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Found 93 results
  1. Event
    until
    The duty of candour is a central to patient safety – the idea that, when things go wrong, healthcare professionals should be open and honest about this with patients and colleagues. But while incident reporting is a central plank to patient safety, the evidence still suggests that adverse outcomes and near misses are under-reported. This even before the challenges of the pandemic – which has left staff understandably exhausted, overstretched and under pressure – is taken into account. So how, in an environment as challenging as the service currently finds itself in, can candour in he
  2. News Article
    Labour is to push for key changes to the government’s NHS reforms, with new laws on transparency in the NHS and a demand for safe staffing levels on hospital wards, following a series of scandals relating to failures in patient care. Amendments to the government’s Health and Care Bill will also include plans for the investigation of stillbirths by medical examiners, and for limits on the power of the health secretary to interfere in investigations. Labour’s shadow health secretary Jonathan Ashworth believes the changes – which also include giving local NHS regions the ability to obje
  3. Content Article
    'To support all prescribers in prescribing safely and effectively, a single prescribing competency framework was originally published by the National Prescribing Centre/National Institute for Health and Care Excellence (NICE) in 2012. NICE and Health Education England approached the Royal Pharmaceutical Society (RPS) to manage the update of the framework on behalf of all the prescribing professions in the UK. A Competency Framework for all Prescribers was first published by the RPS in July 2016. Going forward, the RPS will continue to maintain and publish this framework in collabora
  4. Content Article
    The Ombudsman transparently and thoughtfully reflects on improvements needed in the Ombudsman’s service. Derek reflects on the improvements he is looking for from other organisations and the healthcare system. Messages and themes include: not listening to the concerns of the mother and failings during labour and birth patients having to join the dots to get information and investigations confusing system and organisational responsibilities for responding to complaints is the system is learning and taking action to prevent future avoidable harm?
  5. Content Article
    Read the full article here. Related reading The history of Duty of Candour and why Robbie’s Law matters (September 2020) The Duty of Candour – where are we now? By Peter Walsh (January 2020) When the Duty of Candour becomes personal by Sarah Sneddon (September 2020) Other articles by this author Primodos: The next steps towards justice (November 2020) Mesh: Denial, half-truths and the harms (March 2021) Sodium Valproate: The Fetal Valproate Syndrome Tragedy (June 2021) Primodos, Mesh and Sodium Valproate: Recommendations and the UK Gove
  6. Content Article
    In the two weeks before his death Robbie was seen seven times by five different GPs. The child was seen by three different GPs four times in the last three days when he was so weak and dehydrated he was bedbound and unable to stand unassisted. Only one GP read the medical records, six days before death, and was aware of the suspicion of Addison's disease, the need for the ACTH test and the instruction to immediately admit the child back to hospital if he became unwell. The GP informed the Powells that he would refer Robbie back to hospital immediately that day but did not inform them that
  7. News Article
    An NHS trust has become the first in the country to individually contact every family of patients who caught coronavirus while they were in hospital in a large-scale bid to be transparent over the scale of infections. Bosses at the Queen Elizabeth Hospital Kings Lynn NHS Trust have set up a team to work through hundreds of cases where patients caught coronavirus in hospital. At least 99 patients are known to have died after becoming infected with more cases still to review. In a unique approach to transparency the trust is sending a letter by recorded delivery to every affected
  8. News Article
    Hospitals have been accused of “unnecessary secrecy” for refusing to disclose how many of their patients died after catching Covid on their wards. The Patients Association, doctors’ leaders and the campaign group Transparency International have criticised the 42 NHS acute trusts in England that did not comply fully with freedom of information request for hospital-acquired Covid infections and deaths. The Guardian revealed on Monday that up to 8,700 patients lost their lives after probably or definitely becoming infected during the pandemic while in hospital for surgery or other treat
  9. News Article
    Nearly 90% of organisations representing doctors agree that the UK should have a mandatory and public register of doctors’ interests, a survey by The BMJ has found. Last year the Independent Medicines and Medical Devices Safety Review, chaired by Julia Cumberlege, called for the General Medical Council (GMC) to expand its register to include a list of financial and non-pecuniary interests for all doctors. That review investigated harmful side effects caused by the hormone pregnancy test Primodos, the anti-epileptic drug sodium valproate, and surgical mesh. One of its key conclusions
  10. Content Article
    Grundy et al. used Carol Bacchi’s problem-questioning approach to policy analysis to compare the Sunshine policies in three different jurisdictions, the United States, France and Australia. We found that transparency had emerged as a solution to several different problems including misuse of tax dollars, patient safety and public trust. Despite these differences in the origins of disclosure policies, all were underpinned by the questionable assumption that informed consumers could address conflicts of interest. The authors conclude that, while transparency reports have provided an unprecedente
  11. Content Article
    A recent blog I wrote (see link below) brings together key information for clinicians, and especially for prescribers, from a variety of sources, including patients, relatives and carers. The aim is to help to prevent patients with autism and learning disabilities being harmed by inappropriate medicines. I began this in 2018 following the death of Oliver McGowan, which I cover in teaching for (non-medical) prescribing students and in my clinical education work. It links to the NHS Learning Disability Mortality (LeDeR) Review Programme. Key points: Most of the prescribing in thi
  12. News Article
    The Department of Health and Social Care (DHSC) has been criticised by the national health ombudsman for the ‘maladministration’ of a 2018 review into the death of a teenage girl under the care of one of England’s top specialist hospitals, HSJ can reveal. The Parliamentary and Health Service Ombudsman (PHSO) came to the conclusion after investigating a DHSC review into the 1996 death of 17-year-old Krista Ocloo which had been requested by her mother. Krista died at home of acute heart failure in December 1996. She had been admitted to the Royal Brompton Hospital with chest pains in J
  13. Community Post
    I've been posting advice to patients advising them to personally follow up on referrals. Good advice I believe, which could save lives. I'm interested in people's views on this. This is the message I'm sharing: **Important message for patients relating to clinical referrals in England** We need a specific effort to ensure ALL referrals are followed up. Some are getting 'lost'. I urge all patients to check your referral has been received, ensure your GP and the clinical team you have been referred to have the referral. Make sure you have a copy yourself too. Things
  14. Community Post
    Do you have a patient safety newsletter in your Trust? It would be very interesting for others to see how your is set out and the content. Here is one from Cardiff and Vale.
  15. Content Article
    When considering the persistence of unsafe care, a recurring theme that emerges is a failure to involve patients in their own care. Patient safety concerns raised by patients and family members are too often not acted on and, when harm occurs, they are often left out of the investigation process. As set out in Patient Safety Learning’s A Blueprint for Action, we share the view that patient engagement is key to improving patient safety, with this forming one of our six foundations of safer care.[1] The NHS Patient Safety Strategy identifies the involvement of patients in patient safety “th
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