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News ArticleA children’s nurse who raised legitimate concerns over racial discrimination at a major London trust was suspended and victimised by her managers for doing so, an employment tribunal has ruled. Jeyran Panahian-Jand, who worked on a children’s ward at Whipps Cross Hospital, parts of Barts Health Trust, had raised concerns with her manager in 2019 that staff were divided on “racial lines”, with an “unfair allocation of work”, as well as bullying of two junior staff. Her manager Heather Roberts, as well as other superiors, told Ms Panahian-Jand she should raise a formal complaint, without offering to look at the issues raised and keep the complaint informal, which the tribunal said they should have done under whistleblowing policies. Ms Roberts later accused Ms Panahian-Jand, who identified as white, of continuing to talk about her allegations on the ward, and with the agreement of Ghislaine Stephenson, the associate director of nursing for children, Ms Panahian-Jand was suspended for the “disruption” and “upset” she was causing, the tribunal judgment said. Ms Panahnian-Jand then lodged a formal complaint over race discrimination, as well as accusing two other bank nurses of making “racially abusive” remarks. A subsequent internal investigation supported three allegations of race discrimination made by Ms Panahian-Jand, while a separate probe into her own alleged misconduct found there was no case to answer. Read full story (paywalled) Source: HSJ, 23 February 2021
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News Article
Unsafe maternity care has cost the NHS £8.2bn in 15 years
Patient Safety Learning posted a news article in News
Negligent maternity care in the NHS has cost taxpayers an “eye-watering” £8.2bn over the past 15 years, The Independent reveals. Ministers face calls to urgently increase spending to ensure maternity units are safe for women and babies by providing adequate staffing levels, training and equipment. New data, obtained by The Independent from NHS Resolution, which handles clinical negligence costs for the service, reveals that total payments made following settled cases and legal costs rose from £271m in 2006-07 to an estimated £920m in 2020-21. The number of maternity claims being made by families has almost doubled in the past decade, rising from 391 in 2009-10 to 765 in 2019-20. Recent maternity scandals at the Shrewsbury and Telford Hospital Trust, East Kent Hospitals University Trust and at hospitals in Nottingham have all had common themes around poor culture, a lack of honesty and not enough staff or equipment. The Department of Health and Social Care is exploring how it can make changes to the UK clinical negligence system to reduce the costs to the taxpayer. Health minister Nadine Dorries told MPs on the Commons health committee in February that the reforms would look “across the NHS… not just maternity, at how issues of no-blame, no-fault compensation and clinical negligence are treated”. Read full story Source: The Independent, 20 September 2021 -
EventThis one day masterclass will focus on a toolkit to allow organisations to use patient experience and incident to improve patient safety. The Toolkit uses 3 phases: planning, implementation and review. The Francis Report showed that the NHS had stopped listening to the needs of its users. Patient experience is still an underutilised tool in the armoury of a healthcare organisation and commissioners. The toolkit uses the priorities of the Francis Report to improve patient experience and patient safety. These include putting patients first, openness, candour, accountability, complaints handling, culture of caring and compassionate leadership. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/patient-experience-and-learning-from-incidents-to-improve-safety or email aman@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code.
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Event
NHS Complaints Summit
Patient Safety Learning posted an event in Community Calendar
This National Virtual Summit focuses on the New National NHS Complaint Standards that were published in March 2021 and are due to be introduced across the NHS in 2022. Through national updates, practical case studies including NHS Complaints Standards early adopters sites, and in depth expert sessions the conference aims to improve the effectiveness of complaints handling within your service, and ensure that complaints are welcomed and lead to change and improvements in patient care. The conference will also reflect on managing complaints regarding Covid-19 – understanding the standards of care by which the NHS should be judged in a pandemic and in particular responding to complaints regarding delayed treatment due to the pandemic. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/nhs-complaints-summit or email kate@hc-uk.org.uk hub members receive 20% discount. Email info@pslhub,org for discount code Follow on Twitter @HCUK_Clare #NHSComplaints -
EventThis conference, chaired by Simon Hammond Director of Claims Management NHS Resolution will update clinicians and managers on Clinical Negligence with a particular focus on current issues and the Covid-19 pandemic and the impact on clinical negligence claims. Featuring leading legal experts, and experienced clinicians the event will provide an update on current claims the conference will discuss why patients litigate, and responding to claims including claims regarding Covid-19. There will be an extended masterclass on trends in clinical negligence claims and responding to claims followed by an extended focus on maternity claims, and also claims related to medication error. The conference will close with a case study on the advantages of bringing together complaints, claims and patients safety investigation, and practical experiences of Coronavirus complaints at claims at an NHS Trust – including understanding the standard of care on which services should be judged, and a final session on supporting clinicians when a claim is made against them. For further information and to book your place visit: https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/clinical-negligence or email nicki@hc-uk.org.uk We are delighted to offer 3 free places for hub members. Email info@pslhub.org for the discount code. Follow on Twitter @HCUK_Clare #clinicalnegligence
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Event
NHS Complaints Summit
Patient Safety Learning posted an event in Community Calendar
This National Virtual Summit focuses on the New National NHS Complaint Standards that were published in March 2021 and are due to be introduced across the NHS in 2022. Through national updates, practical case studies including NHS Complaints Standards early adopters sites, and in depth expert sessions the conference aims to improve the effectiveness of complaints handling within your service, and ensure that complaints are welcomed and lead to change and improvements in patient care. The conference will also reflect on managing complaints regarding Covid-19 – understanding the standards of care by which the NHS should be judged in a pandemic and in particular responding to complaints regarding delayed treatment due to the pandemic. This conference will enable you to: Network with colleagues who are working to improve complaints handling. Update your knowledge on the March 2021 NHS Complaint Standards and how it will change complaints handling for the better. Understand how to manage complaints regarding Covid-19. Reflect on the perspective of a complainant who has been through the system to understand what person centred really means in practice. Learn how to bring kindness and compassion into complaints management, investigation, responses and learning. Understand what PHSO and the CQC look for in a good complaint response. Self assess your service against the NHS Complaint Standards. Improve the way complaints and investigations involving serious incidents are handled. Develop your skills in complex complaints handling including disputes, vexatious complainants and complaints across organisations. Understand how you can improve frontline resolution of complaints in real time. Develop your skills in de-escalation and conflict and dispute resolution. Support staff through the complaints process including inquests. Identify key strategies for ensuring change occurs as a result of complaints. Ensure you are up to date with the latest legal issues including ensuring adherence to the duty of candour. Self assess, reflect and expand your skills in complaints handling. Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register -
Event
NHS Complaints Summit
Patient Safety Learning posted an event in Community Calendar
This National Virtual Summit focuses on the New National NHS Complaint Standards that were published in March 2021 and are due to be introduced across the NHS in 2022. Through national updates, practical case studies including NHS Complaints Standards early adopters sites, and in depth expert sessions the conference aims to improve the effectiveness of complaints handling within your service, and ensure that complaints are welcomed and lead to change and improvements in patient care. The conference will also reflect on managing complaints regarding Covid-19 – understanding the standards of care by which the NHS should be judged in a pandemic and in particular responding to complaints regarding delayed treatment due to the pandemic. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/nhs-complaints-summit or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for a discount code. Follow on Twitter @HCUK_Clare #NHSComplaints -
Event
Complaints resolution & mediation
Patient Safety Learning posted an event in Community Calendar
This course is suitable for anybody who deals with complaints as part of their job role, or anybody who may have to handle a complaint. This includes dedicated complaints teams & customer support teams and managers. The programme includes a section on handling complaints regarding COVID-19 - understanding the standards of care by which the NHS should be judged in a pandemic. A highly interactive and effective workshop to improve confidence and consistency in handling complaints. A simple model to facilitate effective responses will be shared and delegates will have the opportunity to practise the use of our unique AERO approach. For more information visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/complaints-resolution-and-mediation or email kate@hc-uk.org.uk hub members receive a 20% discount. Email infor@pslhub.org for discount code. -
EventThrough national updates, practical case studies and in depth expert sessions the conference aims to improve the effectiveness of complaints handling within your service, and ensure that complaints are welcomed and lead to change and improvements in patient care. The conference will also reflect on managing complaints regarding COVID-19 – understanding the standards of care by which the NHS should be judged in a pandemic and in particular responding to complaints regarding delayed treatment due to the pandemic. For more information visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/nhs-complaints-summit or email kate@hc-uk.org.uk hub members can receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #NHSComplaints
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Event
Complaints, resolution & mediation
Patient Safety Learning posted an event in Community Calendar
This course is suitable for anybody who deals with complaints as part of their job role, or anybody who may have to handle a complaint. This includes dedicated complaints teams and customer support teams and managers. A highly interactive and effective workshop to improve confidence and consistency in handling complaints. The masterclass explains how mediation works and how techniques can be used effectively within local complaint resolution to develop a person-centred process (for both patient and healthcare professional). Within these key areas, the course will explore how unconscious bias plays a role in complaints and their resolution. A mediation inspired approach to complaint resolution produces invaluable insight to help reduce recurring complaint situations, develop training and development plans and support the teams on the frontline. Further information and to book or email kate@hc-uk.org.uk hub members receive a 20% discount. Email: info@pslhub.org -
EventChaired by Dr Caroline Walker Founder The Joyful Doctor; Psychiatrist and Specialist in Doctors’ Wellbeing, this conference focuses on supporting staff who have been involved in patient safety incidents, or are the subject of complaints or claims. Involvement in an incident, complaint or claim can have severe consequences on staff who may experience a range of reactions including stress, depression, shame and guilt. Download brochure Register
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Event
NHS Complaints Summit 2021
Patient Safety Learning posted an event in Community Calendar
This National Virtual Summit focuses on delivering a person-centred approach to complaints handling, investigation, resolution and learning. Through national updates, practical case studies and in depth expert sessions the conference aims to improve the effectiveness of complaints handling within your service, and ensure that complaints lead to change and improvements in patient care. The conference will reflect on managing complaints regarding COVID-19 – understanding the standards of care by which the NHS should be judged in a pandemic and in particular responding to complaints regarding nosocomial transmission of Covid-19 and delayed treatment due to the pandemic. The conference will also update delegates on the Complaint Standards Framework for the NHS which is in consultation and due to be published by the PHSO in early 2021, and will lead to a single developmental pathway for all complaints staff that rightly acknowledges complaint handling as a professional skill. Further information and registration or email: kate@hc-uk.org.uk hub members receive 10% discount. Email: info@pslhub.org Follow on Twitter @HCUK_Clare #NHSComplaints -
EventThis conference focuses on supporting staff who have been involved in patient safety incidents, or are the subject of complaints or claims. Involvement in an incident, complaint or claim can have severe consequences on staff who may experience a range of reactions including stress, depression, shame and guilt. This conference will enable you to: Network with colleagues who are working to support staff following incidents, complaints or claims. Understand national developments including the requirements in the 2020 Patient Safety Incident Response Framework. Reflect on how we can better support staff experiencing these issues through COVID-19. Deliver a just culture that supports consistent, constructive and fair evaluation of the actions of staff involved in patient safety incidents. Reflect on a healthcare’s professionals personal experience of being the subject of an incident investigation. Improve immediate support and debriefing when an incident occurs. Develop your skills in providing the staff member involved in a patient safety incident specific individual support or intervention to work safely. Understand how you can improve processes for ensuring candour and supporting staff. Identify key strategies for interviewing staff and taking statements and preparing staff for Coroner’s Inquests. Ensure you are up to date with the latest developments in psychological support for staff including building resilience. Self assess and reflect on your own practice. Gain CPD accreditation points contributing to professional development and revalidation evidence. Register
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Event
NHS Complaints Summit 2021
Patient Safety Learning posted an event in Community Calendar
This National Virtual Summit focuses on delivering a person-centred approach to complaints handling, investigation, resolution and learning. Through national updates, practical case studies and in depth expert sessions the conference aims to improve the effectiveness of complaints handling within your service, and ensure that complaints lead to change and improvements in patient care. The conference will reflect on the challenges and complaints that have resulted from the Covid-19 pandemic. The conference will also update delegates on the Complaint Standards Framework for the NHS which is in consultation and due to be published by the PHSO in early 2021, and will lead to a single developmental pathway for all complaints staff that rightly acknowledges complaint handling as a professional skill. Further information and to book your place or email kate@hc-uk.org.uk Follow the conversation on Twitter #NHSComplaints We are pleased to offer hub members a 10% discount. Email: info@pslhub.org for the code. -
Content ArticleOur health services face an unprecedented challenge in recovering from the pandemic and coping with ongoing waves of covid. With such demand for healthcare services from the general population and covid cases rising once more, some customers are bound to be angry or unhappy. But, as we recover from the pandemic, our handling of complaints must surely change, writes David Oliver in this BMJ article.
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Content ArticleThis study, published in the Journal of the Royal Society of Medicine, examines national policies of complaint handling in English hospitals, how they are understood by those responsible for enacting them, and explores if there are any discrepancies between policies-as-intended and their reality in local practice.
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Content Article
UK Government guidance - Whistleblowing for employees
Patient-Safety-Learning posted an article in Whistle blowing
This guidance by the UK Government provides information and advice for employees who want to understand their rights regarding whistleblowing. It includes information on: What is a whistleblower? Who is protected by law Complaints that count as whistleblowing Who to tell and what to expect What to do if you're treated unfairly after whistleblowing -
Content ArticleRisk managers and the insurers with whom we work have the greatest opportunity in healthcare today to improve patient safety. Our most egregious mistakes become medical malpractice claims and lawsuits. Some of these go to trial where the outcome is public; however, the least defensible cases are settled without a trial. Almost every settlement includes a confidentiality or nondisclosure clause (NDC). Such clauses become “gag orders.” Providers who could learn from the mistake of a colleague do not, and the same mistake is repeated, often many times over. The stories of these settlements are a rich source of learning, and it’s time to tell them—anonymously. No naming names, no disclosure of settlement amounts, no “blame and shame.” Stories are powerful, attention-grabbing, and memorable. Telling them is a unique opportunity to link the prevention of patient harm to the healing mission of healthcare and acknowledge the common wish of every plaintiff that “this won’t happen to someone else.”
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Content ArticleThe aim of this study was to determine the distribution of formal patient complaints across Australia's medical workforce and to identify characteristics of doctors at high risk of incurring recurrent complaints. It found that a small group of doctors accounts for half of all patient complaints lodged with Australian Commissions. It is feasible to predict which doctors are at high risk of incurring more complaints in the near future. Widespread use of this approach to identify high-risk doctors and target quality improvement efforts coupled with effective interventions, could help reduce adverse events and patient dissatisfaction in health systems.
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Content ArticleThe distribution of malpractice claims among physicians is not well understood. If claim-prone physicians account for a substantial share of all claims, the ability to reliably identify them at an early stage could guide efforts to improve care. Using data from the National Practitioner Data Bank, Studdert et al. analysed 66,426 claims paid against 54,099 physicians from 2005 through 2014. The authors calculated concentrations of claims among physicians. They found over a 10-year period, a small number of physicians with distinctive characteristics accounted for a disproportionately large number of paid malpractice claims.
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Content ArticleDo patients’ and families’ experiences with communication-and-resolution programmes suggest aspects of institutional responses to injury that could better promote reconciliation after medical injuries? This interview study of 40 patients, family members, and hospital staff in Australia found that patients have a strong need to be heard after medical injury that is often unmet. Although 18 of 30 patient and family participants (60%) reported positive experiences with communication-and-resolution programmes overall and continued to receive care at the hospital, they reported that hospitals rarely communicated information about efforts to prevent recurrences. Opportunities are available to provide institutional responses to medical injuries that are more patient centred.
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Content ArticleThe aim of this study from Bismark et al. was to identify characteristics of doctors in Victoria, Australia, who are repeated subjects of complaints by patients.
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Content Article
PHSO - Our strategy 2022 to 2025 (5 April 2022)
Patient-Safety-Learning posted an article in PHSO investigations
This document sets out the Parliamentary and Health Services Ombudsman's (PHSO) strategy 2022-25 and outlines its vision to be a voice for improvement in public services, providing an independent, impartial and fair complaints handling service. The document describes how PHSO will achieve its three strategic objectives: People who use public services have a better awareness of the role of the Ombudsman and can easily access our service People we work with receive a high quality, empathetic and timely service, according to international Ombudsman principles We contribute to a culture of learning and continuous improvement, leading to high standards in public service -
Content ArticleThis annual report sets out how NHS Resolution's dispute resolution strategy has continued to drive down litigation against the NHS in England in 2021-22. 77% of claims made by patients were resolved in 2021/22 without court proceedings, continuing the year-on-year reduction for the last five years, and in line with the organisation's strategy to keep patients and healthcare staff out of court. NHS Resolution achieved this reduction through a range of dispute resolution approaches and continued cooperation across the legal market. It emphasises that the reduction in litigation has not been at the expense of a rigorous approach to investigation.
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Content ArticleDrugwatch is a US consumer advocacy organisation that works with certified medical and legal experts to educate the public on dangerous drugs and medical devices and to empower consumers to assert their legal rights. In this article, Terry Turner, writer for Drugwatch, examines the history of the medical tech company C.R. Bard, which specialises in vascular, urology, surgery and oncology devices. Bard manufactures thousands of medical devices and sells them worldwide. The article looks at how the company was established and then examines several legal issues Bard has faced, including criminal charges stemming from medical fraud and accusations of selling defective devices that have killed patients or caused serious complications. The author looks at criminal charges concerning heart catheters to which Bard pleaded guilty. They also highlight problems with Bard's transvaginal and hernia mesh products and inferior vena cava (IVC) filters—devices designed to catch blood clots before they reach the lungs or the heart.
