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Content ArticleAs part of my quality improvement study at university, I developed and introduced an oxygen reference card that was shown to improve newly qualified clinical staffs' knowledge and confidence when using an oxygen cylinder. The project's literature review captured that clinical staff may not have the memory recall to support them in clinical practice and, therefore, a lack of embedded knowledge, which could compromise care. It is paramount that users of oxygen cylinders have the knowledge to understand how to use a cylinder safely and to understand how to assess the remedial gas in the cylinder to support oxygen administration. The study found that there is minimal training accessed to support staffs' knowledge and skill foundations for using cylinders. The outcome of the study recommended that there needs to be better support for clinical staff to use cylinders within their pre/post training to be able to using the device correctly. Introducing a oxygen reference card that they could keep on them whilst at work is a useful tool to support decision-making when using the cylinder. You can download the card from the attachment below. Both NAMDET – National Association of Medical Device Educators and Trainers and Northumbria Healthcare Facilities Management - NHS FOUNDATION supported the QI project.
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We asked the Patient Safety Group (PSG) of The Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top 10 priorities for patient safety in surgery. This resource is for surgeons, anaesthetists and other healthcare professionals who work in surgery and contains links to useful tools and further reading. See also: Safety in surgery series Top 10 tips for surgical safety: ‘Think Safety, think SEIPS’ Top 10 patient safety tips for surgical trainees 1. Foster a culture of safety through design Establish a psychologically safe environment, through design, where staff feel empowered to speak up without fear of blame. Promote a Just Culture, balancing personal accountability with systems-based learning from adverse events and near misses. Actively encourage multidisciplinary teamwork and peer support, with support from senior leadership, to enhance safety and well-being. Other useful RCSEd resources: Anti bullying and undermining campaign Sexual misconduct in surgery - Lets remove it campaign Addressing conflict in surgical teams workshop 2. Implement team-based quality and safety reviews Use team-based quality reviews (TBQRs) and structured case analysis to learn from everyday work, incidents and near misses. Translate findings into sustainable improvement initiatives that enhance both patient outcomes and staff experience. Foster a culture of collective learning, ensuring safety insights lead to actionable change. Other useful RCSEd resources: Making sense of mistakes workshop 3. Apply Human Factors principles and systems thinking principles in surgical and clinical practice Design resilient systems that mitigate work and cognitive overload and enhance performance reliability. Use TBQR principles to support this. Standardise workflows, optimise usability of IT systems and medical devices, and integrate cognitive aids (e.g. WHO Safe Surgery Checklists, prompts). Ensure governance processes support safe, efficient and user-friendly surgical environments. Other useful RCSEd resources: Systems safety on surgical ward rounds Improving the working environment for safe surgical care Improving safety out of hours 4. Enhance communication & handover processes Implement structured communication tools such as SBAR (Situation, Background, Assessment, Recommendation) to improve clarity and effective decision-making. Optimise handover processes with digital tools, checklists and standardised documentation. Reinforce closed-loop communication, ensuring critical information is confirmed and acted upon. Other useful RCSEd resources: Consultation Skills that matter for Surgeon (COSMOS) 5. Strengthen leadership & accountability in patient safety Senior leaders must visibly support safety initiatives and proactively engage frontline staff in decision-making. Embed structured mechanisms for raising concerns, including TBQR, safety huddles and escalation pathways. Ensure staff have access to training, resources and protected time for safety and quality improvement work. 6. Minimise medication errors in surgery Implement electronic prescribing and technology assisted medication administration to mitigate errors. Enforce double-check procedures for high-risk medications and standardised drug labelling. Improve intra and peri-operative medication safety with clear labelling, colour-coded syringes and real-time verification. 7. Improve early recognition & response to deterioration Appropriate regular training of teams on processes and pathways supported by good design of staff rota ensuring adequate staffing levels. Implement early warning scores and establish rapid response pathways for deteriorating patients. Standardise post-operative surveillance strategies, ensuring timely escalation and intervention. Other useful RCSEd resources: Recognition and prevention of deterioration and injury (RAPID) course for training in recognising critically ill patients 8. Engage patients & families as safety partners Encourage shared decision-making to align treatment plans with patient expectations and values. Provide clear communication on risks, benefits and post-operative care, using tools like patient safety checklists and focus on informed consent processes. Actively involve patients and families in safety and quality initiatives and hospital discharge planning. Other useful RCSEd resources: Patient/carer/families resources and information Informed consent courses (ICoNS) 9. Standardise, simplify & optimise surgical processes Reduce unnecessary complexity in clinical workflows, making processes intuitive, efficient and reliable. Co-design standard operating procedures, policies and pathways with frontline teams to minimise variation. Implement automation and digital solutions where feasible to streamline repetitive tasks. Other useful RCSEd resources: NOTSS (Non Operative Technical Skills for Surgery) courses for surgeons DenTS courses for dentists 10. Promote continuous learning & simulation-based training Conduct regular simulation training for critical scenarios (e.g. sepsis, airway emergencies, human factors). Use insights from TBQR and incident reviews to target training needs and refine clinical practice. Ensure ongoing professional development by providing staff with time, resources, incentives and institutional support for learning. Other useful RCSEd resources: Education pages Edinburgh Surgery OnLine MSc in Patient Safety and Clinical Human Factors -
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The Royal College of Surgeons of Edinburgh (RCSEd) have drawn up their top 10 tips for surgical safety using the SEIPS (Safety Engineering Initiative for Patient Safety) model. Click on image to enlarge or download from the attachment below: See also: Safety in surgery series Top 10 priorities for patient safety in surgery Top 10 patient safety tips for surgical trainees- Posted
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Content Article
Safety in surgery series
Patient Safety Learning posted an article in Surgery
Patient Safety Learning asked the Patient Safety Group (PSG) of the Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top tips for patient safety in surgery to share on the hub. They came up with three useful resources for surgeons and surgical trainees: Top 10 priorities for patient safety in surgery Top 10 tips for surgical safety: Think Safety, think SEIPS Top 10 patient safety tips for surgical trainees In this blog, Anna Paisley, Consultant Upper GI Surgeon and RCSEd Council Member and Chair of the PSG, reflects on the process her and the team went through to collate these patient safety resources. We hope you find these resources useful. When asked to do this by Patient Safety Leaning, we were delighted to contribute. However, what seemed initially to be a straightforward task, turned out to be rather challenging. Patient safety covers such a vast area, and it proved very difficult to select only 10 key tips. Each member of the multi-disciplinary surgical team will have a slightly different outlook and perspective; the safety principles most important to their specific practice will inevitably vary. No one size fits all. Each member of the PSG had a slightly different set of tips based on their experience, skill set and discipline. All submissions were of course valid and we thought it would be helpful to include the three main approaches. 1 Top 10 priorities for patient safety in surgery Manoj Kumar, Consultant General and Upper GI Surgeon in Aberdeen, PSG Educational Lead and Convenor of the RCSEd Team Based Quality Review workshop, spearheaded a comprehensive set of patient safety tips for surgery aimed primarily for surgical patient safety leaders. His strong belief is that improving patient safety in surgery requires more than isolated interventions—it demands a sustained cultural and systemic shift. His top 10 priorities are grounded in evidence-based practice and real-world experience, recognising that safer care emerges when we design systems that support people to do the right thing, every time. This approach combines Human Factors principles, team-based quality reviews and learning, psychological safety as well as leadership engagement to drive improvement from the ground up. It moves beyond reactive fixes to proactive action, reduces unwarranted variation and enables learning across all levels of the organisation. By embedding these principles into daily practice, surgical teams can move toward high reliability environments and deliver safer, more effective care for every patient. 2 Top 10 tips for surgical safety: ‘Think Safety, think SEIPS’” When asked to give her top 10 tips for patient safety in surgery, Claire Morgan, Consultant in Restorative Dentistry, PSG Deputy Chair and Member of RCSEd Dental Council, chose to structure her response using Carayon’s Systems Engineering Initiative for Patient Safety (SEIPS). The SEIPS framework allows us to consider any patient safety issue or question using a systems-based approach. This affords a broad view, including application of a Safety 2 thinking; i.e. why do things normally go well. From Claire’s personal perspective, ’Think Safety, Think SEIPS’ ensures a constant recheck of all factors that might contribute to any patient safety incident. SEIPS is a relatively simple tool to use with consideration of six contributory systems to patient safety: tasks tools and technology person organisation internal environment external factors. However, it does not stop there, as it is the interaction between all these systems and then processes that determines outcomes. This approach produced a visual map demonstrating the complexity of the socio-technical systems involved in surgical safety from a human factors perspective. 3 Top 10 patient safety tips for surgical trainees As a consultant Upper Gastro-intestinal surgeon from Edinburgh, RCSEd Council Member and PSG Chair, I compiled a simple list with trainee members of the surgical team in mind. Introducing key patient safety principles early in a training pathway is crucial to helping develop an appropriate patient safety culture in any workplace. I wanted to highlight the principle that patient safety is everyone’s responsibility, and not just that of the quality improvement team. I also wanted to emphasise the crucial point that all members of the team have an important voice and should feel empowered and able to speak up if they feel something is not right. So, the RCSEd PSG have used three separate approaches in defining our top ten tips for patient safety in surgery. I hope that you find them useful and that one will resonate with you from your own individual perspective. Share your resources and top tips What more is needed to support surgeons and trainees? Do you have a tool or policy, a personal reflection, peer-reviewed literature that we could share and highlight on the hub. What other top tips would be useful to surgeons, students and patients? Share your ideas in the comments below (you will need to be a hub member, sign up is free and easy) or contact our editorial team at [email protected].- Posted
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EventAimed at Clinicians and Managers, this national virtual conference will provide a practical guide to human factors in healthcare, and how a human factors approach can improve patient care, quality, process, and safety. The conference delves into integrating human factors into healthcare systems and processes, clinical decision making, healthcare system design, quality of patient experience, medication safety, and workload, fatigue, and stress management. Throughout the day there will be interactive sessions, small breakout groups, and collaborative exercises, fostering a dynamic learning experience. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/a-practical-guide-to-human-factors-in-healthcare or email [email protected] Complementary free places for hub members. Please use code hcuk00psl when booking
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News Article
GMC approves 36 courses to teach more than 1,000 NHS physician associates
Patient Safety Learning posted a news article in News
More than 1,000 physician associates (PAs) could begin their careers in the NHS every year after regulators approved dozens of courses to teach them. The General Medical Council (GMC) said it had given 36 courses formal approval to teach PAs and anaesthesia associates (AAs). Overall, these courses had capacity for up to 1,059 PAs and 42 AAs to qualify each year. The GMC said approving training courses would mean that “patients, employers and colleagues can be assured that PAs and AAs have the required knowledge and skills to practise safely once they qualify”. Prof Colin Melville, the GMC’s medical director and director of education and standards, said: “This is an important milestone in the regulation of PAs and AAs and will provide assurance, now and in the future, that those who qualify in these roles have the appropriate skills and knowledge that patients rightly expect and deserve. “As a regulator, patient safety is paramount, and we have a robust quality assurance process for PA and AA courses, as we do for medical schools. We have been engaging with course providers for several years already, and we only grant approval where they meet our high standards.” Read full story Source: The Guardian, 30 April 2025 -
Content ArticleInsulin prescribing in the UK has tripled in the past decade, in particular due to an increase in use among those living with type 2 diabetes, now the largest group of insulin users. As a result, nurses in general practice and the community are increasingly expected to be skilled in supporting people living with type 2 diabetes with insulin therapy and associated glucose monitoring. The management of insulin therapy requires knowledge of the type of diabetes it is being used for and appropriate dosing, as well as correct injection technique, to prevent complications and medication errors. Diabetes nursing specialist Debbie Hicks shares key points on the management of insulin therapy for nurses in primary care.
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Content ArticleLord Darzi’s review into the future of the NHS calls for a “tilt towards technology” to unlock greater productivity. But there’s a hard reality: many parts of the NHS aren’t yet ready to take advantage of what tech has to offer. Meaning, there’s a missed opportunity for trusts to streamline operations and transform care. Only one in five NHS organisations are considered “digitally mature”. And despite lots of progress in the last decade, there are still areas of the NHS relying on paper and non-digital processes. It makes embracing new technologies, such as AI, feel like an unattainable goal – one that goes beyond moving the health service from analogue to digital. As we enter this new era for the NHS, data and digital skills across the workforce will be fundamental to improving patient care, streamlining processes, and making cost savings.
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Content ArticleThe General Medical Council (GMC) has submitted its response to Professor Gillian Leng’s independent review of the physician associate (PA) and anaesthesia associate (AA) professions in England. In its submission the regulator emphasised the importance of statutory regulation for PA and AAs because - as with any regulated healthcare profession - PAs and AAs undertake complex work that will pose some level of risk to the public, and regulation mitigates this risk. The submission also highlighted that, as the multi-professional regulator for doctors, PAs and AAs, the GMC is well placed to work with others across the health system to identify and address issues that concern all three professions. For example, the availability of supervisors and student training placements. The GMC also said that regulation is already beginning to raise standards of practice through ensuring that only those individuals with the right clinical knowledge and skills are entered onto the GMC’s registers.
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Content ArticleIn November 2023 the British Medical Association (BMA) established a reporting portal for doctors and medical students to share concerns regarding the deployment of physician and anaesthesia associates in both primary and secondary care. This report includes all submissions received by February 2025 that concern patient safety. This report presents evidence of doctor substitution, doctors being coerced or pressured into signing prescriptions or ionising radiation requests for patients of whom they have no knowledge, examples of doctors losing out on basic skills training and situations where neither the public nor other healthcare staff know the role or competencies of physician and anaesthesia associates. It also highlights examples of where harm has come to patients, or been narrowly avoided only by subsequent intervention from a doctor.
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News ArticleTens of thousands of doctors across India are being trained to promote the HPV vaccine, in a push to eliminate cervical cancer in the country. They will check with mothers attending medical appointments that they intend to vaccinate their daughters, and visit schools and community centres armed with facts and slideshows to counter vaccine disinformation. One in five cervical cancer cases worldwide occur in India – and the overwhelming majority of those are caused by the human papillomavirus, or HPV. HPV vaccination has become routine practice in many countries and has been available in India privately since 2008, but with low take-up. Sutapa Biswas, co-founder of the Cancer Foundation of India, said imported vaccines were expensive and people were reluctant to spend money on prevention. Misinformation surrounding deaths during, but unrelated to, an HPV vaccine trial in the country had left it with “baggage”, she said. However, India has recently started manufacturing its own cervical cancer vaccine, and the government is expected to make it part of the national vaccination programme later this year or early next year. Last year about 11,000 members of the Federation of Obstetric and Gynaecological Societies of India (Fogsi) underwent virtual training. About 100 of those trainees have now become the National HPV Faculty and will each train 500 general physicians from the Indian Medical Association over the next six months. The idea, Biswas said, “is to build confidence”. Training includes practical information on dosages, details of the World Health Organization’s push to eliminate cervical cancer, and advice on how to answer common questions. The implementation of India’s cervical screening programme had been sluggish, she said. Most cancers are diagnosed late, and most people’s experiences of the disease relate to death. Many non-specialist doctors “didn’t even know that a cancer could be eliminated and vaccination could be such a gamechanger”, Biswas said. Read full story Source: The Guardian, 1 April 2025
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Content ArticleFollowing concerns raised in early 2020 about surgical outcomes of an individual orthopaedic Surgeon, Mr Mian Munawar Shah, his employer, Walsall Healthcare NHS Trust (the Trust) sought external review of a small number (17) of complex upper limb surgery cases by a specialist team from the Royal College of Surgeons (the RCS) through the invited review mechanism. This reported in November 2020 and identified some concerns regarding practice within the trauma and orthopaedic department. The Trust subsequently requested a further RCS review specifically of Mr Shah’s practise, to more fully assess possible concerns regarding outcome after his surgery. Through this the total number of cases reviewed by the RCS was extended to 99. The results of this review were released in April 2022, and following evaluation of both reviews, the Trust decided to undertake a patient notification exercise (PNE) and recall of patients who had undergone complex upper limb surgery by Mr Shah. The recall was initiated in September 2022, the final patient case reviews being completed in September 2024. This report describes the process, oversight, scrutiny and findings of that recall.
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Content ArticleThe aim of this study was to research on the efficacy and safety of UK physician associates and anaesthetic associates in the context of an ongoing policy review. The study found that UK literature on physician associates and anaesthetic associates is sparse and of variable quality, and some is outdated. In this context, the absence of evidence of safety incidents should not be misinterpreted as evidence that deployment of physician associates and anaesthetic associates is safe. Findings of apparent non-inferiority in non-randomised studies may obscure important unmeasured differences in quality of care. New research is urgently needed to explore staff concerns, examine safety incidents, and inform a national scope of practice for these relatively new and contested staff roles. The findings from this UK based study should be interpreted in the context of the wider international evidence base.
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Content Article
Dr Kirsten Howson, Specialist Education Lead at SimComm Academy, discusses the role Simulation-Based Education (SBE) can have in patient safety. Kirsten highlights some of the techniques used in SBE, the benefits for staff and patients, and the importance of involving people with lived experience in the design and delivery of SBE. Background Initially used within the aviation industry, Simulation-Based Education (SBE) has now been adopted within healthcare education and training.[1] Clinical SBE began several decades ago[2] and has continued to successfully grow, providing learners with the opportunity to put their knowledge and skills into practice within a psychologically safe environment. Effective SBE includes a debrief following on from the simulated exercises. Research outlines that the debrief has been identified as a key component of impactful SBE, with the simulated scenarios acting as a catalyst for further reflection, conversation and sharing of experiences and ideas.[3] There are a range of techniques used within SBE: Forum theatre: Participants observe a complete simulated scenario played out in front of them, followed by a group reflection. The scenario is then run again, giving participants the opportunity to pause the scenario at multiple points and change the behaviours and language of one of the simulated characters in an attempt to improve the outcome of the interaction. Fishbowl simulation: Participants are given a scenario and task and interact with simulated characters while their peers observe the interaction and completion of the task. This is followed by a facilitated debrief in which participants are able to explore alternative methods, obtain feedback, discuss learning objectives, and reflect and share ideas. Observational simulation: Participants observe a simulated scenario which is then followed by a facilitated debrief in which participants are able to explore alternative methods, discuss learning objectives, and reflect and share ideas. Monologues: Participants observe while a simulated character delivers a monologue, which may include the character’s reflections, experiences or feelings. This is then followed by a facilitated debrief in which participants are able to explore alternative methods, discuss learning objectives, and reflect and share ideas. How simulation-based education impacts on patient safety SBE has been shown to have a wide range of benefits, many of which impact on patient safety, including: Participant skills and knowledge: SBE enhances participant skills[4] through practice, reflection and feedback, and can span not only technical skills, such as performing procedures and examinations, but also non-technical skills, such as leadership, communication skills, teamwork or prioritisation.[5] Enhancement of the skills and knowledge of clinical staff will likely result in an increase in patient safety. Participant confidence: Simulation training can increase the participant's confidence by providing participants with the opportunity to practise a new skill in a simulated setting in which there will be no safety implications; participants can build their confidence to the point at which they feel safe to use the skills in a non-simulated environment.[6] Participant teamwork: Teamwork skills are often a key focus and improve through the use of simulation training.[7] Dependent on the participant group, this can be on both an intraprofessional and interprofessional basis. Although these skills can be practised within the simulation scenarios, the debrief period also provides the opportunity to share differing points of view within the team, which can enhance teamwork, and again will likely result in an increase in patient safety. Participant mental health, burnout and sick leave: Medical and allied healthcare staff face high levels of mental health concerns and burnout, with the recent General Medical Council (GMC) report, 'The State of Medical Education and Practice in the UK Workplace Experience 2024' stating, “a third of doctors are struggling and feel unable to cope.”[8] Staff burnout impacts negatively on patient safety.[9] Simulation training has been found to have beneficial effects on anxiety, stress and burnout among some staff groups[10] and could also act as a protective factor against sick leave.[11] The importance of co-design and co-production in simulation-based education In 'Learning from Experience', The Royal College of Psychiatrists states, “The involvement of people with lived experience of mental illness either as a patient or carer in educational programmes can provide unique and relevant learning opportunities and teaching experience for doctors and psychiatrists in training.”[12] The GMC have also outlined the patient role within education in 'Patient and Public Involvement in Undergraduate Medical Education.[13] We believe that this concept should be extended across healthcare education. We endeavour to include the perspectives of a range of people with lived experience in the design and delivery of our courses, such as members of staff, parents, relatives, carers and patients where possible and appropriate. Not only does this enrich the quality of the education, bringing a broader perspective, but it also carries benefits to the patients involved, including a sense of fulfilment.[14][15] Some examples of the methods of co-design, co-delivery and stakeholder involvement we have used in our training, include The involvement of one of our Equity and Inclusivity Advisors, who is also a member of the transgender and gender diverse community, in co-design and co-delivery of courses aimed at exploring and outlining the challenges and assumptions that LGBTQIA+ individuals face. The incorporation of staff reflections and experiences into scenarios when designing courses on the following topics:: - cultural allyship - fostering workplace belonging - Band 5 and 6 leadership - managing disability - supporting internationally educated nurses. The incorporation of patient and carer feedback and experiences when designing our course, 'What Matters to Me'. The incorporation of parent experience when designing filmed training scenarios surrounding communication with parents during neonatal resuscitation. You can read more about one of our co-design projects in 'Involving patients and relatives by translating their experiences into simulation-based education'.[16] Conclusions SBE is now widely used across healthcare training to a variety of multi-disciplinary professionals, within a range of specialities, covering both technical and non-technical skills, which demonstrates the degree of versatility of SBE. It is important to incorporate the voice and perspective of people with lived experience where possible to ensure authenticity. This is an extremely exciting time for SBE as new innovative methods, uses and programmes are developed with the ultimate aim of continuing to enhance patient safety. References Oman S P, Magdi Y, Simon L V. Past Present and Future of Simulation in Internal Medicine. In StatPearls. StatPearls Publishing, 2023. Nehring WM, Lashley FR. Nursing Simulation: A Review of the Past 40 Years. Simulation & Gaming, 2009; 40(4): 528-2. Jaye P, Thomas L, Reedy G. 'The Diamond': a structure for simulation debrief. The Clinical Teacher 2015; 12(3): 171–5. Issenberg SB, et al. Simulation technology for health care professional skills training and assessment. JAMA 1999; 282(9): 861–6. Pearson E. McLafferty I. The use of simulation as a learning approach to non-technical skills awareness in final year student nurses. Nurse Education in Practice 2011; 11(6):399–405. Alrashidi N, et al. Effects of simulation in improving the self-confidence of student nurses in clinical practice: a systematic review. BMC Medical Education 2023; 23(1); 815. Gilfoyle E, et al. & Teams4Kids Investigators and the Canadian Critical Care Trials Group. Improved Clinical Performance and Teamwork of Pediatric Interprofessional Resuscitation Teams With a Simulation-Based Educational Intervention. Pediatric Critical Care Medicine 2017; 18(2): e62–9. General Medical Council. The State of Medical Education and Practice in the UK Workplace experience, 2024. Garcia CL, et al. Influence of Burnout on Patient Safety: Systematic Review and Meta-Analysis. Medicina (Kaunas, Lithuania) 2019; 55(9): 553. Couarraze S, et al. Short term effects of simulation training on stress, anxiety and burnout in critical care health professionals: before and after study. Clinical Simulation in Nursing 2023; 75: 25–32. Schram A, et al. Exploring the relationship between simulation-based team training and sick leave among healthcare professionals: a cohort study across multiple hospital sites. BMJ Open 2023; 13(10): e076163. The Royal College of Psychiatrists. Learning From Experience. Working In Collaboration With People With Lived Experience To Deliver Psychiatric Education, May 2021. General Medical Council. Patient and Public Involvement in Undergraduate Medical Education, February 2011. Dijk SW, Duijzer EJ, Wienold M. Role of active patient involvement in undergraduate medical education: a systematic review. BMJ Open, 2020;10(7): e037217. Gutteridge R, Dobbins K. Service user and carer involvement in learning and teaching: a faculty of health staff perspective. Nurse Education Today, 2010; 30(6): 509–14. Hamilton CJ, et al. Involving patients and relatives by translating their experiences into simulation-based education. A31. Abstract from Association for Simulated Practice in Healthcare Annual Conference 2018, Southport, United Kingdom. -
News Article
NHS 111 firm admits fault for not sending ambulance to baby who later died
Patient Safety Learning posted a news article in News
A private call handling firm operating the NHS 111 non-emergency service has admitted it was at fault for failing to send an ambulance to a baby boy who died shortly after falling ill, an inquest has heard. Ben Condon, who was born premature, died aged two months at Bristol children’s hospital in April 2015 after developing a respiratory illness. A first inquest into his death ruled that Ben died as a result of acute respiratory distress syndrome, human metapneumovirus and prematurity but the conclusion was quashed by high court judges. On Monday, a fresh inquest opened into Ben’s death and heard that when the child went home to Weston-super-Mare, North Somerset, with his parents he developed a cold. His father, Allyn Condon, rang the non-emergency 111 service – run at the time by Care UK – at about 6pm on 10 April. The call handler referred Ben for an out-of-hours telephone call-back appointment with a GP within two hours rather than send an ambulance, a decision the coroner said was affected by “bias” as the handler was aware of “external pressures” facing ambulances. The court heard that by 7.45pm when Condon and his wife, Jenny, had not received the call from the GP, they took their son to the Weston general hospital. Reading from a written statement, the assistant coroner Robert Sowersby said Care UK had apologised to the Condon family and the adviser was taken off calls for nearly three weeks and received further training. “Care UK admitted it was at fault for having not sent an ambulance after the call,” Sowersby said. “It said that changes in the recordings of telephone calls needed to be made and apologised for their failings. “Care UK identified in the root cause analysis that the health adviser failed to actively listen and failed to accept the responses provided and there was a failure to select the appropriate pathway responses.” Read full story Source: The Guardian, 3 February 2025 -
Content ArticleThe 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.
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Content ArticleOn 11 July 2023, Susan Evans underwent elective Roux-en-Y gastric bypass surgery. The surgery went to plan and appropriate measures were taken to avoid the possibility of an anastomotic leak, a rare but recognised complication of gastric bypass surgery. Initially, Ms Evans recovered well, but she experienced abdominal pain in the early hours of 13 July 2023. It is likely that this was due to an anastomotic leak. 13 July 2023 was the first day of a junior doctors’ strike. Unrelated to this, the hospital only had the equivalent of one full time specialist bariatric nurse, who was not on duty. Contrary to Queen Alexandra hospital’s written policy for gastric bypass patients, Ms Evans was not seen by a member of the specialist bariatric team on 13 July 2023 and was not seen by a senior doctor after reporting pain in order to rule out the possibility of an anastomotic leak. The hospital at night nursing team, who administered pain relief, were unaware of the latter requirement. In addition, Ms Evans not seen by a member of the bariatric team or any doctor prior to her discharge from hospital on the morning of 13 July 2023. Ms Evans was still in a degree of pain when she left hospital. She was re-admitted to hospital on 15 July 2023. By this point she was extremely unwell with abdominal sepsis from an anastomotic leak. She underwent remedial surgery on 15 July 2023 and a further operation was required on 25 July 2023. Despite appropriate medical care following her re-admission, her condition deteriorated, and she died at Queen Alexandra Hospital on 12 August 2023. It is likely that, if she had been seen by a member of the bariatric team on 13 July 2023, she would have been kept in hospital and would have been operated upon sooner. The failures identified contributed more than minimally to her death. Matters of concern Queen Alexandra’s written post operative care pathway for patients who have undergone a gastric bypass operation states that: There is to be a daily review by a bariatric specialist nurse, consultant or registrar. A senior doctor is to review within 2 hours if there is increased abdominal pain in order to rule out anastomotic leak or bleed. In addition to this, the inquest heard evidence that patients should be seen by a member of the specialist bariatric team prior to discharge. This is not included in the written policy. Neither the written nor informal policy set out above were followed in Ms Evans’ case. She was not reviewed by a member of the specialist bariatric team at any point on day 2 after surgery and the pain she experienced from the early hours of 13 July 2023 was not escalated to a senior doctor at all. The inquest heard evidence that medical staff who were not part of the specialist bariatric team were unlikely to appreciate the significance of pain. The failure to follow policy contributed more than minimally to Ms Evans death and is therefore a matter of concern.
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Content ArticleThe Royal College of Physicians (RCP) has published new interim guidance on the scope, supervision and employment of physician associates (PAs) working in the medical specialties (also known as the physician specialties). The interim guidance covers scope of practice for general internal medicine, supervision and employment of PAs, and how PAs should describe their role to patients, employers, other healthcare professionals and the public. It will be reviewed in collaboration with stakeholders, including RCP fellows and members, following the publication of the report of the Leng review. In the guidance, the RCP is clear that: PAs must support – not replace – doctors, have a nationally defined ceiling of practice, and have a clearly defined role in the multidisciplinary team (MDT). PAs must never function as a senior decision maker, nor should they decide whether a patient is admitted or discharged from hospital. Resident doctors are not, and must not be expected or asked to be, responsible for the clinical supervision of PAs. PAs should only be supervised by consultants, specialist or associate specialist doctors. PAs cannot prescribe medications regardless of any prior healthcare background while working as a PA. PAs must clearly explain their role to patients, their families and carers, as well as colleagues and supervisors, and provide details of their educational and clinical supervision when required.
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Content ArticleRight Care, Right Person (RCRP) is an approach that is aimed at ensuring that people of all ages who have health and/or social care needs, are responded to by the right person, with the right skills, training, and experience to best meet their needs. Home Office and Department of Health and Social Care (DHSC) analysts evaluated the implementation of RCRP through a rapid process evaluation covering police, fire, health and social care services. The findings highlighted the importance of communication, openness and transparency across agencies when implementing RCRP. While generally supportive of RCRP principles, participants highlighted some implementation challenges, such as capacity limitations for health and social care services. Early data monitoring showed a reduction of police time spent on health-related incidents post RCRP implementation. Recommendations to support the implementation of RCRP are included.
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Content ArticleUpcoming regulation will hold physician associates and anaesthesia associates to higher standards, ensuring safer patient care and stronger accountability while addressing doctors’ concerns on team integration; however, there is still more to be which requires our collective energy to find solutions that deliver for all those who work in our health services, and ultimately for all those who rely on them for their care.
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News Article
Unnecessary training wastes 100,000 days a year, says NHSE
Patient Safety Learning posted a news article in News
Unnecessary “mandatory training” is wasting more than 100,000 days of NHS staff time every year, NHS England estimates. This is largely because some refresher training is taking place more frequently than national rules require, according to a survey and analysis by the national body. Some staff groups are completing training which is either “not relevant or has limited benefit”, it said in a letter yesterday. Doctors and others have long complained about the burden of mandatory training on their time, particularly resident doctors, alongside job pressures, pay and working conditions. NHS England now wants to “optimise, rationalise and redesign statutory and mandatory training” to help reduce burden and improve staff experience, it said. The letter to HR, nursing and medical directors said: “We forecast these actions will reduce the time burden on staff by up to 100,000 days each year with no material risk, with particular benefit to resident doctors (postgraduate doctors in training). “Across the NHS in England, approximately 250,000 people go through new starter processes each year, and approximately 50 per cent of these are or were employed by another organisation. “With statutory and mandatory training taking an average of one day to complete, the estimated saving of 100,000 days is considered conservative.” Read full story (paywalled) Source: HSJ, 15 November 2024 -
Content ArticleIn this paper, the authors engage with claims of expert identities within the field of patient engagement by analysing a subset of data collected as part of a 2020 pan-Canadian survey of patient partners. The analysis is based on 446 qualitative responses to one target question: “Do you think the lived experience you bring to your patient partner role makes you an expert? Please explain in the box below”. Through a discursive analysis of the comments, the authors explored the meanings ascribed to concepts of expert, expertise, and experience. Ultimately, they found nuanced and sometimes contradictory understandings. Thus, dilemmas of expertise in the patient engagement field may not be entirely about claims to specialized knowledge. Instead, discourses seem to be mobilised in response to the thorny, political question: “who is authorised to speak on behalf of patients”? To meaningfully advance the conversation within patient engagement research and practice, we argue for more sociological and political understandings of forms of expertise, objects of expertise, and deployments of expert status in different kinds of knowledge spaces.
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