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Found 305 results
  1. Content Article
    Extracts of a letter from David Osborn to the UK Covid-19 Public Inquiry Legal Team regarding misleading evidence by Professor Yvonne Doyle, which: Highlights errors in Prof Yvonne Doyle’s evidence to the Inquiry relating to the declassification of Covid‑19 as a high consequence infectious disease. Calls into question Professor Sir Jonathan Van Tam’s evidence to the Inquiry in which he sought to attribute responsibility for the downgrade from FFP3 to FRSM to Public Health England. The letter sets out his involvement in the issue of the 4-Nations IPC guidance version 1.0 which implemented that downgrade. Further reading on the hub: Healthcare workers with Long Covid: Group litigation – a blog from David Osborn
  2. Content Article
    In December 2022, a newly formed group called 'Long Covid Doctors for Action' (LCD4A) conducted a survey to establish the impact of Long Covid on doctors. When the British Medical Association published the results of the survey, the findings were both astonishing and saddening in equal measure.[1] The LCD4A have now decided that enough is enough and that it is now time to stand up and take positive action. They have initiated a group litigation against those who failed to exercise the ‘duty of care’ that they owed to healthcare workers across the UK during the pandemic.  In this blog, I summarise how and why I feel our healthcare workers have been let down by our government and why, if you are one of these healthcare workers whose life has been effected by Long Covid, I urge you to join the group litigation initiative.
  3. Content Article
    Surgeons' News is a magazine for surgical, dental and allied healthcare professionals. Published quarterly by the Royal College of Surgeons of Edinburgh, it features comment and opinion from leading professionals, plus reviews and reports on subjects relevant to all career levels. In the article 'Truth and compassion' (page 20-21), David Alderson considers the patient’s perspective on mistakes.
  4. News Article
    Next week’s launch of the ‘Wayfinder’ waiting time information service on the NHS App will give patients “disingenuous” and “misleading” information about how long they can expect to wait for care, senior figures close to the project have warned. Briefing documents seen by HSJ show the figure displayed to patients will be a mean average of wait times taken from the Waiting List Minimum Data Set and the My Planned Care site. However, it was originally intended that the metric displayed would be the time waited by 92% of relevant patients. This is more commonly known as the “9 out of 10” measure. Mean waits are likely to be about “half the typical waiting time” measured under the 9 out of 10 metric, according to the waiting list experts consulted by HSJ. Ahead of The Wayfinder service’s launch on Tuesday, NHS trusts and integrated care boards have been sent comprehensive information on how to publicise it, including a “lines to take” briefing in case of media inquiries. This mentions the use of an “average” time but does not provider any justification for this approach. HSJ’s source said the mean average metric was “the worst one to choose” as it would be providing patients with “disingenuous” information that will leave them disappointed. They added that the 92nd percentile metric would be a “far more realistic” measure “for a greater number of people”. They concluded that “using an average” would create false expectations “because in reality nobody will be seen in the amount of time it is saying on the app.” Read full story (paywalled) Source: HSJ, 26 January 2024
  5. News Article
    Senior leaders are resorting to “ticking the duty of candour box” instead of developing a “just and learning” culture in their organisations because their bandwidth is full, the patient safety commissioner has said. Speaking with HSJ as she begins the second year of her first term in the newly-established role, Henrietta Hughes said the bandwidth of senior leaders is “too full for them to make and maintain the necessary culture change”. She warned the duty of candour — giving patients and families the right to receive open and transparent communication when care goes wrong — gets seen as a “bit of a tick box exercise, ‘doc tick’ as it’s described to me, which is a bit depressing really”. A GP herself, she said individual doctors typically respond to concerns or they are handled by someone who knows the patient. Elsewhere, complaints are often addressed through a chief executive’s office, once all staff have provided written statements, she said. She added: “[In general practice] it feels more compassionate and empathetic… I find it’s often quicker to have a conversation with the patient before it turns into a formal complaint and resolves it quickly.” “What needs to change is that [NHS] trusts are currently held accountable to a very narrow set of criteria — financial and operational performance,” she said. “This is how we will improve safety and experience, transparency, a just and learning culture, and improve morale.” Read full story (paywalled) Source: HSJ, 30 January 2024
  6. Content Article
    Traditionally, recommendations regarding responding to medical errors focused mostly on whether to disclose mistakes to patients. Over time, empirical research, ethical analyses and stakeholder engagement began to inform expectations — which are now embodied in communication and resolution programmes (CRPs) — for how healthcare professionals and organisations should respond not just to errors but any time patients have been harmed by medical care (adverse events). CRPs require several steps: quickly detecting adverse events, communicating openly and empathetically with patients and families about the event, apologising and taking responsibility for errors, analysing events and redesigning processes to prevent recurrences, supporting patients and clinicians, and proactively working with patients toward reconciliation. In this modern ethical paradigm, any time harm occurs, clinicians and health care organisations are accountable for minimising suffering and promoting learning. However, implementing this ethical paradigm is challenging, especially when the harm was due to an error.
  7. Content Article
    In this BMJ Leader article, Roger Kline discusses the failings of the Countess of Chester NHS Boards in 2022 following the arrest of Lucy Letby. Roger highlights that this is not unique to the Counter of Chester: Reputation management that avoids timely decisive action is familiar to staff in many NHS organisations. Primacy of finance at a time of gross NHS under-resourcing has roots in Government policy and a national failure to challenge it. The failure of the Countess of Chester Board to be curious and create a culture where staff who raised concerns were seen as “gold dust” not troublemakers, is commonplace not unique. Roger acknowledges that there are no simple solutions but says that the regulation for managers is a performative gesture unless accompanied by other measures. He suggests that we "Make patient safety the prime litmus test for all initiatives and 'stop the line' (from Board to ward) when it is not. Do not allow organisational reputation to ever influence decision making in response to concerns. Be relentlessly 'problem sensing' not “comforting seeking'”.
  8. Content Article
    In this infographic, the Patient Safety Commissioner for England, Dr Henrietta Hughes, sets out her strategy for supporting the development of a new culture for the health system centred on listening to patients.
  9. Content Article
    This constructive commentary reflects on two recent related publications, the Healthcare Safety Investigation Branch (HSIB) report, Variations in the delivery of palliative care services to adults, and an article from Sarcoma UK, Family insights from Dermot’s experience of sarcoma care. Drawing from these publications, Richard, brother-in-law of Dermot, gives a family perspective, calling for a more open discussion around how we can improve palliative care and sarcoma services, and why we must listen and act upon family and patient experience and insight.
  10. Content Article
    As part of the 21st Century Cures Act (April 2021), electronic health information (EHI) must be immediately released to patients in the USA. This study in the American Journal of Surgery sought to evaluate clinician and patient perceptions regarding this immediate release of results and reports. Interviews with patients and clinicians found differences in perceived patient distress and comprehension, emphasising the impersonal nature of electronic release and necessity for therapeutic clinician-patient communication.
  11. Content Article
    In this blog, Scott Ellner, a general surgeon from the US, describes the case of a surgeon colleague who unintentionally harmed a patient, Sarah, during surgery. Sarah ended up in the surgical intensive care unit from septic shock due to a missed bowel injury. Her recovery from what should have been a straightforward procedure was long and complicated. Scott recalls how the surgeon was shocked by the way Sarah's husband responded to him when he explained what had happened—instead of an anger and blame, Sarah's husband expressed compassion for the doctor and reiterated his trust in him. Scott highlights the importance of creating a Just Culture in healthcare systems and outlines challenges to this in the current climate, referring to the case of nurse RaDonda Vaught. He also outlines the impact patient safety incidents and medical errors can have on healthcare professionals, calling on the healthcare community to embrace shared humanity. All of us come with imperfections, vulnerabilities and the capacity for healing and growth.
  12. News Article
    A mother who endured a botched surgery at the hands of a disgraced neurosurgeon claims NHS Tayside tried to silence her against making complaints. Professor Sam Eljamel removed Jules Rose's tear duct during a failed attempt to operate on a brain tumour - setting the 55-year-old on a path to becoming a prolific campaigner for patients' rights. Ms Rose, however, has received sight of documents that show NHS Tayside writing to the then-health minister Humza Yousaf to say she had been "aggressive" and "vulgar" and they would no longer communicate with her. In a letter in response, Mr Yousaf says he sees no evidence of any such conduct by the mother-of-two and tells the health board to enter into mediation with her. Ms Rose said: "In the letter I have been given, Humza Yousaf writes back and say, 'She's quite right to feel aggrieved at the treatment she's received. "'Therefore, I suggest that you continue liaising with Miss Rose and enter into mediation.' "This was last November but I've only just had copies of the letters sent to me and when I saw them I thought, 'They've tried to shut me down, they're tried to silence me'." The ongoing dispute with NHS Tayside is as a result of Ms Rose's long-running campaign for justice for patients - thought to be as many as 270 - harmed by Eljamel while he was in the health board's employ. Read full story Source: The Herald, 16 December 2023
  13. Content Article
    The review into the statutory duty of candour has been established by the Department of Health and Social Care to consider the design of operation of this requirement, assess its effectiveness and make advisory recommendations. The duty of candour is about people’s right to openness and transparency from their health or care provider. It means that when something goes wrong during the provision of health and care services, patients and families have a right to receive explanations for what happened as soon as possible and a meaningful apology.
  14. Content Article
    How would you feel if your doctor offered you a treatment your health condition with good results and very little risk? You might snap it up. But what if you subsequently found out your doctor took thousands of pounds from the treatment makers to write a scientific paper promoting it, attend an all-expenses paid conference to talk about it, or spent time working as their expert consultant? In America, industry must log payments which are published on the open database system. Reporting to this is backed up by law following the American Sunshine Payment Act (2013). Sling the Mesh is calling for similar legislation in the UK to provide up-to-date evidence on industry money exchanging hands we Kath Sansom discusses in a blog on the Patient Safety Commissioner website.
  15. Content Article
    Whistleblowing presentation from Peter Duffy to the Association for Perioperative Practice, September 2022. York University.
  16. Content Article
    Would you know what to do if something went wrong with your medical treatment in private/independent healthcare? This guide from PHIN tells what you should understand before choosing where to have your treatment and what to do if everything doesn’t go to plan.
  17. Content Article
    You have the right to make a complaint about any aspect of NHS care, treatment or service The information on this NHS page will guide you through the NHS complaints process, as well as the core requirements for NHS complaints handling.
  18. News Article
    A study conducted by NHS Education for Scotland and Health Improvement Scotland found patients felt safer by having someone listen to their experiences after adverse events. The findings were published in the BMJ and have been positively received by NHS boards across the country. Healthcare Improvement Scotland’s Donna Maclean said: “The compassionate communications training has seen an unprecedented uptake across NHS boards in Scotland, with the first two cohorts currently under way and evaluation taking place also.” Clear communication and a person-centred approach was seen as being central to helping those who have suffered from traumatic events. Researchers found many said their faith was restored in the healthcare system if staff showed compassion and active engagement. This approach is likely to enhance learning and lead to improvements in healthcare. Health boards were advised that long timelines can have a negative impact on the mental health of patients and their families. Rosanna from Glasgow, who was affected by an adverse event, said: “I believe this study and its findings are crucial to truly understanding patients and families going through adverse events. “Not only does the study capture exactly what needs to change, but it also highlights the elements that are most important to us: an apology and assurance that lessons will be learnt is all we really want. Read full story Source: The National, 30 May 2022
  19. News Article
    The government is to investigate claims an ambulance service covered up details of the deaths of patients following mistakes by paramedics. It follows the Sunday Times report that North East Ambulance Service (NEAS) withheld information from coroners. Labour's shadow health secretary Wes Streeting described the alleged cover-up as "a national disgrace". Health minister Maria Caulfield said she was "horrified" and there would be a further investigation. The newspaper reported that concerns were raised about more than 90 cases and whistleblowers believed NEAS had prevented full disclosure to relatives of people who died in 2018 and 2019. Speaking in the House of Commons, Mr Streeting asked why the regulator - the Care Quality Commission (CQC) - had failed to take action. Ms Caulfield said that while both the NEAS and the CQC had both reviewed the allegations, further investigation was required. The minister said non-disclosure agreements have "no place in the NHS", adding: "Reputation management is never more important than patient safety." Read full story Source: BBC News, 23 May 2022
  20. News Article
    A website that tells patients how long they are likely to wait for NHS treatment will be made available in Scotland this summer. Humza Yousaf, the Scottish health secretary, said people queuing for tests and procedures and their doctors would be able to access information about any delays in their area using the software. Many patients living in pain are waiting years to have common operations such as hip and knee replacements. In theory, the SNP guarantee hospital treatment within 12 weeks of patients joining the waiting list, but this law was broken extensively before the pandemic and has now been breached hundreds of thousands of times. One orthopaedic surgeon, who did not wish to be named, said he was operating on patients whose joints had entirely collapsed after a two-year wait for a limb replacement made their case an emergency. Other patients who did not reach crisis faced even longer delays, he said. Dr Sandesh Gulhane, a GP and health spokesman for the Scottish Conservative Party, asked Yousaf, during a meeting of the Scottish Parliament’s health committee yesterday: “Why can’t we have in the future, in the [recovery] plan, indicative waiting times which are relatively live so we can all go on a website and see how long we need to wait.” Yousaf said it was fair for patients and NHS staff to expect to have information on waiting times, and that a website to provide this was being developed. “We are working closely with Public Health Scotland, we are working closely with boards to develop the infrastructure in order to collate and publish this data,” he said. “It’s an ambition of ours to have that available in a way that is easy to find, easy to understand, both for the patient but for the health professional too.” Read full story (paywalled) Source: The Times, 11 May 2022
  21. News Article
    Patients who have “lost hope” of ever seeing a doctor are falling off NHS waiting lists due to poor record-keeping by the SNP government, Scotland’s public spending watchdog has revealed. Stephen Boyle, the auditor-general, said there was no record of patients who drop off the waiting list to go private or who simply give up. Humza Yousaf, the health secretary, said he was aware of “a small number of people” who had gone abroad for transplants, including one of his own constituents. He admitted there was no way of knowing the scale of the issue, or whether the organs were obtained legally. Boyle said: “I don’t wish to be blasé and say it is straightforward, but it really should not be an insurmountable problem to have a clear vision and strategy, reviewed and commented on, with an annual transparent plan to track progress. “The government themselves don’t have the complete data we think they should have to make some of the decisions about the delivery of health and social care services and reform.” Gillian Mackay, an SNP MSP, said some constituents told her that they have been put on a waiting list and “they hear nothing more about when they will be seen, or how they will be prioritised”. Boyle said the NHS needs to “manage patients’ expectations about how long they will have to wait”. He said: “Everybody who is waiting for services needs to have a clear expectation of when they will receive those services, whether it is [for] cancer, or other treatments on clinical prioritisation. There is clear missing part in transparency.” Read full story (paywalled) Source: The Times, 19 April 2022
  22. News Article
    The UK medicines watchdog has been urged to strengthen its conflict of interest policy after it emerged that six of its board members are receiving payments from the pharmaceutical industry. Board members involved in overseeing the regulator’s “strategic direction” also have financial interests in companies including US and Saudi drug giants and firms with ambitions to break into the UK’s healthcare market. Some offer consultancy services while others help run or own shares in drug and medical device firms, according to official transparency records. There is no suggestion of wrongdoing, but the findings have led to concerns about perceived conflicts of interest among senior figures at the Medicines and Healthcare products Regulatory Agency (MHRA), an executive agency of the Department of Health and Social Care responsible for regulating drugs and medical devices and ensuring they are safe. The MHRA said that “in order to be an effective regulator” it needed to “bring together the right expertise from across industry, academia, the public and beyond”, adding that board meetings are held in public and non-executive board members – to whom the potential conflicts relate – are not involved in “any work or decisions relating to the regulation of any products”. But critics raised concerns about the potential for bias – or the perception of it – and called for stricter rules on conflicts of interest for those working in pharmaceutical regulation. Read full story Source: The Guardian, 17 April 2022
  23. News Article
    The NHS ombudsman has told a health trust chief to withdraw “not accurate” remarks about him amid an alleged attempt to play down up to 1,000 avoidable patient deaths. Rob Behrens wrote to Stuart Richardson, the head of the Norfolk and Suffolk mental health NHS trust, over remarks he made about him to Norfolk county council’s health scrutiny committee. The councillors on the committee were questioning Richardson over claims reported by the BBC’s Newsnight programme that his trust had “watered down” a report into what are thought to be the avoidable deaths of up to 1,000 patients. The changes between different versions of the document toned down criticism of the trust’s leadership, a move that drew criticism from Behrens and bereaved relatives. For example, the auditors, Grant Thornton, removed references included in the first version to the trust’s governance being “poor, … weak [and] inadequate”, after discussions with trust bosses. The trust and Grant Thornton said the changes were part of a normal factchecking process. Referring to the changes, Behrens had told Newsnight that “the differences in the texts at key points are so huge that this is not just a bureaucratic drafting issue”. Read full story Source: The Guardian, 5 October 2023
  24. News Article
    A critical report into how a mental health trust mismanaged its mortality figures was edited to remove criticism of its leadership, the BBC has found. In June, auditors Grant Thornton revealed how the Norfolk and Suffolk NHS Foundation Trust (NSFT) had lost track of patient deaths. But earlier drafts included language around governance failures that were missing in the final version. NSFT and Grant Thornton said the changes were due to fact-checking. A number of drafts of the report were produced, with the first dated 23 February this year. The first version described "poor governance" in the way deaths data was managed, with governance also being called "weak" and "inadequate". But many of these critical words were missing from the report released to the public, with "governance" also being replaced with "controls", according to leaked documents. After losing her son Tim in 2014, Caroline Aldridge has been highlighting what she and others claimed had been the trust's undercounting of deaths. "I think people need to know what was removed and what was changed, because I suspect that the first report is a lot nearer to the truth," she said. Ms Aldridge added: "It takes all responsibility from governance, removing the words 'inadequate', 'poor', 'weak' governance, removing significant pieces of information that's not factual accuracy. "We cannot have people watering it [the report] down when it's about deaths." Read full story Source: BBC News, 29 August 2023
  25. News Article
    NHS England could have gone further to insist that errors and failures by senior NHS leaders are disclosed to future employers, according to the leading barrister who reviewed the NHS’s fit and proper person test (FPPT). Tom Kark KC’s review of the FPPT was delivered to government five years ago and made public the following year, and changes were finally proposed by NHSE earlier this month. In an interview with HSJ, Mr Kark said he broadly welcomed the plans, and that the revised framework should provide greater consistency across NHS boards “if applied correctly”; and could “strengthen the hand” of chairs and chief executives. Part of the purpose of the regime is to prevent senior managers and other board members who make big errors in one role, from keeping this secret from a future employer. Mr Kark told HSJ he had heard evidence that when “someone leaves under a cloud, they pop up somewhere else, and the information is lost.” Read full story (paywalled) Source: HSJ, 16 August 2023
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