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Sam

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  1. News Article
    A child safeguarding expert who faced vilification after raising concerns about the safety of children undergoing treatment at a London NHS gender identity clinic has won an employment tribunal case against the hospital trust. Sonia Appleby, 62, was awarded £20,000 after an employment tribunal ruled the NHS’s Tavistock and Portman trust’s treatment of her damaged her professional reputation and “prevented her from proper work on safeguarding”. Appleby, an experienced psychoanalytical psychotherapist, was responsible for protecting children at risk from maltreatment. The tribunal heard evidence she raised concerns about the treatment of increasing numbers of children being referred to the trust’s Gender Identity Development Service (Gids). The service in Hampstead has been at the heart of a controversy over its treatments, including the provision of drugs known as puberty blockers to children as young as 10. The tribunal heard evidence that after she raised the concerns, instead of addressing them, the trust management ostracised her and attempted to prevent her from carrying out her safeguarding role, by sidelining her. Appleby said the management’s action amounted to a “full-blown organisational assault”. Read full story Source: The Guardian, 4 September 2021
  2. News Article
    More than one in five ‘covid deaths’ were both probably hospital-acquired, and caused at least in part by the virus, at several trusts, according to analysis released to HSJ. HSJ obtained figures from more than 30 trusts which have looked in detail at cases where patients died after definitely, or probably, catching covid in hospital. Thirty-two acute trusts provided HSJ with robust data, out of the total 120 in England. Across all 32, they had recorded 3,223 covid hospital deaths which were either “definitely” or ‘probably’ nosocomial — making up around 17% of their total reported 19,020 hospital deaths. The trusts said 2,776 of the 3,223 deaths also had covid listed on their death certificate, either as an “immediate cause” or as a contributory factor. That constitutes about 15% of all the hospitals’ covid deaths, and 86% of the nosocomial deaths. When approached by HSJ, these trusts said they followed robust infection control practices, and that high community covid prevalence, and covid admissions, were the main cause of hospital-acquired infection. Some trusts also cited their ageing infrastructure. Read full story (paywalled) Source: HSJ, 6 September 2021
  3. News Article
    Shortfalls in mental health services and staffing have been flagged as concerns in dozens of inquests since 2015, the Observer has revealed, with coroners issuing repeated warnings over patients facing long waiting lists or falling through gaps in service provision. The Observer has identified 56 mental health-related deaths in England and Wales from the start of 2015 to the end of 2020 where coroners identified a lack of staffing or service provision as a “matter of concern”, meaning they believed “there is a risk that future deaths could occur unless action is taken”. Coroners issue Reports to Prevent Future Deaths (PFD) when they believe action should be taken to prevent deaths occurring in future, and send them to relevant individuals or organisations, who are expected to respond. In one case, a woman referred to psychotherapy services had still not received any psychotherapy by the time she died 11 months later. In another, someone had endured a seven-month wait for a psychological assessment. Alison Cobb, senior policy and campaigns officer at the mental health charity Mind, said: “It’s shocking that so many should lose their lives because there isn’t enough capacity in mental health services to provide adequate care. These prevention of future deaths notices are meant to inform better ways of working, and it’s especially concerning that similar stories are repeating over and over again.” Read full story Source: The Guardian, 5 September 2021 Coroner's reports on the hub
  4. News Article
    The family of a senior medic and lifelong NHS campaigner have called for an investigation into his death as it took paramedics more than half an hour to arrive at his home after operators were told he was suffering a cardiac arrest. Professor Kailash Chand, a former British Medical Association deputy chair, had complained of chest pains before one of his neighbours, a consultant anaesthetist at Manchester Royal Infirmary, called 111 for help before telling the call handler within three minutes that he believed his friend was having a cardiac arrest. “I was answering their questions when Kailash’s eyes began rolling and he slipped into unconsciousness. That’s when I said ‘this looks like a cardiac arrest’ and to upgrade the call. They kept asking questions as I started CPR and asked for an urgent ambulance. That was two or two and a half minutes into the call." Evidence seen by i News shows that it took another 30 minutes after the neighbour told the operator about the cardiac arrest for the paramedics to arrive at Professor Chand’s flat in Didsbury, Greater Manchester. National standards for ambulance trusts show that ambulance trusts must respond to category 1 calls – those that are classified as life-threatening and needing immediate intervention and/or resuscitation, such as cardiac or respiratory arrest – in 7 minutes on average, and respond to 90% of Category 1 calls in 15 minutes. Read full story Source: iNews, 3 September 2021
  5. Event
    We live in a world marked by massive global changes, moving us rapidly into rather unprecedented and unknown directions. It has never been so vital for us to understand the interactions among humans and other system elements. This necessitates the creation and adoption of theories, principles, data, and methods of design, as well as new capabilities, technologies, skills, procedures, policies, strategies to find new ways of engaging with a rapidly changing world and optimise wellbeing and performance. Find out more at the Human Factors & Ergonomics Society of Australia (HFESA) virtual conference. Register
  6. Event
    This Westminister Forum conference from will examine policy priorities for improving patient safety in the NHS in light of forthcoming regulatory changes and plans to tackle key areas of concern through the updated Patient Safety Strategy. It will be an opportunity to discuss patient safety during COVID-19 and how best to drive improvements in the recovery from the pandemic, as well as the impact of recent developments including: the recently introduced Health and Care Bill, which includes measures aiming to strengthen the role of the Healthcare Safety Investigation Branch in improving patient safety an updated Patient Safety Strategy, including a new commitment to developing understanding of how patient safety can contribute to tackling health inequalities. Keynote contributions from Keith Conradi, Chief Investigator, Healthcare Safety Investigation Branch and Natasha Swinscoe, National Patient Safety Lead, AHSN and Chief Executive Officer, West of England AHSN. The agenda is structured to bring out latest thinking on: policy priorities - ensuring patient safety across the health and care system, and identifying areas for improvement the Healthcare Safety Investigation Branch - the evolving role of the HSIB, and the potential impact of proposed reforms patient safety during COVID-19 - improving continuity of care, the uptake of technology and innovative practice, and informing the future NHS approach developing a focus on patient safety: learning from previous failures embedding a focus on patient safety across the health and care system the role of the Patient Safety Commissioner and Patient Safety Specialists the health and care workforce - meeting training needs around patient safety, developing processes for early intervention, and the role of leadership and management in supporting culture change. Register
  7. Event
    In the dawn of a new era for digital and health tech transformation, the Leading Healthcare Innovation Summit looks to bring together emerging communities in healthcare to solve the most pressing issues facing the UK healthcare sector. It will be addressing the sector’s biggest challenges and concerns including the mental health of clinicians and patients; clinical pathways; diversity and inclusion in data and products; service and user inclusive design; remote patient monitoring; virtual consultations and ICS development. You will leave with action points to push forward your digital health projects, aided with the tools and knowledge to make digital innovation a reality in your organisation. Register
  8. Event
    This one day masterclass will focus on teams working effectively and productively through improving the culture within Healthcare organisations. There will be a focus on how safety and culture is perceived by healthcare staff and how culture relates to QI and audit. The outcome of the day is to not only improve safety culture and patient safety but also staff experience and staff engagement. Key learning objectives: Define culture within healthcare. Understand safety culture. Explore culture of quality improvement and audits. Improve civility within teams. Learn how to lead cultural change. Register
  9. Event
    This national conference looks at the practicalities of Serious Incident Investigation and Learning. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) which has now been published for the early adopter sites as introductory guidance. This conference will enable you to: Network with colleagues who are working to improve the investigation of serious incidents. Ensure your approach to Serious Incident Investigation is in line with the NHS Patient Safety Strategy. Update your knowledge with national developments including the New Patient Safety Incident Response Framework. Understand developments in the PSIRF early adopter sites. Reflect on the management and investigation of serious incidents involving COVID-19. Learn from outstanding practice in the development of serious incident investigation and mortality review. Reflect on the perspectives of a patient who has been involved in a serious incident. Develop a risk based response to incident investigation. Reflect on the development of mortality governance within your organization and understand the challenges of COVID-19. Understand how to work with staff to ensure a focus on learning and continuous improvement. Develop your skills in Serious Incident Investigation: applying the human factors to move the focus of investigation from acts or omissions. of staff, to identifying systems improvement. Identify key strategies for improving investigation of serious incidents. Gain CPD accreditation points contributing to professional development and revalidation evidence. Register
  10. Content Article
    Watch presentations from the Improving Patient Safety & Care 2020 Conference.
  11. Event
    This Westminister Health Forum Policy conference takes place with the Government drafting a Women’s Health Strategy, aiming to address the gender health gap, and it will be an opportunity to discuss the way forward with the consultation on the strategy having just closed, after seeking views on key themes including: putting women at the centre of their care education on women’s health health infrastructure priorities for research. Delegates will also be able to consider priorities for women’s health in the context of other significant developments, including the inquiry report from the APPG on endometriosis and recent inquiries from the Women and Equalities Committee, as well as wider health reforms proposed in the Health and Care Bill. Agenda Register
  12. Event
    WHO Patient Safety Flagship invites you to participate in a virtual event for the launching of the “Global Patient Safety Action Plan 2021-2030”. This global action plan aspires for “a world in which no one is harmed in health care, and every patient receives safe and respectful care, every time, everywhere.” The event marks the achievement of an important and historic milestone, and prominent health leaders and patient safety champions will take you through the global patient safety journey. Speakers include: Dr Tedros Adhanom Ghebreyesus, Director-General, WHO Mr Jeremy Hunt, Chairperson, Health and Social Care Select Committee, UK Sir Liam Donaldson, WHO Patient Safety Envoy Dr Neelam Dhingra, Unit Head, WHO Patient Safety Flagship Further information and registration
  13. Community Post
    The new Health and Care Bill gives NHS Digital powers to create a new ‘medicine registry’ The bill, published earlier this month, will allow NHS Digital to collect a range of information about the use of medicines and their effects in the UK and hold this data in one or more information system(s). The MHRA would be able to then use the information held in an information system to establish and maintain comprehensive UK-wide medicines registries. “This would improve post-market surveillance on the use [of] medicines. For example, where a safety issue has led to the introduction of measures to minimise risk to patients, registries would facilitate the early identification and investigation of potential noncompliance so that additional action can be taken by regulators in conjunction with health service providers at a national, local, or individual patient level.” The notes added the power is “restricted to purposes relating to the safety, quality and efficacy of human medicines and the improvement of clinical decision-making in relation to human medicines”. Anybody who inappropriately shares NHS data collected for the new registry could face a fine and a prison sentence. What does this mean for patient safety? What impact will this has on the NHS and for private providers? @Helena Gregory. @Kathryn Howard, @Kristen, @Alison Smith, @Phaeds, @CYC, @Dakota, @Steve Turner
  14. News Article
    Researchers from the 'Therapies for Long COVID (TLC) Study Group' at the University of Birmingham are studying long COVID is and what influences it by pooling data from lots of separate studies to find out the prevalence of reported symptoms and to see what the impacts and complications of long COVID are. Their review showed just how varied long COVID is. Patients may experience symptoms related to any system in the body – including respiratory, neurological and gastroenterological symptoms. The pooled data showed that the ten most commonly reported symptoms in long COVID are fatigue, shortness of breath, muscle pain, cough, headache, joint pain, chest pain, an altered sense of smell, diarrhoea and altered taste. Other common symptoms include “brain fog” – when thinking is fuzzy and sluggish – memory loss, disordered sleep, heart palpitations and a sore throat. Rare but important outcomes include thoughts of self-harm and suicide and even seizures. Most long COVID patients complain of symptoms experienced during their acute infection persisting beyond it, with the number of symptoms experienced tending to decline as patients move from acute to long COVID. Some, though, report developing new symptoms during their long COVID illness, while some also report symptoms reoccuring that had previously resolved themselves. What the huge variability of long COVID suggests is that it actually comprises a number of different syndromes, potentially with different underlying causes. A better understanding of the underlying biological and immunological mechanisms of long COVID is therefore urgently needed if we’re to develop effective treatments for it. Read full story Source: The Conversation, 27 July 2021
  15. News Article
    The Medicines and Healthcare products Regulatory Agency (MHRA) are warning that thermal cameras and other such “temperature screening” products, some of which make direct claims to screen for COVID-19, are not a reliable way to detect if people have the virus. In July 2020 the Agency told manufacturers and suppliers of thermal cameras that they should not make claims which directly relate to COVID-19 diagnosis, and now are reminding businesses to follow Government advice on safe working during COVID-19. Graeme Tunbridge, MHRA Director of Devices, said: "Many thermal cameras and temperature screening products were originally designed for non-medical purposes, such as for building or site security. Businesses and organisations need to know that using these products for temperature screening could put people’s health at risk. These products should only be used in line with the manufacturer’s original intended use, and not to screen people for COVID-19 symptoms. They do not perform to the level required to accurately support a medical diagnosis." Read full story Source: BBC News, 27 July 2021
  16. News Article
    A review into the work of a locum consultant radiologist has so far identified "major discrepancies" affecting 12 cases. A full lookback review of 13,030 radiology images was launched last month. The doctor worked at hospitals run by the Northern Health Trust between July 2019 and February 2020. The review steering group chair said it was "images in levels one and two that we are most concerned about". "To date there are 12 level ones and twos [approximately 0.5% of the total number reviewed]," said Dr Seamus O'Reilly, the Northern Trust medical director. "Most of these concern CT scans where inaccurate initial reading of the scans could, or is likely to, have had an impact on the patient's clinical treatment and outcome." More than 9,000 patients have been contacted as part of the review, which is looking at radiology images taken in Antrim Area, Causeway, Whiteabbey and Mid Ulster Hospitals as well as the Ballymena Health and Care Centre. Read full story Source: BBC News, 28 July 2021
  17. News Article
    More than one in three middle-aged British adults are suffering from at least two chronic health conditions, including recurrent back problems, poor mental health, high blood pressure, diabetes and high-risk drinking, according to research that warned that health in midlife is on the decline. The study of “generation X” adults born in 1970 found that those who grew up in poorer families were 43% more likely to have multiple long-term health conditions than their peers from wealthier households. Those who had been overweight or obese as children, who had lower birthweight and who had experienced mental ill-health as teenagers were also at increased risk of poor health in midlife. Dawid Gondek, the UCL researcher who authored the paper, said: “This study provides concerning new evidence about the state of the nation’s health in midlife. It shows that a substantial proportion of the population are already suffering from multiple long-term physical and mental health problems in their late 40s, and also points to stark health inequalities, which appear to begin early in childhood.” Read full story Source: The Guardian, 28 July 2021
  18. News Article
    The boss of a NHS trust that asked hospital staff for fingerprints and handwriting samples as it hunted a whistleblower is stepping down. Dr Stephen Dunn will leave West Suffolk NHS Foundation Trust in the summer after seven years as chief executive. An independent inquiry into the way management handled the affair is expected to report in the autumn. In 2018, Jon Warby received a letter two months after the death of his wife, Susan. It claimed mistakes were made during her bowel surgery. An inquest into her death was subsequently told how she had been given glucose instead of saline fluid via an arterial line. The Doctors' Association described the hospital's attempt to find the author of the letter a "witch-hunt". A subsequent Care Quality Commission (CQC) inspection said the way internal investigations had been conducted by the hospital was "unusual and of concern". Read full story Source: BBC News, 28 July 2021
  19. Event
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    What is next for urgent and emergency care across the country? With the COVID-19 pandemic transforming service delivery and reshaping what was once thought possible, the next challenge is to consider the state of urgent and emergency care services as another difficult winter approaches. Despite moves away from hospital-based care towards alternative solutions, urgent and emergency care is still under great pressure. Join this King's Fund event to hear about the latest debates and solutions to a very challenging issue: trying to ease the pressure on urgent and emergency care delivery. You will hear evidence-based examples from areas that are trying to re-imagine A&E departments and other services that provide and support urgent treatments, so patients get the right care in the right place. You will hear from international speakers, national leaders and a host of experts on a range of questions. The transition to 111: has it really happened, and has it yielded the anticipated results? What does the new integrated care systems structure have in store for urgent and emergency care? How should we shape targets and measure what works in urgent and emergency care? How can we support highly trained staff and avoid burn-out? Register
  20. Event
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    Anchor institutions are large organisations, connected to their local area, that can use their assets and resources to benefit the communities around them. Health and care organisations, as well as providing healthcare services, are well-placed to use their influence and resources to improve the social determinants of health, health outcomes and reduce health inequalities. This King's Fund event will explore what anchor institutions are, what they look like in practice and how we can embed some of those ways of working within health and care. We will look at how health and care organisations, working in partnership with other local anchor institutions, are leveraging their role as large employers and purchasers of goods and services and playing an active role in protecting the health, wellbeing and economic resilience of their local communities. Register
  21. Event
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    When things go wrong in health and social care, there can be significant consequences for patients, staff, and leaders. But, too often, the voices of people who use services and their families have gone unheard, while staff have feared being blamed for mistakes that result from systemic failings or human error. So how can health and social care leaders at all levels create a just culture, where mistakes lead to learning? And how can organisations take accountability for learning and improving after something goes wrong? The King’s Fund is co-hosting this virtual conference in partnership with the Parliamentary and Health Service Ombudsman from 13–16 September, in the lead up to World Patient Safety Day on 17 September, to explore how culture is key to enable professionals, patients and organisations to use the learning from mistakes and serious incidents to drive improvement in the safety and quality of care. Drawing on stories of learning and accountability told from several different perspectives, including case studies, we will examine how taking responsibility for learning offers a positive alternative to a culture of fear or blame. Register
  22. Event
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    The King's Fund's flagship event brings together senior leaders working in health and social care to celebrate the latest best practice and explore the most pressing opportunities and challenges facing the system. Hear about: the role of the NHS and the wider health and care system in tackling health inequalities what the new health and social care Bill means for the system in England how the recovery from the impact of the COVID-19 pandemic is being managed and plans to meet the backlog challenge how to meet the needs of the health and care workforce. Register
  23. Event
    The NHS Long Term Plan 2021 conference will set out the main commitments in the plan and provide a view of what they might mean, highlighting the opportunities and challenges for the health and care system as it moves to put the plan into practice post COVID-19. This conference will provide delegates with the opportunity to hear from key speakers on the NHS’s priorities for care quality and outcomes improvement for the decade ahead. The programme will inform and educate delegates on subjects that affect their everyday life all of which will help contribute both to patients and the UK economy. Confirmed speakers include: Matthew Taylor - Chief Executive, NHS Confederation Chris Hopson - Chief Executive, NHS Providers Professor Matthew Cripps - Director of Sustainable Healthcare, NHS England & Improvement Lisa Hollins - Director of Innovation Delivery, NHSX Further information and registration 10 fully funded (no charge) places are currently available exclusively to members of the hub and are limited on a first come first served basis. Email info@pslhub.org for a code.
  24. Event
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    In September 2020 the UK Government announced the winners of its first Artificial Intelligence (AI) in Health and Care Awards and Kheiron's bid was successful. The funding that's been won will accelerate the roll out and rapid adoption of Mia (Mammography Intelligent Assessment) to address critical workforce challenges in NHS breast screening services in the UK. Kheiron is using the next 3 years to technically deploy and generate the evidence that our AI tool (Mia) can be safely adopted as the second reader in the breast screening workflow. They will be doing this across 15 NHS Breast Screening sites in the UK to prove generalisability. The tool will need to work for any woman, anywhere. This webinar presents an opportunity to find out more about the strategic context of the work with talks from the national leads at NHSEI and NHSx backing the project, clinicians helping to run the research and Kheiron itself on what we hope to achieve. Register
  25. Event
    The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. The course is facilitated by Tracy Ruthven and Stephen Ashmore who have significant experience of undertaking patient safety reviews in healthcare. They were commissioned to write a national RCA guide by the Healthcare Quality Improvement Partnership. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/root-cause-analysis-1-day-masterclass or email nicki@hc-uk.org.uk hub members receive a 20% discount. Please email info@pslhub.org for discount code
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