unit and upon Sarah's arrival at hospital, the sepsis pathway was not followed," she added. Read full story Source: BBC News, 19 May 2022- Posted
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Heart surgery patients in London have died “unnecessarily” and faced increased risk of death as botched NHS investigations into dozens of deaths reduced a hospital’s ability to treat people, a coroner has warned. “Unnecessary” patient deaths have occurred as a result of heart surgery at St George’s University Hospital Trust being restricted and emergencies diverted to other “over stretched” hospitals, following investigations by national NHS bodies. The warning that deaths have occurred and may occur in the future, comes following the conclusion of a series of inquest hearings in March, during which it was found the NHS’ wrongly blamed a team of cardiac surgeons for the deaths of dozens of patients. Coroner Fiona Wilcox, in a report published on Wednesday, has now said the “inadequate” NHS led investigations, which criticised the care of 67 patients, led to people being put increased risk of death. The NHS’ investigations into the deaths of 67 patients ruled there were “shortcomings” in care. It led to complex operations being diverted elsewhere and doctors being referred to the General Medical Council. Two doctors have sinced been exonerated following GMC hearings. According to the coroner’s findings, capacity within cardiac surgery at the unit is down by 60% and staff are becoming “deskilled.” Read full story Source: The Independent, 11 May 2022- Posted
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News Article
NHS management overly ‘task focused’, government review finds
Patient Safety Learning posted a news article in News
NHS management and leadership are overly ‘task focused’, according to briefings by the senior military leader who has carried out a major review of health and care for the government. General Sir Gordon Messenger has nearly completed the work, which had been due to be published shortly before Easter but was delayed by the government, and has briefed several senior leaders on several of his main observations. According to several senior figures, he has said NHS management and leadership are heavily “task focused” — a management term referring to an approach devoted to completing certain tasks or meeting certain short-term objectives; in contrast to an approach which focuses on people, relationships or skills. HSJ has spoken to several senior sources who have been briefed on Sir Gordon’s findings so far. One said the former military figure had observed that “NHS leadership is… very focused on getting things done, and not focused enough on how things get done – which I think is very fair if you think particularly what the last 10, 15 years have been like”. Another finding, according to those briefed, is the need for better support for NHS leaders running the most difficult local organisations, including providing what has been described as “support packages”. Read full story Source: HSJ, 26 April 2022- Posted
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Care home resident died after unqualified nurse administered wrong medication
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A nurse with no qualifications gave a care home resident a fatal dose of the wrong drug, leading to her death before she then tried to cover up her mistake. Katherine Hutchinson gave Fiona Jayne Thorne a fatal overdose of a powerful anti-psychotic drug, which was meant for another patient, an inquest heard. She then tried to cover up her errors which contributed to the death of the 36-year-old with learning difficulties, Derbyshire Live reported . Ms Hutchinson had, at the time, been the nurse in charge at Whitwell Park Care Home, in Whitwell, Derbyshire despite not having any qualifications. She gave Miss Thorne clozapine, which had been intended for another resident, on October 6, 2010. Instead of owning up to what she did, Ms Hutchinson then tried to cover up her mistake by taking Miss Thorne to bed and leaving her there until she was discovered, Senior Coroner Dr Robert Hunter said. Miss Thorne was "found by the care support worker around midnight, when undertaking routine checks on residents”, the inquest heard. And then Ms Hutchinson’s mistake was only discovered after an audit was carried out of the medication trolley and a dosage of clozapine was found. Read full story Source: Mirror, 8 April 2022- Posted
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Hospital inspectors have uncovered repeated maternity failings and expressed serious concern about the safety of mothers and babies in Sheffield just days after a damning report warned there had been hundreds of avoidable baby deaths in Shrewsbury. The Care Quality Commission (CQC) found Sheffield teaching hospitals NHS foundation trust, one of the largest NHS trusts in England, had failed to make the required improvements to services when it visited in October and November, despite receiving previous warnings from the watchdog. As well as concerns across the wider trust, a focused inspection on maternity raised significant issues about the way its service is run. When it came to medical staff at the Sheffield trust, the “service did not have enough medical staff with the right qualifications, skills, and experience to keep women and babies safe from avoidable harm and to provide the right care and treatment”, the report said. Inspectors found that staff were not interpreting, classifying or escalating measures of a baby’s heart rate properly, an issue that was raised by Donna Ockenden in her review of the Shrewsbury scandal. Despite fetal monitoring being highlighted as an area needing attention in 2015 and 2021, the most recent inspection “highlighted that the service continued to lack urgency and pace in implementing actions and recommendations to mitigate these risks, therefore exposing patients to risk of harm”. Read full story Source: The Guardian, 5 April 2022 -
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Learning disability training for all nurses set to be mandated in law
Patient Safety Learning posted a news article in News
Members of the House of Lords have passed an amendment to the Health and Care Bill to enshrine mandatory training for health and care staff on learning disabilities and autism in law. The Oliver McGowan Mandatory Training in Learning Disabilities and Autism programme is being developed by Health Education England in partnership with organisations such as Skills for Care and the Department of Health and Social Care, and alongside Oliver’s family. “It means that organisations have no choice but to free up their staff to attend this training” The training is named after Oliver whose death shone a light on the need for health and social care staff to have better training on learning disabilities and autism, and has been campaigned for by his parents Paula and Tom McGowan who believe his death was avoidable. The 18-year-old, who had mild hemiplegia, focal partial epilepsy, a mild learning disability and high-functioning autism, died in November 2016 after he was given antipsychotic medication even though he and his family warned it could be harmful to him. Following campaigning efforts and a consultation on training proposals for health and care staff, in November 2019, the government committed to developing a standardised training package. It draws on existing best practice, the expertise of people with autism, people with a learning disability and family carers and subject matter experts. Read full story Source: Nursing Times, 18 March 2022- Posted
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Staff failed to provide kind and compassionate care and did not treat children with respect at a private hospital downgraded from ‘good’ to ‘inadequate’, a report by health inspectors has revealed. Huntercombe Hospital Stafford was placed in special measures in 2016, but was rated “good” by the Care Quality Commission two years later. Now, its first inspection under provider Huntercombe Young People Ltd in October 2021 has exposed a raft of safety concerns and instances of poor care. Huntercombe Young People Ltd took over the service in February 2021. Heavy reliance on agency staff, workers spotted with their “eyes closed” on observations, and staff not respecting young people’s pronouns were among concerns inspectors flagged. Staff observation of patients was also found to be “undermined” by a blind spot where people could self-harm unseen, the CQC report, published today, said. Children also told the CQC they felt staff did not always understand their mental health condition or know how to support them, particularly those on the psychiatric intensive care ward with eating disorders or autism. Read full story (paywalled) Source: HSJ, 10 March 2022- Posted
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Resident died after treatment at failing care home
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A resident at an inadequate care home died after their blood glucose increased to high levels and staff acted too slowly, a report found. Inspectors said The Berkshire Care Home in Wokingham breached guidelines in nine areas and must improve. They found residents were put at risk after medicines were not used properly and that records were not up to date. The Care Quality Commission (CQC) said an ambulance was only called for the person who died when they were found to be unresponsive. They later died in hospital. Its report said staff were "not sufficiently skilled" to safely care for people with diabetes. A resident was given paracetamol and co-dydramol eight times over three days, when they should not be used together because they both contain paracetamol, the report said. Another person was burned by a cup of tea and staff did not treat the injury properly, leading to the person developing an infection and later being admitted to hospital. Staff sometimes felt "rushed and under pressure", the report found. Read full story Source: BBC News, 18 December 2021- Posted
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A hospital trust has been told to "immediately improve" its maternity and surgical services. The Care Quality Commission (CQC) made unannounced inspections in September and October at four of the hospitals run by University Hospitals Sussex NHS Foundation Trust. Inspectors raised concerns about staff shortages, skills training and risk management. At the trust's four maternity services, inspectors found departments "did not have enough staff to keep women and babies safe" and staff were "not up to date" with training. Infection prevention measures in surgical services at the Royal Sussex County Hospital were "not consistently applied" and managers were not running services well, inspectors noted. The report also said morale was low and often staff "did not have time to report incidents". The trust said it has taken "urgent action" to make improvements. Read full story Source: BBC News, 10 December 2021- Posted
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