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Found 72 results
  1. Event
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    The importance of healthcare data and good data practices continues to grow as the COVID-19 pandemic drives further digitalisation and creates new data streams. This free online event from the King's Fund explores the importance of patients trusting that their health and care data will be safely and responsibly used by the NHS. Now is the time to come together and look at how we can modernise protocols and ensure trust is built with the public. This event is the first in a series exploring how we put trust, transparency and fair value at the centre of digital health and care. Our expert panel will discuss what public institutions, industry and decision-makers that hold, control and use our most personal data are doing to help to maintain and improve trust in England while simultaneously modernising best practice. Register
  2. Content Article
    In the early days of my career, I worked with clinical teams while managing a hospital and later a network of hospitals. I must say, the experience I gathered in these different roles shaped me into what I am today. I can fit into healthcare conversations easily because of these early relationships and interactions with clinical experts. When I look back to my experience as a hospital administrator, a particular incident keeps coming back to mind; I sometimes link this to my later involvement in patient safety but most times I feel it is my conscience speaking to me. There was a patient we were trying to give a surgical intervention to; although he was already in a bad condition, he stood a chance to survive yet he died. We had an antenatal case we had managed from conception and the lady had opted for an elective caesarean section (CS). When she was term, we brought her in and prepared her for the theatre. At the time set of the surgery, our anaesthetist was not available; he was assisting another surgery in another facility, but he gave us a name of his anaesthetist colleague we could use for this patient. We brought this new anaesthetist in to assist in the patient’s CS. While we stretchered in the lady for her elective CS, a severe emergency case was rushed in needing an urgent surgical intervention. This case obviously had to override the elective CS in order of triage. We returned the lady to her ward while we rushed to the emergency case. The medical team that was going to operate on the CS patient was now needed for this new case. About 20 minutes into the surgery, our lead surgeon came out of the theatre with an upset look on his face. I sensed something was wrong and I immediately led him into my office which was near to the theatre and locked the door. I asked him what happened? He told me that there had been an anaesthesia accident. The new anaesthetist we brought in to assist with the surgery had not understood our anaesthetic machine as he had never used it before. He had used the machine incorrectly and had given the patient an overdose of gas and the patient’s heart packed up. The lead surgeon was very upset. I was thinking, this could have been my Dad, my Mum or any of my family members; it was a totally life-changing experience for me. The relatives of the patient were notified that the patient had died; there was wailing and shouting in the hospital. I locked myself inside my office and cried because I knew this patient should not have died from an error of one man. I imagined the pain we had caused the family; the grief and the vacuum we created by our error. It was all too much horror for my fragile heart to deal with at that time. But the greatest mistake we made was that the error was never discussed among the team for us all to learn from and we were also not honest enough to own up to the patient’s relatives. This incident led me into researching and reading materials on medical safety and this was how I got into patient safety advocacy. But when I look back at the incident today, was it the anaesthetist’s fault? No not at all; it was the fault of the system. The anaesthetist should not have been allowed access to that machine in the first place as he had not been trained to use that machine. This was where we should have trapped the risk before it got to the patient. In safety, when you change or replace a machine or a piece of equipment your policy must be reviewed to capture the new equipment and users must be trained on the new machine in its specifications and peculiarities. This is what happens in aviation. A pilot cannot fly an aircraft which he has not been simulated to fly and this is one of the reasons why aviation is still one of the safest sectors in the world today.[1] Having established that it was a system error, we should have also been professional and honest enough to let the relatives of the patient know what had actually happened. When we are honest it shows clear transparency, but when we try to sweep things under the carpet it is mostly misunderstood that our actions could have been deliberate. As I am writing this article, I am sure the relatives of the patient, many years down the line, still don’t know what actually happened. Following the Communication and Optimal Resolution (CANDOR) processes,[2] we should have made an early and honest disclosure of the adverse event known to the patient’s relatives, offered them an apology, refunded their payment and let them know how much this mattered to us and what we were going to do to improve our system. Our actions totally contravened all required amicable and fair resolution for the patient’s family. Owing to the fact that every man is fallible – this is why we are mere mortals in the first place – there may be errors but losing the opportunity to learn from those errors is deliberately creating new levels of errors. We never discussed what happened to our patient. I was the only one who got to know about this incident outside the clinical team who were in the theatre when this happened. The Medical Director may not have even known, so the case was never discussed and we could never all learn from it. When I think of this, I feel we need more openness and information sharing in healthcare, allow teams to discuss and share experiences, give room for reporting without blame, design a system that encourages patient safety conversation and liberalise communication processes. Each time this incident crosses my mind, I think of the lady who we had originally booked for elective CS. This clinical team was put together for her CS before the sudden emergency that came to take her place. She never knew what happened. The evening of that same day her CS was done and she had her baby boy who should be a grown man now. This brings to mind the bible verse Isaiah 43.4 “…I will give people in exchange for you, nations in exchange for your life”. Could this have been what happened? No, the system is what killed the patient and I think we should all own up to this. References Kai-Jorg S. Pilot training: What can surgeons learn from it? Arab Journal of Urology 2014;1: 32-35. Agency for Healthcare Research and Quality (AHRQ). Communication and Optimal Resolution (CANDOR).
  3. 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 Addison's disease had been suspected. The referral letter was not typed until after Robbie had already died and was backdated to the day following the consultation. In a statement after Robbie's death this GP stated: "An Addisonian crisis is precipitated by an intercurrent illness and the stress it induces." Dyfed-Powys Police investigated Robbie's death between 1994 and 1996 but asserted, supported by the Crown prosecution Service in Wales, that there was no evidence of crimes committed by the GPs who, incidentally, were retained by this police force as police surgeons. Following a complaint by Will Powell (Robbie's father) in 1998 against the Deputy Chief Constable of Dyfed-Powys Police, regarding the inadequacies of the criminal investigation, a second criminal investigation was agreed, which commenced in January 1999. As with the first criminal investigation, there was a gross failure to adequately investigate the criminality of the doctors. This resulted in Will Powell making a formal complaint against the Chief Constable of Dyfed-Powys Police in late 1999. This complaint against the Chief Constable resulted in Dyfed-Powys Police appointing an outside police force to review Robbie's case in 2000. Detective Chief Inspector Robert Poole [DCI Poole] from West Midlands Police was appointed. DCI Poole’s investigation report, entitled 'Operation Radiance', which was based on the documents provided to Dyfed Powys Police in March 1994, by Will Powell and his solicitor, was submitted to CPS York in March 2002. This report put forward 35 suggested criminal charges against five GPs and their medical secretary. The listed charges were: gross negligence manslaughter forgery attempting to pervert the course of justice conspiracy to pervert the course of justice. DCI Poole's investigation also resulted in a disciplinary inquiry by Avon & Somerset Constabulary into Will Powell's allegations of misconduct against Dyfed-Powys Police officers with regards to their two inept criminal investigations between 1994 and 2000. Dyfed-Powys Police was found to have been 'institutionally incompetent' but no police officer was made accountable. In April 2003, Will Powell met representatives from the CPS in London, who accepted there was sufficient evidence to prosecute two GPs and their secretary for forgery and perverting the course of justice. However, they would not prosecuted because of (1) the passage of time, which was caused by a decade of cover ups between 1990 and the appointment of DCI Poole in 2000, (2) Dyfed Powys Police had provided the GPs with a letter of immunity, and (3) the available evidence had been initially overlooked by the police and the CPS, between 1994 and 2000, for a variety of reasons. Following a 2013 adjournment debate, in the House of Commons, the Director of Public Prosecutions subsequently agreed, in October 2014, that there would be an independent review of the decisions made by Crown Prosecution Service, in 2003, not to prosecute, when there was sufficient evidence to do so. The reviewing Queen's Counsels have been provided with a report, written by myself ( a healthcare IT professional, former head of IT in an NHS trust and clinician) on major anomalies in Robbie's Morriston Hospital computerised records, which were erased during the first criminal investigation between 1994 and 1996. The review has not been concluded six years on. The letter below (and also attached) from the English and Welsh Ombudsman was sent on 10 November 2020 sets out the case for a Public Inquiry.
  4. Event
    The approach to resolution of adverse events in hospital and healthcare organisations has remained subpar for decades and open and honest communication is often compromised in favour of litigation. Models like CANDOR have been recognized as essential to transparency, person-centeredness, and healthcare quality and safety. The impactful implementation of CANDOR into organisational culture requires commitment, prioritisation, involvement from all, and event analysis for continuous improvement. Register
  5. News Article
    The chief inspector of hospitals has called for honesty about the impact of the coronavirus pandemic on patients warning poor care could become normalised. Professor Ted Baker told The Independent it was vital staff continued to report incidents and revealed the Care Quality Commission had seen a 60% rise in whistleblowing concerns during the last national lockdown in November. He said staff must report incidents and be free to speak up about any concerns as well as being transparent with families where things have gone wrong. He emphasised that where a patient was unable to get the care they clinically needed because of the demand on services, this would amount to a notifiable patient safety incident. Professor Baker’s comments follow multiple anonymous leaks from NHS staff to The Independent in recent weeks, showing how bad the situation has become in some hospitals. Many staff have only spoken out on condition of anonymity. Many hospitals have declared major incidents, cancelled operations and been forced to stretch staffing ratios to unsafe levels to cope with the increasing numbers of COVID-19 patients. Read full story Source: The Independent, 7 January 2021
  6. News Article
    Patient Safety Learning Press Release 10th December 2020 Today the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust published its first report on its findings.[1] The report made recommendations for actions to be implemented by the Trust and “immediate and essential actions” for both the Trust and the wider NHS. The Review was formally commissioned in 2017 to assess “the quality of investigations relating to new-born, infant and maternal harm at The Shrewsbury and Telford Hospital NHS Trust”.[2] Initially it was focused on 23 cases but has been significantly expanded as families have subsequently contacted the review team with their concerns about maternity care and treatment at the Trust. The total number of families to be included in the final report is 1,862. These initial findings are drawn from 250 cases reviewed to date. This is another shocking report into avoidable harm. We welcome the publication of these interim findings and the sharing of early actions that have been identified to make improvements to patient safety in NHS maternity services. We commend the ambition for immediate responses and action. Reflecting on the report, there are a number of broad patient safety themes, many of which have been made time and time again in other reports and inquiries. A failure to listen to patients The report outlines serious concerns about how the Trust engaged and involved women both in their care and after harm had occurred. This was particularly notable in the example of the option of having a caesarean section, where there was an impression that the Trust had a culture of wanting to keep the numbers of these low, regardless of patients’ wishes. They commented: “The Review Team observed that women who accessed the Trust’s maternity service appeared to have little or no freedom to express a preference for caesarean section or exercise any choice on their mode of deliver.” It also noted a theme in common with both Paterson Inquiry and Cumberlege Review relating to the Trusts’ poor response to patients raising concerns.[3] The report noted that “there have also been cases where women and their families raised concerns about their care and were dismissed or not listened to at all”. The need for better investigations Concerns about the quality of investigations into patient safety incidents at the Trust is another theme that emerges. The review reflected that in some cases no investigation happened at all, while in others these did take place but “no learning appears to have been identified and the cases were subsequently closed with it deemed that no further action was required”. One of the most valuable sources for learning is the investigation of serious incidents and near misses. If these processes are absent or inadequate, then organisations will be unable to learn lessons and prevent future harm reoccurring. Patient Safety Learning believes it is vital that Trusts have the commitment, resources, and frameworks in place to support investigations and that the investigators themselves have the right skills and training so that these are done well and to a consistently high standard. This has not formed part of the Report’s recommendations and we hope that this is included in their final report. Lack of leadership for patient safety Another key issue highlighted by the report is the failure at a leadership level to identify and tackle the patient safety issues. Related to this one issue it notes is high levels of turnover in the roles of Chief Executive, executive directors and non-executive directors. As part of its wider recommendations, the Report suggests trust boards should identify a non-executive director who has oversight of maternity services. Good leadership plays a key role in shaping an organisations culture. Patient Safety Leadership believes that leaders need to drive patient safety performance, support learning from unsafe care and put in place clear governance processes to enable this. Leaders need to be accountable for patient safety. There are questions we hope will be answered in the final report that relate to whether leaders knew about patients’ safety concerns and the avoidable harm to women and their babies. If they did not know, why not? If they did know but did not act, why not? Informed Consent and shared decision-making The NHS defines informed consent as “the person must be given all of the information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead”.[4] The report highlights concerns around the absence of this, particularly on the issue of where women choose as a place of birth, noting: “In many cases reviewed there appears to have been little or no discussion and limited evidence of joint decision making and informed consent concerning place of birth. There is evidence from interviews with women and their families, that it was not explained to them in case of a complication during childbirth, what the anticipated transfer time to the obstetric-led unit might be.” Again this is another area of common ground with other recent patient safety reports such as the Cumberlege Review.[5] Patient Safety Learning believes it is important that patients are not simply treated as passive participants in the process of their care. Informed consent and shared decision making are vital to respecting the rights of patients, maintaining trust in the patient-clinician relationship, and ensuring safe care. Implementation for action and improved patient safety In its introduction, the report states: “Having listened to families we state that there must be an end to investigations, reviews and reports that do not lead to lasting meaningful change. This is our call to action.” Responding with an official statement in the House of Commons today, Nadine Dorries MP, Minister for Mental Health, Suicide Prevention and Patient Safety, did not outline a timetable for the implementation of this report’s recommendations. In 2020 we have seen significant patient safety reports whose findings have been welcomed by the Department of Health and Social Care but where there has subsequently been no formal response nor clear timetable for the implementation of recommendations, most notably the Paterson Inquiry and Cumberlege Review. Patient Safety Learning believes there is an urgent need to set out a plan for implementing the recommendations of the Ockenden Report and these other patient safety reports. Patients must be listened to and action taken to ensure patient safety. [1] Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Emerging findings and recommendations form the independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, 10 December 2020. https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2020/12/ockenden-report.pdf [2] Ibid. [3] The Right Reverend Graham Jones, Report of the Independent Inquiry into the Issues raised by Paterson, 2020. https://assets.publishing.serv...; The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020. https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf [4] NHS England, Consent to treatment, Last Accessed 16 July 2020. https://www.nhs.uk/conditions/consent-to-treatment/ [5] Patient Safety Learning, Findings of the Cumberlege Review: informed consent, Patient Safety Learning’s the hub, 24 July 2020. https://www.pslhub.org/learn/patient-engagement/consent-and-privacy/consent-issues/findings-of-the-cumberlege-review-informed-consent-july-2020-r2683/
  7. News Article
    The NHS is under pressure to publish a delayed review into a bullying scandal at Matt Hancock’s local hospital that involved senior clinicians being asked to provide fingerprint samples in a “witch-hunt” for a whistleblower. The “rapid review” into West Suffolk hospital, which Hancock had to recuse himself from because of his friendship with the boss at the trust, was ordered in January and had been due for completion in April. Its publication was put back to this month because of the coronavirus pandemic. But it is now not expected until spring. The Doctors’ Association UK suspects the conclusions are being sat on because they make embarrassing reading for the trust’s chief executive, Steve Dunn, described by Hanock as a “brilliant leader”. A consultant who chairs the hospital’s medical staff committee wrote to the NHS’s regional director for the east of England, Ann Radmore, last week warning that senior medics felt the hospital could not move on until the review was published. The NHS East insists the review will be published as soon as possible, but a source confirmed this is likely to be “spring next year”.
  8. Event
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    Harmed Patients Alliance we will be hosting an online webinar focusing on restorative healing after healthcare harm. This online webinar will explore the issue of second harm in healthcare with a range of patient, academic and clinical expert members of our advisory group. Each panel member will give a presentation sharing their experience and perspective, followed by an interactive panel discussion chaired by Shaun Lintern, Health Correspondent for the Independent. Register
  9. News Article
    The lateral flow devices used in the community testing pilot in Liverpool only picked up half the COVID-19 cases detected by polymerase chain reaction (PCR) tests and missed 3 out of 10 cases with higher viral loads, according to the government’s own policy paper. Given the low sensitivity of the Innova lateral flow devices when used in the field, experts are questioning how they can be used to allow care home residents to have contact with relatives over Christmas safely or for students to know for certain that they are not infected before returning home. The information can only be found by looking in annex B of the document, Community testing: a guide for local delivery, which was published on 30 November. This is the first publicly available information about the field evaluation of the Innova tests in Liverpool which has been criticised for its lack of transparency, accuracy of the tests used, and costs and potential harms. Read full story Source: BMJ, 4 December 2020
  10. News Article
    Regulators have apologised to a health manager who went through “five years of hell” while being investigated for misconduct, before being told there was no case to answer. Debbie Moore was a senior manager at the former Liverpool Community Health Trust, where there was a major care scandal in the early 2010s. As head of healthcare at HMP Liverpool, where many of the most serious failings were identified, Ms Moore was suspended in 2014 and referred to the Nursing and Midwifery Council. She was accused of multiple failures to take action or escalate concerns, of failing to investigate deaths, and discouraging staff from reporting incidents. However, in a first public interview about her experience, she told HSJ she was “scapegoated” for the problems at the prison, where she says she worked tirelessly to address the issues and had repeatedly flagged concerns to the LCH management team. External inquiries have found the trust would routinely downgrade risks escalated by divisional managers, as it sought to make drastic cost savings in pursuit of foundation trust status. Read full story (paywalled) Source: HSJ, 30 November 2020
  11. Community Post
    It's #SpeakUpMonth in the #NHS so why isn't the National Guardian Office using the word whistleblowing? After all it was the Francis Review into whistleblowing that led to the recommendation for Speak Up Guardians. I believe that if we don't talk about it openly and use the word 'WHISTLEBLOWING' we will be unable to learn and change. Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. So many genuine healthcare whistleblowers seem to be excluded from contributing to the debate, and yes not all those who claim to be whistleblowers are genuine. The more we move away for labelling and stereotyping, and look at what's happening from all angles, the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and with a genuine desire to learn and change.
  12. News Article
    The death of a premature baby in 2001 led to a "20-year cover-up" of mistakes by health workers, an independent inquiry has found. Elizabeth Dixon, from Hampshire, died due to a blocked breathing tube shortly before her first birthday. The government, which ordered the inquiry in 2017, said the mistakes in her care were "shocking and harrowing". The inquiry report by Dr Bill Kirkup said some of those involved had been "persistently dishonest". Elizabeth, known as Lizzie, died from asphyxiation after suffering a blockage in her tracheostomy tube while under the care of a private nursing agency at home. Dr Bill Kirkup, who was appointed by the government to review the case, said her "profound disability and death could have been avoided". He said: "There were failures of care by every organisation that looked after her, none of which was admitted at the time, nor properly investigated then or later." "Instead, a cover-up began on the day that she died, propped up by denial and deception." Read full story Source: BBC News, 26 November 2020 Patient Safety Learning's statement on the Dixon Inquiry report
  13. Content Article
    Elizabeth Dixon was a child with special health needs. She had been born prematurely at Frimley Park Hospital on 14 December 2000. Following treatment and care at Great Ormond Street Hospital and a children’s hospice she was nursed at home under a care package. As a result of a failure to clear a tracheostomy tube she asphyxiated and was pronounced dead at Frimley Park hospital on 4 December 2001. The investigation chaired by Dr Bill Kirkup looked at the events surrounding the care of Elizabeth and makes a series of recommendations in respect of the failures in the care she received from the NHS. Recommendations Hypertension (high blood pressure) in infants is a problem that is under-recognised and inconsistently managed, leading to significant complications. Its profile should be raised with clinicians; there should be a single standard set of charts showing the acceptable range at different ages and gestations; and a single protocol to reduce blood pressure safely. Blood pressure should be incorporated into a single early warning score to alert clinicians to deterioration in children in hospital. Community care for patients with complex conditions or conditions requiring complex care must be properly planned, taking into account and specifying safety, effectiveness and patient experience. The presence of mental or physical disability must not be used to justify or excuse different standards of care. Commissioning of NHS services from private providers should not take for granted the existence of the same systems of clinical governance as are mandated for NHS providers. These must be specified explicitly. Communication between clinicians, particularly when care is handed over from one team or unit to another, must be clear, include all relevant facts and use unambiguous terms. Terms such as palliative care and terminal care may be misleading and should be avoided or clarified. Training in clinical error, reactions to error and responding with honesty, investigation and learning should become part of the core curriculum for clinicians. Although it is true that curricula are already crowded with essential technical and scientific knowledge, it cannot be the case that no room can be found for training in the third leading cause of death in western health systems. Clinical error, openly disclosed, investigated and learned from, must not be subject to blame. Conversely, there should be zero tolerance of cover up, deception and fabrication in any health care setting, not least in the aftermath of error. There should be a clear mechanism to hold individuals to account for giving false information or concealing information relating to public services, and for failing to assist investigations. The Public Authority (Accountability) Bill drawn up in the aftermath of the Hillsborough Independent Panel and Inquests sets out a commendable framework to put this in legislation. It should be re-examined. The existing haphazard system of generating clinical expert witnesses is not fit for purpose. It should be reviewed, taking onto account the clear need for transparent, formalised systems and clinical governance. Professional regulatory and criminal justice systems should contain an inbuilt ‘stop’ mechanism to be activated when an investigation reveals evidence of systematic or organisational failures and which will trigger an appropriate investigation into those wider systemic failures. Scrutiny of deaths should be robust enough to pick up instances of untoward death being passed off as expected. Despite changes to systems for child and adult deaths, concern remains that without independent review such cases may continue to occur. The introduction of medical examiners should be reviewed with a view to making them properly independent. Local health service complaints systems are currently subject to change as part of wider reform of public sector complaints. Implementation of a better system of responding to complaints must be done in such a way as to ensure the integration of complaints into NHS clinical governance as a valuable source of information on safety, effectiveness and patient experience. The approaches available to patients and families who have not been treated with openness and transparency are multiple and complex, and it is easy to embark inadvertently on a path that is ill-suited to deliver the answers that are being sought. There should be clear signposting to help families and the many organisations concerned. Ministerial Statement Anne and Graeme Dixon reaction to Dr Bill Kirkup’s report Patient Safety Learning's statement on the Dixon Inquiry report
  14. News Article
    Former health secretary and chair of the Commons health committee Jeremy Hunt has criticised Great Ormond Street Hospital after it was accused of covering up errors that may have led to the death of a toddler. Writing for The Independent, Mr Hunt, who has set up a patient safety charity since leaving government, said it was “depressing” to see how the hospital had responded to the case of Jasmine Hughes, which has now been taken to the Parliamentary Health Service Ombudsman for a new investigation. Mr Hunt said the hospital had chosen to issue a “classic non-apology apology of which any politician would be proud” and added he was left angry over the hospital’s “ridiculous decision” to stop talking to Jasmine’s family and the refusal to apologise for what went wrong. The MP for South West Surrey said the case was symbolic of a wider problem in the health service of a blame culture that prevents openness and transparency around mistakes. Read full story Source: The Independent, 24 November 2020
  15. 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 January of that year. The PHSO report states her mother was told “there was no cause for concern” and that another appointment would be scheduled in six months. This follow-up appointment did not happen. The young woman’s death was considered by the hospital’s complaints process, an independent panel review and an inquiry into the hospital’s paediatric cardiac services. They concluded the doctor involved was not responsible for Krista’s death – though the paediatric services inquiry criticised the hospital for poor communication. A coroner declined to open an inquest into the case. Civil action against the hospital, brought by Ms Ocloo, found Krista’s death could not have been prevented. However, a High Court judge found that the failure to arrange appropriate follow-up by the RBH was “negligent”. A spokeswoman for PHSO said: “Our investigation found maladministration by the Department for Health and Social Care, which should have been more transparent in its communication. The department’s failure to be open and clear compounded the suffering of a parent who was already grieving the loss of her child.” A DHSC spokeswoman said: “We profoundly regret any distress caused to Ms Ocloo. “[The PHSO] report found that in communicating with Ms Ocloo the department’s actions were – in places – not consistent with relevant guidance. The department has writen to Ms Ocloo to apologise for this and provide further information about the review.” Read full story (paywalled) Source: HSJ, 12 November 2020
  16. Content Article
    Mersey Care outlines the work they are doing to embrace a just and learning culture, centred on the desire to create an environment where staff feel supported and empowered to learn when things do not go as expected, rather than feeling blamed. You can watch a short film about the issues they want to address and see how they've created a practical tool to aid some of the most delicate staffing conversations. They've also developed free online training aimed at HR staff but accessible to all from their web page.
  17. Content Article
    I believe all clinicians should read this latest report. There is so much to be learned and so many changes in clinical practice that can be made right away. Since 2018, I have been teaching using Oliver's tragic story to promote reflection on best practice in prescribing and in implementing the Mental Capacity Act. I could write a lot here; however, I believe this is a report all clinicians, and especially all prescribers, need to read in full. A summary of how I see this (or indeed how any individual sees it) it will not be adequate.
  18. 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 “throughout the whole system” as a key part of achieving its future patient safety vision.[2] The strategy includes plans to create a patient safety partners framework; earlier this year, the NHS published a consultation on its draft Framework for involving patients in patient safety.[3] In this blog, we will provide a summary of our feedback to the consultation. You can find our full submission at the end of this blog. Involving patients in their own safety The NHS Framework is divided into two parts, the first of which sets out the broad approach that should be taken to involving patients in their own healthcare and safety. We particularly welcome its emphasis on: encouraging patients to ask questions; if problems occur, the importance of providing information and help to maintain patients’ safety; the role of patient incident reports and complaints as a source of learning. In our response, we fed back with our thoughts on improvements in two specific areas - complaints and patient safety incident reporting. Complaints We share the view set out in the Framework that patient complaints should be viewed as “a valuable resource for monitoring and improving patient safety”.[3] We believe it’s important the Framework is joined up with the ongoing work of the Parliamentary and Health Service Ombudsman (PHSO), who have recently completed a consultation on a new Complaints Standard Framework for the NHS.[4] We believe that this presents an opportunity to embed patient safety into these processes and we responded to the PHSO consultation highlighting this. Patient safety incident reporting The Framework highlights the importance of patients reporting patient safety incidents, noting that the future introduction of a new Patient Safety Incident Management System will create “new tools to more easily participate in the recording of patient safety incidents and to support national learning”.[3] We believe more needs to be to be done to address the cultural barriers that deter patients from reporting concerns. Patients, carers and families need to feel assured that their stories and testimonies are welcome. Alongside this, it is crucial that, when concerns are reported, they are used to inform the assessment of risk and patient safety. As noted in the Cumberlege Review, not only are incidents not being reported but the existing systems “cannot be relied upon to identify promptly significant adverse outcomes arising from a medication or device because it lacks the means to do so”.[5] Patient Safety Partners The second part of the Framework is concerned with the newly proposed role of Patient Safety Partners (PSPs) in NHS organisations. PSPs would formally participate in safety and quality committees, patient safety improvement projects and investigation oversight groups. In our consultation response, we highlighted several areas where we feel these proposals require strengthening if they are to be successful. Training and guidance for staff The Framework rightly acknowledges the importance of having appropriate training and guidance for staff to help support the new PSP roles, pointing towards the new National patient safety syllabus as a key source. We have concerns that the National patient safety syllabus, in its current form, does not have a strong enough focus on patient involvement to provide this support. We highlighted the need for a greater emphasis on the skills and knowledge required to understand why and how patients can be actively involved in patient safety in our response to the consultation on the draft syllabus earlier this year.[6] We believe the syllabus could be significantly strengthened by drawing on further research and resources available in this area, such as the World Health Organization (WHO) Patient Safety Curriculum Guide.[7] Support and peer networks for PSPs We believe there needs to be more clarity about the induction and training that would be made available to PSPs. We also make the case that PSPs need access to networks with their peers PSPs in other organisations, enabling them to share good practice for safety improvement and receive support from others. We believe that it would be beneficial to create these networks alongside the new PSP roles. We suggest it would be helpful to draw on experiences of other programmes involving patients in patient safety, such as the WHO Patients for Patient Safety programme in the UK and the Canadian Patients for Patient Safety programme.[8] [9] Patient Safety Specialists The Framework makes brief reference to the relationship between future PSPs and the newly proposed Patient Safety Specialists, which all trusts and CCGs have been asked to put in place by the end of November.[10] We believe that if Patient Safety Specialists are to work effectively in organisations then these roles will need to be filled by leaders with expertise in patient engagement. Responding to a consultation earlier this year, we commented that those filling these roles will need strong skills and experience.[11] We also believe the Framework should place a great emphasis on the role of Patient Safety Specialists in supporting the work of PSPs. Co-production In our feedback, we also argue that there should be a strong emphasis on co-production with PSPs and more broadly throughout this Framework. ‘Co-production’ is an activity, an approach and an ethos which involves members of staff, patients and the public working together, sharing power and responsibility across the entirety of a project.[12] In our view, projects and patient safety programmes should always be co-produced with patients where possible. What needs to be included in the Framework As well as commenting on the specific proposals of the Framework, we identified two additional areas which we believe should be added to it: 1. Measuring and monitoring performance Patient Safety Learning believes that, to make improvements in the involvement of patients in patient safety, we need to be able to clearly measure and monitor our progress. Publicly reporting on changes and improvements made through patient involvement and patient safety allows for sharing examples of good practice. It would also mitigate against concerns that the role of PSP could become tokenistic in some organisations, resulting in little real impact. 2. Restorative Justice Many national healthcare systems and organisations are actively listening to, and engaging with, patients for learning through restorative justice. Restorative justice in healthcare allows patients to be heard, listened to, and respected. By patients, clinicians, healthcare leaders and policy makers engaging with one another on patient safety, it can help to establish trust with the patient. This can also provide the impetus for learning and action to be taken to prevent future harm. We commend the approach adopted by New Zealand’s Ministry of Health in how it responded to harm from surgical mesh and the impact this has had on improvements in patient safety.[13] Closer to home, there are some beacons of good practice within the NHS, such as the Mersey Care NHS Foundation Trust.[14] We believe that the NHS should do more to share and promote a just and learning culture, asking organisations to develop and publish goals on their progress. Only one piece of the puzzle We welcome and recognise the positive steps being set out in the Framework to improve patient involvement in patient safety within the NHS. Our comments and suggestions for improvement are mainly centred around the need to ensure other key pieces are in place. Significant change is still needed. The Framework focuses on increasing patient involvement in governance and decision-making. This wider need for change in how we engage patients in patient safety is outlined in the recently published WHO Global Patient Safety Action Plan 2021-2030.[15] It promotes a range of actions for governments and healthcare organisations to help engage patients and their families in patient safety; we would expect to see this reflected in the work of NHS England and NHS Improvement. Strengthened as we suggest, we believe that the Framework could make a big difference to improving patient involvement with patient safety. References Patient Safety Learning. The Patient-Safe Future: A Blueprint for Action, 2019. NHS England and NHS Improvement. The NHS Patient Safety Strategy: Safer culture, safe systems, safer patients, July 2019. NHS England and NHS Improvement. Framework for involving patients in patient safety, 10 March 2020. PHSO. Making Complaints Count: Supporting complaints handling in the NHS and UK Government Departments, July 2020. The Independent Medicines and Medical Devices Safety Review. First Do No Harm, 8 July 2020. Patient Safety Learning. Patient Safety Learning’s response to the National patient safety syllabus 1.0, 28 February 2020. World Health Organization. Patient Safety Curriculum Guide, 2011. Action Against Medical Accidents. Patients for Patient Safety, Last Accessed 15 October 2020. Canadian Patient Safety Institute, Patients for Patient Safety Canada, Last Accessed 16 October 2020. NHS England and NHS Improvement. Patient Safety Specialists, Last Accessed 15 October 2020. Patient Safety Learning. Response to the Patient Safety Specialists consultation, 12 March 2020. Dr Erin Walker, What should co-production look like?, 1 April 2019; National Institute for Health Research, Guidance on co-producing a research project, March 2018. Jo Wailling, Chris Marshall & Jill Wilkinson. Hearing and responding to the stories of survivors of surgical mesh: Ngā kōrero a ngā mōrehu – he urupare (A report for the Ministry of Health). Wellington: The Diana Unwin Chair in Restorative Justice, Victoria University of Wellington, 2019. Mersey Care NHS Foundation Trust. Just and Learning Culture – What it Means for Mersey Care, Last Accessed 16 October 2020. World Health Organization. Global Patient Safety Action Plan 2021-2030: Towards Zero Patient Harm in Health Care, 28 August 2020.
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