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Found 86 results
  1. Content Article
    On the 9 December 2022, Dennis John William King suffered sudden chest pain which extended down his arm. His wife called 999 and spoke with an ambulance service call handler. Following triage of the call, the response to Mr King's call was graded as a Category 3 (a potentially urgent condition which is not life threatening with a target response of 120 minutes). This call was subsequently re-graded following review in the call centre to a Category 2 (a potentially serious condition requiring rapid assessment, urgent on scene intervention or transport to hospital, with a response within 40 minutes and a target of 18 minutes).   Upon hearing that the waiting time for an ambulance could be as long as six hour, Mr and Mrs King decided to make their own way to the West Suffolk Hospital. The ambulance service were advised and the response stood down.   Within 40 minutes of arrival Mr King had been diagnosed as suffering an ST segment elevation myocardial infarction (STEMI). Treating clinicians assessed his condition as necessitating an urgent transfer to the Royal Papworth and for the angioplasty procedure to be conducted forthwith. The ambulance call centre was contacted by the hospital emergency department with a request for an urgent transfer to the Royal Papworth. Emergency department staff were advised that there would be a 5 hour delay for an ambulance to attend. The call from the hospital emergency department to the ambulance service was graded by the ambulance call handler as a category 2 response. When the response timing was challenged the emergency department matron was advised that the hospital was a place of safety. The ambulance call handler assessment did not seem to take into account the clinical assessment of accident and emergency department staff who, in consultation with the regional cardiac intervention hospital, had determined Mr King's further treatment at the regional cardiac centre was a matter of urgency. An ambulance subsequently arrived at West Suffolk Hospital Accident and Emergency Department and transferred Mr King to the Royal Papworth Hospital where he underwent treatment for what was identified as an occluded left anterior descending artery. About 1 hour after the procedure, Mr King's condition deteriorated and he suffered a left ventricular wall rupture, a recognised complication of either the myocardial infarction he had suffered or the surgical procedure to correct the occluded artery, or both. He received emergency surgery to repair the rupture by way of a patch which was successful. However, his condition deteriorated and he died on the 13 December 2022. The medical cause of death was confirmed as: 1a Multi Organ Failure 1b Post myocardial infarction left ventricular free wall rupture (operated on).
  2. News Article
    The availability of ambulances to transfer patients to specialist units is a "matter of concern", a coroner has warned. Darren Stewart, area coroner for Suffolk, made the comments in a Prevention of Future Deaths report. It followed the death of 84-year-old Dennis King, who waited three hours to be transferred from West Suffolk Hospital to Royal Papworth in 2022. Mr King had made his own way to the West Suffolk Hospital's accident and emergency department in December 2022, after being told an ambulance could take six hours to arrive at his home due to high demand in the area, the report said. His call had been graded as category two, which should have led to a response within 40 minutes - or a target of 18 minutes. After tests at West Suffolk Hospital showed Mr King had suffered a STEMI heart attack, emergency clinicians liaised with experts from the regional heart unit and decided he needed an urgent transfer to Royal Papworth in Cambridgeshire. The report said a matron at West Suffolk told ambulance call handlers they needed an urgent transfer - but because Mr King was classed as being in a "place of safety", control room staff said the delay would be "several hours". Mr Stewart said: "the availability of ambulances to carry out transfers in a timely manner, in urgent cases" was "a matter of concern". In the report, Mr Stewart said the circumstances of the case "raised concerns about the NHS approach to centralising care in regional centres" if the means to deliver it were "inadequate". Read full story Source: BBC News, 23 January 2024
  3. Content Article
    Diagnostic errors contribute to patient harm, though few data exist to describe their prevalence or underlying causes among medical inpatients. The aim of this study published by Jama Internal Medicine was to determine the prevalence, underlying cause, and harms of diagnostic errors among hospitalised adults transferred to an intensive care unit (ICU) or who died. The results showed that diagnostic errors were common and associated with patient harm. Problems with choosing and interpreting tests and the processes involved with clinician assessment are high-priority areas for improvement efforts.
  4. Content Article
    Ileostomy is a common treatment option for various gastrointestinal conditions. This study in Surgery aimed to examine how receiving care at different facilities might increase the risk of post-discharge complications and readmission following ileostomy. The authors used a national cohort to explore the associations of care fragmentation among ileostomy patients experiencing adverse outcomes and increased hospitalisation.
  5. Content Article
    Andrew Guillaume was admitted to Warwick Hospital on the 6 June 2023. Following a review, it was agreed that the likely diagnosis was severe aortic stenosis requiring an urgent Consultant to Consultant referral to University Hospitals Coventry and Warwickshire (UHCW) cardiology team. However, no referral was made as the Consultant was unable to get through to the switchboard at UHCW, so Mr Guillaume remained at Warwick Hospital. Subsequently his condition worsened and on the 16 June 2023 a plan was made to update the cardiothoracic surgery team at UHCW to expedite his surgery, but again they were unable to reach the team through the switchboard. Mr Guillaume was admitted to the unit on 19 June 2023, but sadly died on 20 June 2023 due to a further sudden deterioration in his condition.
  6. Content Article
    This observational cross-sectional study in the American Journal of Surgery aimed to quantify the association between US state trauma funding and both in-hospital mortality and transfers of injured patients. The authors concluded that Increased state trauma funding is associated with decreased adjusted in-hospital mortality and fewer interfacility transfers to a second acute care hospital.
  7. Content Article
    Christina Ruse was admitted to the Spire Hospital on 14 December 2021 and underwent a total left hip replacement. Her condition deteriorated and observations were commenced at five minute intervals. Mrs Ruse was reviewed and on further deterioration in her condition it was decided to transfer her to the High Dependency Unit, Norfolk and Norwich University Hospital. On arrival of the ambulance Mrs Ruse was undergoing a further investigatory procedure. On this being completed Mrs Ruse was taken to the Norfolk and Norwich University Hospital, where her condition continued to deteriorate and she died on 15 December 2021.
  8. Content Article
    Barbara Hollis underwent a total left knee replacement operation on 22 February 2022. The surgery was uneventful with no complications, however after her return to the ward Mrs Hollis became restless and confused. Following a review of her deteriorating condition the decision was made to transfer her to the High Dependency Unit at the Norfolk and Norwich University Hospital. Arrangements were made for the transfer and the ambulance service was called at 19.51 and were told that immediate clinical intervention was needed, but the agreed hospital to hospital transfer pathway was not followed. There was a two hour delay in ambulance attendance, during which time Mrs Hollis continued to deteriorate. Mrs Hollis was subsequently taken to the High Dependency Unit at the Norfolk and Norwich University Hospital where her condition continued to deteriorate and she died in the early hours of the 23 February 2022.
  9. News Article
    A coroner has warned that a private hospital is relying on NHS ambulances to transport patients despite “being fully aware” of the pressures on the ambulance service and resulting delays. The warning came at the end of an inquest into a patient who died after a 14-hour wait for an ambulance to transfer him from the private Spire hospital in Norwich to the NHS-run Norfolk and Norwich university hospital a few minutes’ drive away. The last two years have seen a succession of inquests relating to ambulance delays. But in the latest case Jacqueline Lake, senior coroner for Norfolk, expressed concerns over Spire hospital’s use of NHS ambulances when complications and emergencies mean its patients need NHS care. “Spire Norwich hospital does not deal with multi-disciplinary and emergency treatment at its hospital and transfers patients requiring such treatment to local acute trusts, usually the Norfolk and Norwich university hospital,” Lake wrote in a prevention of future deaths (PFD) report. “Spire Norwich hospital continues to rely on EEAST [East of England Ambulance Service NHS Trust] to transport such patients to the acute hospital, being fully aware of the demands placed on the EEAST generally and the delays which occur as a result.” Research suggests that nearly 600 patients were urgently transferred from private healthcare to NHS emergency care in the year to June 2021 across the UK – around one in a thousand private healthcare patients. But previous analysis by the Centre for Health and the Public Interest (CHPI) thinktank found that some private hospitals were transferring more than one in every 250 of their inpatients to NHS hospitals. ‘“Transferring unwell patients from a private hospital to an NHS hospital is a known patient safety risk which all patients treated in the private sector face – including the increased numbers of NHS patients who are now being treated in private hospitals because of government policy,” said David Rowland, director of the CHPI. “And despite numerous tragedies and despite the fact that politicians and regulators are fully aware of this risk, nothing has been done to address it.” Read full story Source: The Guardian, 23 September 2023
  10. Content Article
     On 3 August 2022, Geoffrey Hoad underwent a total hip replacement at The Spire Hospital. On 5 August 2022, Mr Hoad was diagnosed with a paralytic ileus and some respiratory compromise with gradually deteriorating renal function. On 6 August 2022, Mr Hoad’s transfer to Norfolk and Norwich University Hospital was agreed due to possible bowel obstruction, possible pulmonary infection and deteriorating renal function.   Ambulance service was called at 18:16 hours and again at 23.45. On 7 August 2022, the ambulance service was called again at 07.38 hours. The ambulance was on scene at 08:26 hours.         The medical cause of death was: 1a) Sub Acute Myocardial Infarction 1b)  Coronary Artery Atherosclerosis 2) Hospital Admission for Post Operative lieus.
  11. Content Article
    Recent polling from Healthwatch England shows that a fifth of patients referred by a GP for consultant-led care end up in a ‘referral black hole’, with more than two million patients each year having to make four or more visits to their GP before a referral is accepted. The result is that tens of thousands of patients could be on a ‘hidden’ waiting list, meaning that GPs are managing greater clinical risk and a greater number of patients whose conditions are often worsening in primary care, whilst communication between providers and access to diagnostics are often not up to scratch.  This report by the think tank Policy Exchange looks at reforms that could be made to the interface between primary and secondary care in order to improve care and prevent patient harm. It considers how improved flows of information and expertise can: better support growing demand in general practice reduce unwarranted variation in service provision enhance care coordination – particularly for those referred for elective procedures enable opportunities to boost generalist medical skills for a new generation of doctors create opportunities for hospital specialists to deliver a greater proportion of care in primary or community care settings, reducing waiting times and the use of more expensive settings for care.
  12. Content Article
    Delayed discharges, where a patient is medically fit to leave hospital but is not discharged, were a particular problem in England in the winter of 2022/23. In this article, Camille Oung from the Nuffield Trust highlights some possible solutions to help better prepare health and care services for discharge pressures next winter.
  13. Content Article
    Delays in the handover of patient care from ambulance crews to emergency departments (EDs) are causing harm to patients. A patient’s health may deteriorate while they are waiting to be seen by ED staff, or they may be harmed because they are not able to access timely and appropriate treatment. This national investigation sought to examine the systems that are in place to manage the flow of patients through and out of hospitals and consider the interactions between the health and social care systems (the ‘whole system’). This report brings together the findings from the investigation’s three interim reports and provides an update since they were published. You can view the interim reports on the hub: Interim report 1 (16 June 2022) Interim report 2 (3 November 2022) Interim report 3 (27 February 2023)
  14. Content Article
    The eDischarge Information Record Standard was first published in 2015. Despite significant investment in programme initiatives, the widespread implementation of the standards has been slow.  In this report from the Professional Record Standard Body, authors identify the challenges that have inhibited the adoption of the standard, make recommendations for improvements and set out the anticipated benefits that this will bring. The aims of this discovery and user-design phase were: To review the current state of adoption of transfer of care messages between secondary care senders and primary care receivers of transfers of care and identify reasons for the low uptake to date. To understand GP’s needs and priorities for computer readable data that can be shared with primary care systems without loss of meaning. To make recommendations for what needs to happen to enable widespread adoption that supports the needs of GPs to deliver safer patient care.
  15. News Article
    Private and NHS ambulance services are reviewing safety procedures after the Care Quality Commission identified a series of risks to mental health patients being transported by non-emergency providers. The care watchdog wrote to all providers of non-emergency patient transport earlier in the summer, warning of concerns identified at recent inspections about use of restraints, sexual safety, physical health needs, vehicle and equipment safety standards, and unsafe recruitment practices. The letter, seen by HSJ, stated: “We know there are many independent ambulance providers providing a good standard of care. Unfortunately, our recent inspections suggest that this is not always the case." “We expect providers to deliver on their commitment to provide safe, high-quality care and we will do everything within our powers to ensure this happens.” Read full story (paywalled) Source: HSJ, 4 August 2022
  16. News Article
    Several trusts have now started reporting thousands of 12-hour waits in their emergency departments, representing a huge difference to the numbers published nationally under a slightly different measure. This year, trusts have started submitting data to NHS England on the number of patients waiting over 12 hours from time of arrival in ED, until discharge, admission or transfer. Many trusts are now reporting these statistics in their public board reports. This is a slightly different measure to the publicly reported “trolley wait” figures, which count waits of over 12 hours from decision to admit until admission. Experts have long argued the trolley wait measure does not capture the true problem of ED overcrowding and delayed care. The new data captures a far higher number of patients and has not been published nationally by NHSE. Read full story (paywalled) Source: HSJ, 2 August 2022
  17. News Article
    A woman who died shortly after giving birth to her daughter did not receive the correct medication, a coroner has ruled. Jess Hodgkinson, 26, from Chesterfield, died from a pulmonary embolism in 2021. Assistant coroner Matthew Kewley said there was a "failure" to ensure Ms Hodgkinson received blood thinners right up until the birth. Chesterfield Coroner's Court heard Ms Hodgkinson had a high risk pregnancy due to severe hypertension. On 21 April 2021, a consultant in Chesterfield prescribed a prophylactic dose of tinzaparin due to an increased risk of clotting, the inquest heard. During the inquest, the consultant said the intention was for Ms Hodgkinson to continue to receive a daily dose of anticoagulant medication up until birth. Ms Hodgkinson was transferred to a hospital in Sheffield the next day, but there was a "failure to communicate" the medication plan, Mr Kewley said. After being discharged, clinicians in Chesterfield "failed to identify" Ms Hodgkinson was no longer receiving the medication, the coroner said in his ruling. On 13 May, Ms Hodgkinson attended Chesterfield Royal Hospital and a decision was made to carry out an emergency Caesarean section. The procedure was successful and Ms Hodgkinson's baby was born. But after delivery, Ms Hodgkinson went into cardiac arrest and later died. In his concluding remarks, Mr Kewley said: "There was a failure to ensure that Jess received anticoagulant medication that a clinician had intended should be taken until birth. This failure made a more than minimal, negligible or trivial contribution to Jess' death". Read full story Source: BBC News, 31 January 2023
  18. Content Article
    This study in the journal Dove Press aimed to explore the experience of patient safety culture among South Korean advanced practice nurses in hospital-based home healthcare. 20 nurses involved in home healthcare were recruited from twelve hospitals located in three different cities throughout South Korea. The authors concluded that there were significant aspects of patient safety culture in hospital-based home healthcare, allowing for good continuity of care for patients. These aspects include communicating with caregivers, building community partnerships, understanding unexpected home environments and enhancing the safety of nurses.
  19. Content Article
    Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system. This article explores how HFE can be used to improve patient safety, in particular using the Systems Engineering Initiative for Patient Safety (SEIPS) model, which depicts key characteristics and interactions between three core components: work system process outcomes
  20. Content Article
    The Patients Association has been working with NHS England to look at how to improve GP referrals of patients to hospital. The goal was to look at ways specialists could support GPs so they could reduce the number of outpatient appointments patients have to attend, without compromising care. This report includes an overview of the patient panel workshops, key themes and findings from the workshops, and a set of recommendations.
  21. News Article
    Angry exchanges between paramedics and A&E staff in Liverpool have broken out after new measures were deployed to hold and treat patients in the back of ambulances. Sources said there have been “Mexican standoff” situations at Aintree Hospital in recent days, after hospital staff insisted patients who had been brought inside should be returned to ambulance vehicles. Staff at North West Ambulance Service told HSJ they were informed of a new protocol last week, which said patients should be kept in the back of ambulances if the corridor of the emergency department is full with patients. There have been repeated orders from NHS England and the Care Quality Commission over the past year for hospitals to ensure patients can be offloaded by ambulance crews, even if they fear they do not have adequate staffing or beds to accept them. One senior source at NWAS said: “To see a new protocol like this is absolutely unprecedented. I very much doubt the execs had approved it. “We’ve had Mexican standoff situations over the weekend with crews who have brought patients into ED being told to take them back out to their vehicles, but they’ve refused to do this as it means they cannot cohort. “We completely accept that taking extra patients means the ED and hospital staff have to deal with additional and unacceptable risk, but holding ambulances is not the solution because the risks to patients out in the community are even greater. Despite repeated instructions from NHS England and the CQC this still doesn’t seem to be understood.” Read full story (paywalled) Source: HSJ, 17 October 2022
  22. Content Article
    Improving medication safety during transitions of care is an international healthcare priority. While existing research reveals that medication-related incidents and associated harms may be common following hospital discharge, there is limited information about their nature and contributory factors at a national level which is crucial to inform improvement strategy. This study in the journal Therapeutic Advances in Drug Safety aimed to characterise the nature and contributory factors of medication-related incidents during transitions of care from secondary to primary care. The authors found several themes for future research that could support the development of interventions, including: commonly observed medication classes older adults increase patient engagements improve shared care agreements for medication monitoring post hospital discharge.
  23. News Article
    GP leaders have written to NHS England to demand that an NHS hospital trust urgently restores routine referrals as it has 'closed its doors' to some patients, ‘destabilising’ practices in the process. Oxfordshire LMC said local GPs are ‘concerned and angry’ about the ‘ongoing closure’ to routine referrals across multiple ‘high-demand’ specialties by Oxford University Hospital Foundation Trust, while warning GPs are also being asked to carry out tests that should be done in hospital. A ‘significant’ number of specialties are affected, including ENT, general gynaecology, dermatology, ophthalmology, endoscopy and urology, as well as plastics and maxillofacial, it added. The hospital trust said it had remained open for urgent and emergency care and was accepting clinically urgent and suspected cancer referrals, while reinstating services to support 'the vast majority' of routine referrals. But Oxfordshire LMC has this week written to NHS England and the council of governors at OUHFT to demand that there are ‘no further delays’ in restoring the services amid concerns of ‘patient harm’. It said: ‘The LMC believes the continuing closure of some specialty services to routine referrals is now so serious for patients that it has taken a decision to formally raise the concerns of Oxfordshire’s GPs with NHS England.’ Read full story Source: Pulse, 13 August 2020
  24. News Article
    The first hospital dedicated to helping coronavirus patients recover from the long-term effects of the illness has received its first patients. Surrey's NHS Seacole Centre opened this month at Headley Court, a former rehab centre for injured soldiers. COVID-19 patients can be left with tracheostomy wounds from having a tube inserted in the windpipe or need heart, lung or muscle therapy, the NHS said. Others who have survived the virus may need psychological or social care. NHS chief executive Sir Simon Stevens said: "While our country is now emerging from the initial peak of coronavirus, we're now seeing a substantial new need for rehab and aftercare." He said while patients had survived life-threatening complications, many would see a longer-lasting impact on their health. Read full story Source: BBC News, 29 May 2020
  25. News Article
    The next few months will be full of grim updates about the spread of the new coronavirus, but they will also be full of homecomings. Patients hospitalised with severe COVID-19, some having spent weeks breathing with the help of a mechanical ventilator, will set about resuming their lives. Many will likely deal with lingering effects of the virus — and of the emergency treatments that allowed them to survive it. “The issue we’re all going to be faced with the most in the coming months is how we’re going to help these people recover,” says Lauren Ferrante, a pulmonary and critical care physician at the Yale School of Medicine. Hospital practices that keep patients as lucid and mobile as possible, even in the throes of their illness, could improve their long-term odds. But many intensive care unit doctors say the pandemic’s strain on hospitals and the infectious nature of the virus are making it hard to stick to some of those practices. Read full story Source: Science, 8 April 2020
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