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Defensiveness is often implicated in systemic organisational failures to explain why early warning signs were ignored and organisational resilience was compromised. But how does an organisation become defensive? The authors of this study propose that defensiveness can arise as a response to contradictory work demands. The research focuses on UK hospital staff tasked with responding to criticism online (herein complaint handlers). It examines these responses to criticism using a mixed methods explanatory sequential design. Six defensive tactics were reliably identified: redirecting patients to other channels, evading issues, psychologising concerns, invalidating concerns as incomplete, closing the feedback episode, and individualising concerns with bespoke workarounds. These defensive tactics were generally associated with less organisational learning and were sometimes viewed as unhelpful. To explain these results, the authors introduce the complaint handler’s bind: staff are tasked with responding to complaints without a viable pathway for organisational learning and an implicit injunction against voicing this dilemma. This demand-control double bind unwittingly gives staff little alternative but to be defensive. Future research, the authors conclude, needs to conceptualise defensiveness as sometimes a symptom rather than a cause of problems in organisational learning. -
News Article
Spending on agency staff across NHS in England drops by almost £1bn
Patient Safety Learning posted a news article in News
Spending on agency staff across the NHS in England dropped by almost £1bn in the last financial year, ministers have said, after a pledge by Wes Streeting to cut the amount going to agencies by 30%. According to the Department of Health and Social Care, the total spent by trusts on agency staff during 2024-25 was nearly £1bn lower than the previous year. In a speech to the NHS Providers conference in November, Streeting, the health secretary, said a lack of permanent staff had seen gaps filled by more expensive agency-provided replacements totalling about £3bn a year. Under proposals outlined at the time, but not yet enacted, Streeting suggested that NHS trusts could be completely banned from using agency staff for lower level jobs such as healthcare assistants and domestic support workers. In addition to employing agency staff, which can mean paying a doctor thousand of pounds for a single shift, NHS trusts also routinely plug gaps by using what are known as “bank” staff – NHS employees who do extra shifts at their own workplace or one nearby, via an organisation usually run by the trust. UK-wide figures reported by the Guardian in January 2024 showed that the combined spend of hospitals and GP surgeries for agency staff was an annual £4.6bn, with another £5.8bn used for bank shifts. As part of the clampdown on agency spending, Streeting and James Mackey, the chief executive of the imminently abolished NHS England, have jointly written to all NHS providers and integrated care board executives to set out that each should target the 30% reduction, and that their progress will be monitored. Read full story Source: The Guardian, 2 June 2025- Posted
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Health secretary urges no strikes as ballot of UK junior doctors begins
Mark Hughes posted a news article in News
The Secretary of State for Health and Social Care, Wes Streeting MP, has urged doctors to vote against industrial action as the British Medical Association (BMA) ballots resident doctors, formerly known as junior doctors, for strike action that could last for six months. Resident doctors say their pay has declined by 23% in real terms since 2008. If they choose to go on strike, walkouts could begin in July and potentially last until January 2026. The government accepted salary recommendations from pay review bodies earlier this month, resulting in an average 5.4% rise for resident doctors. Read full story Source: The Guardian, 29 May 2025- Posted
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The purpose of this study was to identify which, and to what extent, demographic and operational factors are indicative of likelihood for a new call handler or paramedic to remain in role within the first two years of employment at an ambulance trust using data held in the trust’s bespoke data warehouse. Several factors showed a significant contribution to the likelihood of remaining in post within an ambulance NHS Trust. Among the findings, short-term sick leave in the first two years of employment was associated with increased retention for paramedics. In addition, female call handlers were found to have increased retention and paramedic retention increased with time outside of ‘job cycle time’ (JCT) activities (ie, activities other than responding to calls). This study presents a method for extracting new insights from routinely collected operational data, identifying common drivers and specific predictors for retention among the ambulance NHS workforce. It emphasises the importance of workforce-centred retention strategies, highlighting the need for non-JCT time, which in turn would allow paramedics to have time to reflect and recuperate to avoid burnout and attrition. The study also suggests that a lack of sick leave might indicate a lack of trust and self-care culture, potentially leading to paramedic staff attrition. Our approach to retention analytics provides a new mechanism for trusts to monitor and respond to their attrition risks in a timely, proactive fashion.- Posted
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CEO: TV show sparked ‘overwhelming’ regulator scrutiny
Patient Safety Learning posted a news article in News
An “overwhelming” number of regulators were involved with a trust after an undercover documentary exposed care failings, its chief executive has said. Channel 4 aired hidden camera footage from Essex Partnership University Foundation Trust mental health inpatient wards in 2022. This revealed staff sleeping on duty and concerns over use of restraints. Trust CEO Paul Scott said on Thursday: “Understandably, those with regulatory responsibilities were very interested in the Dispatches programme and our response to it. But the sheer volume of people who wanted some assurance that we were taking seriously and making improvements [was] overwhelming.” He estimated he had attended around 19 boards or equivalent structures to provide assurance from different angles. “Nineteen regulators over one organisation felt overwhelming.” Mr Scott made the comments during his evidence to the Lampard Inquiry, which is looking into thousands of mental health patient deaths in Essex between 2000 and 2023. The probe is expected to report its findings before the end of 2027. In his written submission, Mr Scott had mentioned the “complexity of the nature and oversight of regulation” facing trusts from multiple parties within health and social care. Read full story (paywalled) Source: HSJ, 16 May 2025- Posted
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Sweeping changes to immigration rules could cut the “lifeline” of international recruitment for the UK care sector and negatively impact the NHS, leaders have warned. The government unveiled its Restoring Control over the Immigration System white paper on 12 May in which it said it would close social care visas to new applications from abroad because of “significant concerns over abuse and exploitation of individual workers.” “The agreements will move the UK away from dependence on overseas workers to fulfil our care needs,” said the paper, which aimed to tackle longstanding levels of low pay and poor working conditions in the sector in other ways, such as through establishing fair pay agreements. Read full story (paywalled) Source: BMJ, 13 May 2025- Posted
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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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Earlier C-section could have saved baby
Patient Safety Learning posted a news article in News
A baby who died three days after birth would have survived if her mother had been offered a caesarean section, a coroner has said. Emmy Russo was delivered at Princess Alexandra Hospital in Harlow but died on 12 January 2024. Mother Bryony Russo told an inquest at Essex Coroner's Court that her requests for a C-section were "laughed off" during the hours she was there in labour. Assistant coroner for Essex, Thea Wilson, said there were five missed opportunities to offer Ms Russo a C-section, and that Emmy's chances would have been different had she been born an hour earlier. "She would have been born in a better condition and on the balance of probabilities she would have survived," she said. "There was a failure to respond adequately to the request for a C-section" Independent expert obstetrician Teresa Kelly had told the coroner there was enough evidence "this baby wasn't coping with labour" and staff should have acted sooner. Giving evidence, midwife Megan Fletcher defended her decision not to escalate concerns to a more senior doctor, saying she was trying to avoid any further "invasive procedures". Read full story Source: BBC News, 7 May 2025- Posted
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A government crackdown on visas for overseas workers could put overstretched care homes under threat of closure, with tens of thousands fewer staff coming to the UK, The Independent can reveal. Applications for Britain’s health and care worker visa are at a record low after care workers were prevented from bringing children and other dependants with them in a bid to curb climbing migration numbers. Between April 2023 to March 2024, when the new rules came in, there were 129,000 applicants, but that plummeted to just 26,000 in the year to March 2025, according to government figures. The revelation comes as care homes struggle to retain staff, with more than 100,000 vacancies across England last year - a rate of 8 per cent and three times the national average. Age UK warned that overseas recruits were “keeping many services afloat” and some care homes could be forced to shut if they could not find alternatives, piling more pressure on NHS hospitals. Read full story Source: The Independent, 6 May 2025- Posted
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Assisted dying bill to include protection for NHS staff not wishing to take part
Patient Safety Learning posted a news article in News
NHS staff including doctors, nurses and pharmacists who do not wish to take part in assisted dying will have specific protection against discrimination under a new amendment from the bill’s sponsor Kim Leadbeater, backed by ministers. Leadbeater, who is hoping to shore up support for the bill before a crucial Commons vote next week, will add the additional protections for any staff involved in the proposed process, including ancillary staff, who will not have to give any reason for their refusal. The private member’s bill, which faces its next Commons stage next Friday (16 May), currently says doctors and health professionals may refuse to take part. But the Guardian understands this will be extended to any person who may possibly be involved in the process and will be amended to say “no person is under any duty to participate in the provision of assistance”. There will also be an amendment to the current Employment Rights Act that will specifically ban discrimination, dismissal or disciplinary action if a person chooses not to participate. “Choice is at the heart of the bill,” Leadbeater said. “Assisted dying is not for everyone and nor should it be. But for those who do make that choice, the bill that MPs will be debating again in less that two weeks, contains even more protections and is more effective and workable than it was before.” Read full story Source: The Guardian, 5 May 2025- Posted
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CEO tells staff ‘silence is complicity’ after record sexual misconduct reports
Patient Safety Learning posted a news article in News
An ambulance trust has dismissed “multiple staff” for sexual misconduct offences this year following its “highest year ever for reported sexual safety incidents” in 2024, HSJ has learned. East of England Ambulance Service Trust’s chief executive Neill Moloney wrote to staff to warn them they all have a “moral obligation” to “step up when [they] see inappropriate behaviour”. In the letter, seen by HSJ, Mr Moloney said: “Silence is not neutrality. It is complicity. We all have a moral obligation to support those that experience this behaviour… If you witness or experience inappropriate sexualised behaviour, I am encouraging you to report it.” He added: “Last year alone, 44 sexual safety incidents were reported — our highest year ever for reported sexual misconduct — figures driven in part by higher reporting of incidents. “Already in 2025, we have dismissed multiple staff for sexual misconduct. This includes sexualised conversation and language in ambulances and crew rooms. This is considered sexual misconduct and we need your support to continue to eradicate this.” The trust told HSJ that four people were dismissed for sexual misconduct in 2024, and to date in 2025, a further four people have been dismissed. The concerns follow the results of the NHS Staff Survey published last month, which highlighted the depth of the sexual misconduct problems across the whole ambulance sector, with the Association of Ambulance Chief Executives calling for a “cultural reset”. Read full story (paywalled) Source: HSJ, 28 April 2025- Posted
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Physicians in the USA are facing a number of changes and challenges in 2025 — with some good news about burnout rates, some bad news around aging physicians and some surprising shifts in the physician workforce makeup. This article highlights 10 things to know about the current state of the physician workforce.- Posted
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News Article
Systems still reliant on agency staff
Patient Safety Learning posted a news article in News
Six systems are still using more than 30% of their temporary staffing spend to employ agency workers, HSJ research has revealed. The investigation also highlights that the NHS will need to reduce spending on bank staff by almost as much as that on agency workers for the first time. Internal NHS England figures seen by HSJ reveal providers were on course to spend £8.3bn on temporary staffing in 2024-25, down from just under £10bn the previous year. Three quarters of the overall spend in 2024-25 (£6bn) went on employing bank workers, with the remainder used for agency staff. Providers have been encouraged to shift agency workers to their staff banks for a number of years. However, HSJ research has revealed some systems are still struggling to move away from a reliance on agency staff. Read full story (paywalled) Source: HSJ, 22 April 2025 Related reading on the hub: Speaking up as an agency nurse cost me my career My experience as an agency nurse- Posted
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As health systems continue to grapple with ongoing workforce challenges, healthcare leaders like Stacie Call, MSN, RN, CNO for Mercy Health – Loraine & Youngstown (Ohio), and her team have worked to cultivate a resilient and engaged workforce. Becker’s Hospital Review connected with Ms Call to discuss how implementing strategies that prioritise strategic partnerships, a listening culture and innovation can help not only address existing staff demands but lay the groundwork for a future-ready and sustainable healthcare workforce.- Posted
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Best and worst trusts to work at, according to bank staff
Patient Safety Learning posted a news article in News
NHS bank staff are almost always more likely to recommend their employer as a good place to work than permanent staff. Results published this week found that 67% of responding bank staff would recommend their organisation as a place to work. This compares to 60% of substantive staff. The bank staff score increased slightly on last year, while that for salaried staff fell – again marginally. The survey, which is coordinated by Picker on behalf of NHS England, revealed a quarter (25.3% of bank staff reported experiencing at least one incident of physical violence from patients and the public in the last 12 months The proportion of bank workers experiencing discrimination from patients and the public has also risen, from 13.1 to 14.8%. Other results from the survey showed improvements in work-life balance and a reduction in burnout rates. Picker Group chief executive Chris Picker said: “These latest results paint a mixed picture of life as a bank-only worker in the NHS. “While many continue to benefit from the flexibility and improved work-life balance offered by bank roles, rising reports of incidents of violence and discrimination from patients and the public are a cause for concern, particularly for the many bank nursing and healthcare assistants reporting experiences of these unacceptable behaviours.” Read full story (paywalled) Source: HSJ, 17 April 2025- Posted
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The 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.- Posted
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Baby deaths trust claimed £2m 'good care' payments
Patient Safety Learning posted a news article in News
An NHS trust criticised over the avoidable death of a newborn baby was paid £2m for providing good maternity care, the BBC can reveal. A senior coroner ruled on Friday that University Hospitals of Morecambe Bay (UHMB) NHS trust contributed to Ida Lock's death and had failed to learn lessons from previous maternity failures. Despite this, the trust claimed it had met all 10 standards under an NHS scheme aimed at promoting safe treatment. Ida's mother Sarah Robinson said it was "another kick in the teeth" while her father Ryan Lock labelled it "disgusting". The trust, which has previously apologised for its failings in Ida's care, declined to comment about the NHS payment scheme. Senior coroner for Lancashire James Adeley concluded that Ida had died due to the gross failure of three midwives to provide basic medical care. Ida, who was born at the Royal Lancaster Infirmary (RLI) on 9 November 2019, died a week later after suffering a serious brain injury due to a lack of oxygen. Dr Adeley ruled her death had been caused by the midwives' failure to deliver the infant "urgently when it was apparent she was in distress" and contributed to by the lead midwife's "wholly incompetent failure to provide basic neonatal resuscitation". He said eight opportunities had been missed "to alter Ida's clinical course". Read full story Source: BBC News, 26 March 2025- Posted
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On 9 November 2019, a woman who was pregnant with Ida, attended the Royal Lancaster Infirmary Labour Ward in early labour. Ida was a normal child whose death was caused by a lack of oxygen during her delivery. This occurred due to the gross failure of the three midwives attending her to provide basic medical care to deliver Ida urgently when it was apparent she was in distress and contributed to by the lead midwife‘s wholly incompetent failure to provide basic neonatal resuscitation for Ida during the first 3 1/2 minutes of her life that further contributed to Ida’s brain damage. Ida died on 16 November 2019 at the Royal Preston Hospital neonatal intensive care unit. The inquest was one in which Article 2 was fully engaged as a result of the Trust’s clinical governance arrangements, inadequate investigations, a lack of transparency and openness, a failure to respond to a detailed complaint letter, a failure to comply with the Duty of Candour, disputing the findings of the Secretary of State for Health’s independent review panel (HSIB now MNSI), failing to notify external monitoring bodies and failing to comply with internal protocols. The Trust’s lack of compliance with clinical governance requirements in the investigation into Ida’s death had significant similarities with the criticisms made in 2015 of the Trust as set out in The Report of the Morecambe Bay Investigation, otherwise known as the Kirkup Report. [REDACTED] who gave evidence at the inquest, expressed the view that there was a deep seated and endemic culture of defensiveness in respect of maternity incidents at the Trust. [REDACTED] also said that the investigation showed elements of failing to identify significant care issues, brevity, defensiveness and was conducted by unskilled investigators. Matters of Concern A: Culture of Candour [Trust, ICB and DHSC] 1. I am concerned that there is not a culture of candour within University Hospitals of Morecambe Bay NHS Foundation Trust (Trust) and the impact that this has on safety, learning and implementing required changes to prevent deaths. Urgent action is required by the Trust to meaningfully embed the Dury of Candour. 2. [REDACTED]’s evidence to the inquest was that a deep-seated and endemic culture within the Trust leads to denial and a failure to learn. [REDACTED]’s Investigation report was published in 2015, the Trust is ten years on and still issues and themes identified in 2015 were very much in issue in 2019 and still exist at the Trust as identified by Ida’s inquest. 3. The Trust’s approach to the inquest has been one of a lack of transparency and openness, failure to provide relevant information and a failure to identify with candour the defective clinical governance processes that have operated at the Trust from 2019 to present day. 4. The Trust did not disclose that they had failed to notify the external bodies namely the CQC and the then CCG [ICB] via STEIS and the Trust’s internal Serious Incidents Reporting Investigation panel, none of which was noted by the Trust’s Patient Safety Summits .The matter was reported to the Coroner a year after Ida’s death by the family after the Trust took no action to do so, despite being on notice of failures in treatment from the HSIB report Ida’s harm was at no point categorised by the Trust as a harm event that caused “death”. 5. Trust figures to the Board provided in 2025 stated that there were no complaints over 6 months old when the Trust at the time of the inquest have not responded to [REDACTED] and [REDACTED]’s 1 June 2020 complaint. Together with the Trust’s failure to categorise Ida’s death as only “Moderate Harm” (see point 4 above) cause me also to have concern about the reliability of Trust’s data. B: Clinical Governance and Maternity Governance [Trust, ICB and DHSC] 6. I consider the clinical governance arrangements at the Trust require urgent review to ensure the appropriate personnel are in place, with the necessary training and skills to deliver robust clinical governance to ensure patient safety in maternity care. 7. As a result of the Trust’s deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust’s clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements, defensive attitudes and inappropriate self- congratulation. The clinicians’ reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence. This approach caused additional distress to the family who had to sit through an extended court hearing to address these issues 8. [REDACTED] is now Head of Compliance and Assurance at the Trust but that there has been no investigation into her role in respect of reneging on the Trust’s acceptance of the HSIB report at senior management level and with the family as was indicated by her approval of the July 2021 position statement. Similarly, [REDACTED] is now Head of Midwifery at the Trust and there has been no investigation in respect of her disputing the HSIB findings and submission of challenge to the HSIB report in Ida’s case. 9. All investigations conducted by the Trust to date in respect of Ida’s death have been unskilled, superficial, brief, failed to identify issues and left the family without answers and were all features identified by the 2015 Kirkup Report. In view of the continuing culture at the Trust, this cause a significant concern that issues of safety and safeguarding are not properly considered, transparently engaged with and then addressed formally in respect of a child fatality and serious injury by the Trust. 10. The Trust’s clinical governance capability has been the subject of repeated and often severe criticism in the Flynn Review 2009, Fielding Report 2010, Central Manchester Hospital Report 2011, Price Waterhouse Cooper 2012 and Kirkup Report 2015. [REDACTED] in his evidence to the inquest said that the Trust focus on process, which means that you can comply with the process requirements and still produce an inadequate investigation, rather than focussing on outcome, which measures the quality of the investigation and the patient experience. [REDACTED] noted that the Trusts culture impeded transparent and open investigation. I am told that the Trust now uses the PSIRF model and is to appoint 3 whole time equivalent Response Leads by 30 September 2025. However, I remain concerned that the Trust has not fully engaged with the duty of candour such that I am not satisfied that the work on PSIRF to date has truly addressed the issues in respect of Trust’s investigations. C. Mandatory Training, expired training and remedial training [Trust and ICB] 11. The Band 5 midwife supporting [REDACTED] in Labour had not undertaken her required mandatory training and this fact had not been provided and was only revealed at the inquest as part of the evidence of the Head of Midwifery in March 2025. I was also concerned to learn that in 2025 non-completion of mandatory training was still an issue as [REDACTED] had not completed her mandatory training. 12. It concerns me that the Trust do not have robust systems in place to ensure that any midwife who has not completed her mandatory training is subject to immediate action to ensure that all mandatory training is completed and is in date. 13. There was no remedial training was put in place for either the midwives involved in Ida’s delivery and resuscitation or for the paediatric SHO after Ida’s death. This raises a significant concern that the Trust do not operate a system of remedial training when this inquest has identified remedial training was required for [REDACTED], [REDACTED], [REDACTED] and [REDACTED]. D. Grading of harm for incident reporting: Babies who have sustained hypoxic brain injury and undergo cooling [Trust, ICB, DHSC, NHSE, [REDACTED]] 14. The Trust graded Ida’s level of harm as “moderate”, even after her death. This grading should have been adjusted to “severe” by the Trust before Ida was transferred to Royal Preston Hospital as the consultant paediatrician identified that she had sustained a severe hypoxic ischaemic encephalopathy due to fetal bradycardia. 15. The 2024 NHSE Learn from patient safety events (LFPSE) guidance that replaced the National Reporting and Learning System (NRLS) confirms that the recording and analysis of patient safety events that occur in healthcare support the NHS to improve learning from patient safety events to help make care safer. There is a significant risk that if reporting is graded on harm alone, clinical care that resulted in hypoxic brain damage during delivery and which was prevented by therapeutic cooling, will not adequately identify the problems that caused the harm during the delivery. 16. [REDACTED] confirmed that nationally there is inconsistency in categorisation of harm for babies who sustain a hypoxic injury due to fetal bradycardia in labour and who require cooling and clarification guidance would assist prevent further maternity deaths and ensure full and proper investigation of hypoxic injuries sustained in labour. E: Funding for MSNI [DHSC and [REDACTED], NHSE and ICB] 17. But for the HSIB investigation report into Ida’s death [REDACTED] admitted that Ida’s death due to failures by the Trust would never have come to light or resulted in an inquest. 18. The MSNI is now hosted by the CQC with funding secured for the next two years but no certainty as to ongoing funding after this date. These independent investigations by specialist skilled investigators into the most serious of events is an essential safeguard to the lives of mothers and unborn children. 19. Without an assurance that funding will continue beyond 2027 I am concerned that significant harm events to mothers and babies and deaths such as Ida’s will go unrecorded and lessons that should be learned to prevent future maternal and baby deaths will go unnoticed, and there will be a risk of future maternity deaths.- Posted
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Don’t get surgery on a Friday
Patient Safety Learning posted a news article in News
If you have any say, you might want to avoid scheduling your next surgery on a Friday. The most comprehensive analysis of what happens to patients who have surgery on Fridays versus Mondays, published in JAMA by more than a dozen US and Canadian researchers, is unequivocal: The people who underwent all kinds of procedures before the weekend suffered on average more short-term, medium-term, and long-term complications than people who went under the knife after the weekend was over. The study was based in Ontario and included more than 450,000 patients who received one of the 25 most common surgeries between 2007 and 2019. Previous studies have generally found the same effects across different types of health systems: One UK-based study had reported better outcomes for Monday surgeries after 30 days. A paper looking at Dutch patients detected higher mortality rates after one month for patients who had Friday surgeries compared to Monday. This appears to be a phenomenon no matter the country, as prior US-based research also attests. People who received pre-weekend surgeries — defined as a Friday or a Thursday before a long weekend — were overall about 5% more likely to experience one of those complications within a year of their surgery than people who got post-weekend procedures (on Monday or the Tuesday after a long weekend). The effect was stronger for heart and vascular surgeries; it was negligible for obstetric and plastic surgeries. Researchers found Friday surgeries were more likely to be performed by junior surgeons when compared to Monday surgeries. “This difference in expertise may play a role in the observed differences in outcomes,” they wrote, based on a statistical analysis that controlled for other factors. There could also be fewer senior colleagues on the hospital campus for the junior physicians to consult with, the authors said. In addition, the weekend doctors and nurses may be less familiar with the patient’s case, raising the risk that complications will be caught later and therefore lead to worse outcomes. Read full story Source: Vox, 21 March 2025- Posted
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CEO: Staff suffering ‘moral injury’ from poor estates
Patient Safety Learning posted a news article in News
Staff are suffering “moral injury” as deteriorating estates disrupt their ability to provide care, a chief executive whose hospital rebuild has been delayed has warned. Thom Lafferty said Princess Alexandra Hospital Trust needed around £120m to fix its basic infrastructure – far outstripping normal capital allocations. The CEO, who joined in November, said: “Our staff cannot provide the level of care that they wish to because of the deteriorating estate which causes moral injury.” He said: “If something is mission critical safety, then we would have access to other resources to fix it. What we don’t have is the ability to guard against that level of operational disruption, which ends up providing a poor service for our patients and also causes moral injury to staff.” Moral injury is persistent psychological distress from acting against your ethical code, according to NHS Confederation. Read full story (paywalled) Source: HSJ, 24 March 2025 -
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By the entrance to Furness General Hospital in Barrow-in-Furness sits a sculpture of a moon with 11 stars. It is a memorial to the mother and babies who died unnecessarily due to poor care at the hospital between 2004 and 2013. When the memorial was unveiled in 2019, Aaron Cummins who is chief executive at University Hospitals of Morecambe Bay NHS Trust, which runs the hospital, said: "We will never forget what happened. We owe it to those who died to continually improve in everything that we do." Barely a month later, Sarah Robinson stepped into a birthing pool at the Royal Lancaster Infirmary, a hospital run by the same NHS trust. She was about to give birth to her second child. Within an hour, Ida Lock was born; within a week, she was dead. The inquest into Ida Lock's death, which concluded last week, exposed over five weeks why maternity services across England have long struggled to improve - and this one case holds a mirror to issues that appear to be prevalent across a number of trusts. 'That investigation, carried out by Dr Bill Kirkup and published in March 2015, found there had been a dysfunctional culture at Furness General, substandard clinical skills, poor risk assessments and a grossly deficient response to adverse incidents with a repeated failure to properly investigate cases and learn lessons. Morecambe Bay became a byword for poor maternity care and the trust promised to enact all 18 recommendations from the Kirkup review. And yet that never happened. Ida Lock's inquest began last month, more than five years after she died - the delay was down to several reasons, including its particular complexity. What emerged was just how profoundly many of those lessons had not been learned. Particularly egregious, says Ms Robinson, was a suggestion from a midwife – shortly after the birth - that Ida's poor condition was linked to her smoking, something Sarah had never done in her life. As the coroner found on Friday, Ida's death was wholly avoidable, caused by a failure to recognise that she was in distress prior to her birth, and then a botched resuscitation attempt after she was born. By the time she was transferred to a higher dependency unit, at the Royal Preston hospital, she had suffered a brain injury from which she could not recover. Having failed to deliver their daughter safely, Ida's parents would have expected that the trust would properly and openly investigate her death. Instead, they pursued an investigation that Carey Galbraith, the midwife who completed it, would later describe as "not worth the paper it was written on". They didn't take responsibility for their failings despite having an independent report from the Healthcare Safety Investigation Branch (HSIB). Clearly, the Morecambe Bay report was not, as was hoped, a line in the sand for maternity services across England, or a rallying cry for widespread improvements. As the inquest has shown, it did not even lead to sustained improvement at Morecambe Bay. Read full story Source: BBC News, 24 March 2025 Further reading: Ida Lock: Baby girl died from brain injury because midwives failed to provide basic care, coroner rules- Posted
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Staffing vital to high hear and treat rates, say trusts
Patient Safety Learning posted a news article in News
Some 30,000 emergency ambulance trips could be avoided every month if trusts provided more advice over the phone, according to NHS England figures. The proportion of emergency calls dealt with through hear and treat ranges from more than 20 per cent at the best-performing trusts to less than half that in other areas. Typically, this involves patients being given advice such as self-care, seeing a GP or pharmacist, or being directed to an alternative pathway for urgent care. Based on February’s figures, released by NHS England, an additional 30,000 patients could have been seen if every trust matched the performance of West Midlands Ambulance Service University Foundation Trust and London Ambulance Service Trust, both of which dealt with 20.6 per cent of patients in this way. London Ambulance Service Trust has managed more than one in five patients through hear and treat while seeing an additional 500 to 520 calls each day this winter. Michael Ward, deputy director of clinical safety and compliance at LAS, told HSJ the initiative had helped lessen demand on hospitals. He said the trust had boosted recruitment of both band 6 clinical advisers and band 7 clinical support managers, to support control room staff. Advice to control room staff on the most clinically appropriate pathway is readily available, including a 24/7 clinical safety officer. The trust has also worked to make these roles attractive for staff, with the provision of training and development plus timely feedback on decisions, he said, adding that the roles were attractive to paramedics who no longer want the physical strain of frontline work. “I think there is scope for more hear and treat,” Mr Ward said. “There is a natural ceiling but I don’t think we have reached it yet.” Read full story (paywalled) Source: HSJ, 19 March 2025- Posted
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USA: At little-known health agency, DOGE ends dream ‘to make a difference’
Patient Safety Learning posted a news article in News
Heather Sherman is one of the thousands of federal employees dismissed by a weekend email telling them they were “not fit for future employment.” The trauma of that abrupt ending in mid-February — giving her just a few hours before all access was shut off — still lingers. “This was my dream job,” Sherman said. If Sherman were an air traffic controller or nuclear materials expert, her work keeping the public safe would be obvious. But as a mid-level employee with a technical role at a little-known agency in the mammoth Department of Health and Human Services, her curt dismissal and that of an undisclosed number of AHRQ colleagues prompted not even a ripple of news coverage. Yet what a New York Times editorial decried as a “haphazard demolition campaign” by the Elon Musk-led Department of Government Efficiency, one that is undermining “the safety and welfare of the American people,” applies to agencies like AHRQ and low-profile jobs like Sherman’s just as much as to more high-profile positions. In complex systems, of which healthcare is surely one, carelessness has consequences. A 2023 report by the President’s Council of Advisors on Science and Technology declared patient safety “an urgent national public health issue.” In truth, the urgency is embraced mostly by a small number of individuals determined to drastically reduce the estimated 160,000 Americans perishing each year from preventable medical errors in hospitals. Read full story Source: Forbes, 13 March 2025- Posted
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The hospital where Lucy Letby murdered babies is now being investigated for gross negligence manslaughter as well as corporate manslaughter, police have announced. Cheshire Constabulary has released a statement saying that its corporate manslaughter investigation into the Countess of Chester Hospital NHS Foundation Trust has been “widened”. “We will not be confirming the number of people involved or their identity" The scope of the investigation now includes gross negligence manslaughter, which is where a death is caused by an otherwise lawful but grossly negligent “act or omission” by an individual or individuals. The corporate manslaughter investigation, which is looking into the actions of senior leaders at the hospital trust in relation to deaths at the neonatal unit, was launched in October 2023. This happened a few months after the conviction of 35-year-old Letby for the murder of seven babies and attempted murder of six others while working as a neonatal nurse at the trust in 2015 and 2016. Letby was later found guilty of attempting to murder a seventh baby. Read full story (paywalled) Source: Nursing Times, 14 March 2025- Posted
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Two more directors exit trust where ‘poor behaviour was tolerated’
Patient Safety Learning posted a news article in News
Two non-executive directors have left the board of a mental health trust just a few months after the early departure of its chair. HSJ understands Janet Bailey, a non-executive director appointed in January 2022 and also a senior nurse and academic, was suspended by the trust and her three-year term was not renewed. Another NED, Alison Geeson, who is a senior lecturer in mental health nursing at Wolverhampton University, resigned last week. This was described as “unexpected” by sources within the trust. Ms Geeson has been an NED since 2020 and was Freedom to Speak Up Lead and Wellbeing Lead for the board. In an internal email seen by HSJ, interim chair Philip Gayle announced her resignation to staff and wrote that it was with a “heavy heart” he informed staff of Ms Geeson’s decision to step down, which she felt was “the best decision for her at this time”. The 2024 staff survey results, published on Thursday, also saw a decline at BCHFT across numerous key measures. The proportion of staff recommending the trust as a place to work fell from 58 per cent to 52 per cent, far below the 65 per cent national average. The trust also reported the lowest in England for staff agreeing that colleagues “are understanding and kind to one another”, with 69 per cent agreeing. In an internal email to staff as scores were published, BCHFT CEO Marsha Foster said: “The overall picture indicates that we still have a lot of work to do to address the challenges we face. ”We understand for some of you, your experience of working here is positive, but we also know that for others there are significant areas where things are not working as well as they should.” Ms Foster told staff the trust was “committed to making improvements”. Read full story (paywalled) Source: HSJ, 14 March 2025- Posted
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