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Found 305 results
  1. Content Article
    Derek Richford talks to Rob Behrens about the loss of his newborn grandson, Harry, at East Kent Hospitals University Trust. He explains how his sheer persistence uncovered the truth of what went wrong and eventually led to a criminal investigation at the Trust. He also tells us what organisations involved in the complaint process can learn from his family's tragic experience.
  2. Content Article
    In this article Sharon Hartles looks at the tragic case of the death of Robbie Powell and the work of his parents, Will and Diane, in their relentless pursuit for truth, justice and accountability. It looks in detail at the events around and after Robbie's death and their campaign for a individual legal Duty of Candour for healthcare professionals (the current statutory Duty of Candour in the UK covers all care providers registered with the Care Quality Commission, but not individuals).
  3. Content Article
    The Patient Safety and Quality Improvement Act of 2005 (PSQIA) establishes a voluntary reporting system designed to enhance the data available to assess and resolve patient safety and health care quality issues in the United States.
  4. Content Article
    The Government has recently published it's response to the recommendations set out in the First Do No Harm report of the Independent Medicines and Medical Devices Safety Review, chaired by Julia Cumberlege. One of the recommendations was for manufacturers to publish details of payments they make to teaching hospitals, research institutions, and individual clinicians, similar to the American Physician Sunshine Payment Act. The Government has said it is “exploring options to expand and reinforce current industry schemes, including making reporting mandatory through legislation.” In this editorial, Sonia McLeod looks at the gaps that exist in the UK's current system for disclosure and highlights some important considerations when setting up a new system or process if it is to be effective. Read the full article Related reading: A year on from the Cumberlege Review: Initial reflections on the Government’s response (Patient Safety Learning, 23 July 2021) Independent Report of the Patient Reference Group – response to the report of the Independent Medicines and Medical Devices Safety Review (21 July 2021) No such thing as a free lunch – why recording conflicts of interests must be mandatory
  5. Content Article
    Feldman et al. set out to document how NHS trusts in the UK record and share disclosures of conflict of interest by their employees. They found that, overall, recording of employees’ conflicts of interest by NHS trusts is poor. None of the NHS Trusts in England met all transparency criteria.
  6. Content Article
    When students enter medical school or junior doctors start specialist training, they don’t aim to be a “good enough” doctor—they want to be the best. However, we make mistakes or a patient has complained. It’s likely that someone picked up the error and no harm resulted, and the complaint may not be deserved—but still it punctures your pride and reminds you that you’re not perfect. It may even make you question whether you’re good enough. None of us is perfect, and self-criticism can wear us down or burn us out. Helen Salisbury in this BMJ article, suggests however, that in the long term we’re of more use to the world if we can live with our errors, share them, and learn from them. Our patients would prefer that we never made any, but they accept that we’re human and fallible. Learning to admit those errors to patients, and to say sorry, is one of the hardest but most important steps to becoming a good enough doctor.
  7. Content Article
    At the first Patient Safety Management Network (PSMN)* meeting of 2022, we were privileged to hear from a bereaved relative about her shocking experience, which reminded us all of why we do what we do.  Claire Cox, one of the PSMN founders, invited Susan (not her real name to protect her confidentiality) to share with us the causes of her relative’s untimely death and the poor and shameful experience when she and her GP started to ask questions. This kicked off a valuable and insightful discussion about how patients are responded to when things go wrong and about honesty and blame, patient and family engagement in decision making when patients are terminally ill, and how we need to ensure that the new Patient Safety Incident Response Framework (PSIRF) guidance embeds good practice informed by the real-life experience of patients and staff.
  8. Content Article
    Northumbria Healthcare NHS Foundation Trust were awarded the Freedom to Speak Up Organisation of the Year Award at the 2021 HSJ Awards with their demonstration of an integrated approach to speaking up. Kirsty Dickson was appointed as the first Freedom to Speak Up Guardian at Northumbria, following recommendations in the Francis Report. Since then, she has been working proactively to make sure that Freedom to Speak Up is woven into the fabric of the organisation.
  9. Content Article
    The Royal College of Anaesthetists is launching a campaign to prevent future deaths from unrecognised oesophageal intubation following a recently received coroner’s report where an oesophageal intubation took place and was not recognised in time to save the life of the patient. The coroner’s report highlighted the critical importance of human factors in safe anaesthetic practice. In this blog, Matt Bigwood and Chris Frerk discuss how one of the main aims of the campaign is to empower every team member, regardless of position, to be able to speak up if they spot this problem. You can also read more about the campaign here.
  10. Content Article
    'Kicking the Hornet’s Nest' is a documentary that looks at power morcellation, a popular gynaecologic procedure used to perform hysterectomies. The documentary demonstrates how the practice has been inadvertently spreading cancer in patients for decades. It includes first-person testimonies and archival footage and follows two married, Harvard-affiliated whistle-blowers who have been personally impacted by the procedure, as they campaign to expose the controversial practice and prevent future needless deaths.
  11. Content Article
    Disclosure UK is the Database on which all pharmaceutical companies abiding by the Association of the British Pharmaceutical Industry (ABPI) Code of Practice must disclose ‘transfers of value’ to healthcare professionals, other relevant decision makers and healthcare organisations in the UK. Where possible, companies do this by naming the individuals and organisations and according to GDPR law, companies must identify an appropriate lawful basis before they process an individual's information. This guidance document by the ABPI is aimed at pharmaceutical companies using Disclosure UK. It explains and promotes the choice of the basis of 'legitimate interests' for disclosure, with the aim of increasing transparency in the relationships between healthcare professionals, other relevant decision-makers and the industry.
  12. Content Article
    Recently an enduring discussion evolved on Twitter on why safety culture is important for patient safety. My reaction, of course, was: it isn’t. Let me explain why. I think it is possible to address safety without addressing safety culture. Or, rather, to focus on actions that will improve both safety performance and safety culture (as a by-product) at the same time. In this blog I propose some of these actions – showing how to create an understanding of how work is (actually) done (rather than what it says on paper), seeing what makes it difficult and identifying what resources are missing. If we address these challenges, then surely we will be able to improve safety and safety culture will follow naturally.
  13. Event
    until
    The Health Research Authority (HRA) rounds off Make it Public Week with a panel discussion, chaired by Professor Sir Terence Stephenson, HRA Chair. Sir Terence will be joined by a panel representing different parts of the research sector, who will revisit and reflect on the key topics of discussion during the week. We will also be looking forward and at what we – as individuals, organisations, and the sector as a whole – can do next to make research transparent from start to finish, and how we can keep the conversation around research transparency going. Participants can submit questions to the panel ahead of the meeting or live on the day using Slido. You can submit a question in advance when registering for the event. Book now to reserve your free space
  14. Event
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    The Health Research Authority is holding its first research transparency week. The effectiveness and relevance of research is improved when opportunities to be involved in research are made more visible, open and accessible to the public. This is because it gives a study the best chance to involve the full range of people who will benefit from the outcomes of research. By having research opportunities more publicly available, researchers will be able to recruit and retain a wide, diverse range of research participants. As a result of increased diversity and better opportunities to access diversity and better opportunities to access research for more people, research will be more relevant, effective, trusted and transparent. At the same time, health professionals, commissioners, researchers, policy makers and funders can use research findings to make informed decisions, which will enhance public trust in research evidence and enhance public accountability. It is equally important to have an awareness and understanding of potential barriers that may restrict members of the public getting involved in research. Identifying these challenges and putting measures in place to counter them is therefore essential in the delivery of transparent research. This will be a two-hour online workshop, chaired by the co-Chairs of the Make it Public campaign group, Matt Westmore, Chief Executive of the HRA, and Derek Stewart, public contributor. The objective for attendees of this workshop will be to work together in facilitated small groups to explore this theme, and produce a set of 'top tips' to support best practice for those active in research. There will also be a short panel discussion, where attendees can hear directly from the study leads and research participants of studies, as well as organisations, working creatively and progressively in this area. NIHR Be Part of Research Patient Research Ambassador scheme, Maidstone and Tunbridge Wells NHS Trust Register for the workshop
  15. Event
    until
    The Health Research Authority is holding its first research transparency week. This workshop will look at the importance of publishing summary results of trials We believe that publishing summary results and data – not just of trials, but of all research – in an open, accessible and public way is a key factor in ensuring research is transparent. Publishing results in a peer-reviewed journal is not always achievable, and findings published in this way may not be accessible to the public. Making the results of research studies public and as easy to access as possible helps builds trust and accountability, whilst ensuring participants are protected from unnecessary studies. It is also a process that helps ensure research funding is maximised by avoiding duplication. This will be a two-hour online workshop, chaired by the co-Chairs of the Make it Public campaign group, Matt Westmore, Chief Executive of the HRA, and Derek Stewart, public contributor. The objective for attendees of this workshop will be to work together in facilitated small groups to explore this theme, and produce a set of 'top tips' to support best practice for those active in research. There will also be a short panel discussion, where attendees can hear directly from the study leads and research participants of studies, as well as organisations, working creatively and progressively in this area. Abbvie Chief Scientist Office Scotland F1000 ISRCTN Registry Register for the workshop
  16. Event
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    The Health Research Authority is running its first ever research transparency week. They believe that keeping participants updated and informed as a study develops, as well as with the results at the end, should be the norm. When researchers work with patients and the public to plan individual studies, we hear that recruitment is easier, participants are better supported, and findings are more relevant to patient needs. Ongoing communication between researchers and participants throughout a study can offer further improvements. This strengthens relationships, and creates more opportunities for feedback and improvements to be made in the way findings are shared. This will be a two-hour online workshop, chaired by the co-Chairs of the Make it Public campaign group, Matt Westmore, Chief Executive of the HRA, and Derek Stewart, public contributor. The objective for attendees of this workshop will be to work together in facilitated small groups to explore this theme, and produce a set of 'top tips' to support best practice for those active in research. There will also be a short panel discussion, where attendees can hear directly from the study leads and research participants of studies working creatively and progressively in this area: UCL Covid-19 Social Study The INHALE Project Covid Voices Register for the workshop
  17. Event
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    The Health Research Authority (HRE) is holding its first ever research transparency week. This lunchtime webinar will be hosted by the HRE's Chief Executive, Matt Westmore. Matt will be talking about the importance of transparency in research with special guest speaker Professor Lucy Chappell, Chief Scientific Adviser to the Department of Health and Social Care and Chief Executive Officer of National Institute for Health and Care Research. They’ll be talking about why transparency is key to building trust with research participants, practical things you can do to ensure research is transparent and what support is available to you. In the spirit of transparency Matt will also be presenting the HRA's second Make it Public annual report on research transparency. He will talk through the priorities and focus of the report and the Make it Public Campaign Group, what has been achieved over the past year, and plans are for Make it Public in 2023. The session will finish by looking at the rest of the activities planned for Make it Public Week and how you can get involved. The webinar will run from 12pm to 1pm on Zoom. Reserve your free space.
  18. Community Post
    Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS an attractive place to work again, providing the NHS Constitution for England is at the heart of changes and is kept up to date. In my experience, having worked in healthcare for the private sector and the NHS, and lived and worked in other countries, we need to open our eyes. At present it could be argued that we have the worst of both worlds in England. A partially privatised health system and a fully privatised social care system. All strung together by poor commissioning and artificial and toxic barriers, such as the need for continuing care assessments. In my view a change, for example to a German-style system, could improve patient safety through empowering the great managers and leaders we have in the NHS. These key people are held back by the current hierarchical crony-ridden system, and we are at risk of losing them. In England we have a system which all too often punishes those who speak out for patients and hides failings behind a web of denial, obfuscation and secrecy, and in doing this fails to learn. Vast swathes of unnecessary bureaucracy and duplication could be eliminated, gaps more easily identified, and greater focus given to deeply involving patients in the delivery of their own care. This is a contentious subject as people have such reverence for the NHS. I respect the values of the NHS and want to keep them; to do this effectively we need much more open discussion on how it is organised and funded. What are people's views?
  19. 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.
  20. Community Post
    I've been posting advice to patients advising them to personally follow up on referrals. Good advice I believe, which could save lives. I'm interested in people's views on this. This is the message I'm sharing: **Important message for patients relating to clinical referrals in England** We need a specific effort to ensure ALL referrals are followed up. Some are getting 'lost'. I urge all patients to check your referral has been received, ensure your GP and the clinical team you have been referred to have the referral. Make sure you have a copy yourself too. Things are difficult and we accept there are waits. Having information on the progress of your referral, and an assurance that is is being clinically prioritised is vital. If patients are fully informed and assured of the progress of their referrals in real-time it could save time and effort in fielding enquiries and prevent them going missing or 'falling into a black hole', which is a reality for some people. It would also prevent clinical priorities being missed. Maybe this is happening, and patients are being kept fully informed in real-time of the progress of their referrals. It would be good to hear examples of best practice.
  21. Community Post
    Do you have a patient safety newsletter in your Trust? It would be very interesting for others to see how your is set out and the content. Here is one from Cardiff and Vale.
  22. Content Article
    Paula Goss had surgery to implant rectopexy and vaginal meshes which left her with severe pain and other serious complications. In this blog, Paula talks about why she set up Rectopexy Mesh Victims and Support to campaign for adequate treatment, redress and justice for people injured by surgical mesh. She outlines the need for greater awareness of mesh injuries amongst both healthcare professionals and the public and talks about what still needs to be done to enable people to access the treatment and support they need.
  23. Content Article
    Harry's Story is a website set up by Derek Richford, the grandfather of Harry Richford, who died in November 2017 at just a week old following failures in care during and after his birth. The site outlines how Harry's family worked tirelessly to uncover what happened to Harry and the poor standard of care at the maternity unit at East Kent University Hospitals Foundation Trust (EKUHFT). It covers the following aspects of the family's experience: Our Investigation The Inquest Cover Up? - You Decide HSIB Involvement What Happened Next The Kirkup Inquiry Accountability Harry's Legacy The site also contains a section offering advice for parents whose babies die or suffer harm in hospital during the perinatal period.
  24. Content Article
    This Newsnight report looks at the case of Rebecca Wight, an advanced nurse practitioner who raised concerns about a colleague at at Manchester’s Christie cancer hospital and felt her treatment by Trust management as a whistleblower was poor. She is now taking The Christie to an employment tribunal for constructive dismissal. The video also features an interview with Helené Donnelly, a nurse who tried to raise the alarm more than 100 times at Mid Staffs and went on to be a key witness in the subsequent Francis inquiry. She calls for failing NHS managers to be struck off, highlighting that a decade on from one of the worst failings in NHS history, those raising concerns were still not being listened to.
  25. Content Article
    In this consultation, the Department of Health and Social Care (DHSC) is seeking views on the possible introduction of regulations mandating the disclosure of industry payments to the healthcare sector. The consultation concerns the possible introduction of new secondary legislation that would place a duty on manufacturers and commercial suppliers of medicines, devices and borderline substances to report details of the payments and other benefits they provide to healthcare professionals and organisations. This consultation aims to address the second part of recommendation 8 in the Independent Medicines and Medical Devices Safety (IMMDS) Review, regarding real and perceived conflicts of interest in the health system. The proposals will enable respondents to share views on: the information they would need to provide recipients in scope payments that would potentially need to be reported the timing and content of reporting alternatives to regulation. The consultation closes at 11:59pm on 16 October 2023.
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