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Showing results for tags 'Patient / family involvement'.
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Content ArticleIn the dynamic landscape of healthcare, the unexpected deterioration of a hospital patient presents formidable challenges for medical professionals and families alike. It is during these critical moments that the concept of patient rescue becomes profoundly significant. Families, empowered with knowledge and effective communication strategies, play a pivotal role alongside healthcare providers in advocating for their loved ones and contributing to the success of rescue efforts. Watch this video from the World Patients Alliance to enhance your skills and confidence in advocating for patients' needs.
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Content ArticleThe new PIER approach will enable the effective management of acute physical deterioration in health and care and will apply to all conditions, clinical settings and specialities. The new PIER approach views deterioration as a whole pathway which is supported by systems rather than only advocating a single strategy for identification. Acute physical deterioration is the rapid worsening of a patient’s condition. It can be identified from changes in physiology, such as respiratory rate, blood pressure or consciousness, or more subtle signs, such as not eating and a patient or their family’s concerns and observations around wellness, mental status or behaviour. Deterioration can occur in any health and care setting and is the common pathway in all emergency admissions, prolonged illnesses and deaths.
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Content Article
In early 2022, following his wishes, my husband was discharged from hospital for end of life care at home to be provided by his family (his wife, three adult children and son-in-law) and nurses from our local hospice. We were completely unprepared for the challenges and disruption that lay ahead for us all. -
News ArticleThe family of a student who died after hospital staff missed that she had developed sepsis despite a string of warning signs have claimed she was the victim of a “lack of care”, as a coroner ruled there were “gross” failures in her treatment. Staff at Southmead hospital in Bristol failed to carry out the sepsis screening and observations needed to keep 20-year-old Maddy Lawrence safe after she was taken to hospital with a dislocated hip sustained in a rugby tackle. Outside court, the student’s mother, Karen Lawrence, said: “It has been a constant struggle to understand how a healthy, strong and fit 20-year-old could lose her life to sepsis which was allowed to develop under the care of professionals. “Her screams of pain and our pleas for help were merely managed, temporarily quietened with painkillers while the infection progressed unnoticed by hospital staff. “Our daughter was failed by a number of nurses and medical staff; symptoms were ignored, observations were not taken, on one occasion for 16 hours. There was no curiosity, basic tests were not completed even when hospital policy required them. “Maddy herself expressed concern on multiple occasions but her pain was not being taken seriously. As well as failing to fulfil their duty, those nurses and medical staff offered no sympathy, no compassion and little attention. “This failure meant Maddy was not given the chance to beat sepsis. Significant delays in its discovery meant the crucial window for treatment was missed. Maddy did not die due to under-staffing or a lack of money. Her death was the result of a lack of care.” Read full story Source: The Independent, 8 September 2023
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News ArticleDr Shivani Tanna has been working in the NHS for 18 years. "Everything [she] always had concerns about played out" in the care of her husband, who died after NHS hospital failures. A passionate doctor from a circle of acclaimed medics, Dr Tanna was thrust into life ‘on the other side’ as a ‘patient and a relative’ when her husband, Professor Amit Patel, was struck by a life-threatening illness. That experience, the devastated mum-of-two claims, "corroborates what [her] own patients have told [her] about the fact that, currently, the NHS is not fit for purpose". In the wake of her husband's death, Dr Tanna says his case reveals fundamental issues in the health service. “We have been indoctrinated as doctors, service users, and as a society in general to believe that this is a wonderful entity and we are so lucky to have a national health service," she says. “However, nobody wants to address the elephant in the room - that it is operating on less than full staff constantly... there is so much poor practice that it’s become normalised." Three years on and a long-running inquest to find answers later, Prof Patel’s wife is fighting to make changes to the NHS. “It has not been fit for purpose for decades,” Dr Tanna told the Manchester Evening News. "It is operating on less than full staff constantly, relying on bank staff and locums, and we’ve got doctors leaving in droves because they’ve not been nurtured or given the opportunity to work, I think, in a safe and appropriate environment.” The Area Coroner for the Manchester City concluded that the death of a 43-year old Consultant Haematologist and father of two, Prof Amit Patel, would have been avoided were it not for ‘inexplicable’ failures by clinicians to provide a national-level Multi-Disciplinary Team (MDT) with relevant and readily available information about the patient. Prof Patel was suffering from Hemophagocytic lymphohistiocytosis (‘HLH’), a rare disorder in which he himself was an expert. The Coroner found that the local clinicians at Wythenshawe Hospital had failed to provide a National HLH MDT with relevant and readily available information that would have influenced the decision making about Prof Patel’s care. As a result the National MDT, operating on incomplete information, recommended that Prof Patel undergo an Endobronchial Ultrasound guided biopsy (EBUS) procedure, a complication of which ultimately led to his death. The Coroner also found that there were failures in the process by which Prof Patel’s consent was obtained to undergo the procedure and as a result he was not given the opportunity to provide his informed consent to the EBUS that ultimately led to his death. Read full story Source: Manchester Evening News, 17 June 2024
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Content Article
The Voicing Loss project is a collaboration between the Institute for Crime & Justice Policy Research at Birkbeck, University of London, and the Centre for Death & Society at the University of Bath. The research was conducted from May 2021 to May 2024, with funding from the Economic and Social Research Council. The research examined the role of bereaved people in coroners’ investigations and inquests, as defined in law and policy and as experienced in practice. It also explored ways in which the inclusion and participation of bereaved people in the process can be better supported. A range of project outputs are available via the dedicated Voicing Loss project website. They include a short research summary, along with thematic research reports and policy and practice briefings. The website also has an information and resources section for the general public, and an Expert Insights blog to which many stakeholders have contributed. Many of the study’s key findings, and the research context and methodology, are presented in the papers listed on the website. Implications of these findings for policy and practice are considered in a series of briefings also available through the website which you can access via the link below. -
Content Article
Medicines: tips for carers
Patient Safety Learning posted an article in Medication
Managing medicines for someone can be a challenge, particularly if they're taking several different types. Although the person you care for may appreciate your support with their medicines, bear in mind that they have a right to confidentiality. It's up to them to decide how much of their health and medicines information is available to you as their carer, and how much you should be involved in their care. This NHS page gives tips on how to give pills correctly, dosette boxes and medicine reminders, asking for a structured medication review and medicine safety. -
News Article
Mother hopes Martha’s rule will ‘upend hierarchy’ on hospital wards
Patient Safety Learning posted a news article in News
The mother of a 13-year-old girl who died of sepsis has said she hopes Martha’s rule, which gives patients and their families the right to a second medical opinion, will “upend” the “hierarchy” on hospital wards. Merope Mills, who campaigned with her husband, Paul Laity, to give families more say regarding care following the death of their daughter Martha, also called for a “mutual respect” between patients and doctors. More than 140 NHS sites in England have agreed to implement Martha’s rule, a patient safety initiative that will give patients and their families round-the-clock access to a rapid review by an independent critical care team from elsewhere in the hospital if they feel their health, or that of a family member, is deteriorating and they are not being listened to. Speaking at NHS ConfedExpo on Wednesday, Mills, an executive editor at the Guardian, said: “My big thing is, I think we need to be more equal. “It’s a very unequal place, a hospital ward, and there’s hierarchy and it’s very steep and it’s very strict. And, you know, when I first started talking about that, I sort of thought the nurses were at the bottom of the hierarchy. “And I refer to that because they didn’t feel that ability to speak up in Martha’s case. But I’ve actually come to realise that the people at the bottom of the hierarchy are the patients. “They are the ones with the least power and I just would like to upend that and just have a sense of mutual respect between doctor and patient.” Read full story Source: The Guardian, 14 June 2024 -
Content ArticlePatient safety policies increasingly encourage carer (i.e., family or friends) involvement in reducing health care–associated harm in hospital. Despite this, carer involvement in patient safety in practice is not well understood—especially from the carers’ perspective. The purpose of this article is to understand how carers of adult patients perceived and experienced their patient safety contributions in hospital. Constructivist grounded theory informed the data collection and analysis of in-depth interviews with 32 carers who had patient safety concerns in Australian hospitals. Results demonstrated carers engaged in the process of “patient-safety caring.” Patient-safety caring included three levels of intensity: low (“contributing without concern”), moderate (“being proactive about safety”), and high (“wrestling for control”). Carers who engaged at high intensity provided the patient with greater protection, but typically experienced negative consequences for themselves. Carers’ experiences of negative consequences from safety involvement need to be mitigated by practice approaches that value their contributions.
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Content ArticlePhil, Triangle of Care lived experience co-chair at Pennine Care NHS Foundation Trust, shares a short message about why involving carers in patient safety work and sharing expertise with carers is so important.
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Maternity: Broken Trust (itvX documentary)
Patient Safety Learning posted an article in Maternity
Exposure documentary exploring the failures in maternity care at the Nottingham University Hospitals Trust (NUH), and the toll it has taken on those fighting for justice. -
News Article
Parents hope documentary will help maternity inquiry bid
Patient Safety Learning posted a news article in News
A couple whose child died before birth due to failings in her care hope a new documentary can support their calls for a public inquiry into England's maternity services. Jack and Sarah Hawkins' daughter Harriet was stillborn at Nottingham City Hospital in April 2016. They hope an ITV programme - Maternity: Broken Trust - shown on Sunday evening can help their bid for a wider probe. An independent review into failings in maternity services in Nottingham is now the biggest maternity investigation in NHS history, but a report is not expected to be returned until 2025. Dr and Ms Hawkins - who received a £2.8m settlement over failings in their daughter's care - said a wider investigation was needed to highlight national issues. "I think maternity services across England are absolutely terrible," Ms Hawkins said. "We're in contact with people with dead babies from Leeds to Plymouth, and I think what really needs to happen is for there to be a public inquiry into England's maternity services. "It's not just Nottingham, it's everywhere, and hopefully this platform will give people the strength to come forward and speak up." Read full story Source: BBC News, 10 June 2024 -
Content ArticlePatient feedback on diagnostic errors may improve the quality and safety of care. This analysis examined patient feedback on what went well with the diagnostic process. Results mirrored those of studies on diagnostic errors, stating feeling heard, appreciated, and timely communication contributed to a good diagnostic process.
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News Article
My schizophrenic son killed his father. We speak every day
Patient Safety Learning posted a news article in News
Dan Harrison, who had schizophrenia and psychotic delusions about his parents, had been sectioned ten days before he attacked his father. He was detained at Neath Port Talbot Hospital, run by the Swansea Bay University Health Board. During those ten days he received no treatment or medication. He escaped through a door being held open by a member of staff who was talking to someone else and immediately headed for the family home where he killed his father. The attack came after Dan's mother, Jane, and her husband repeatedly asked for help from mental health services as their son’s state of mind and behaviour deteriorated. They were refused. Last month Kirsten Heaven, assistant coroner for Swansea, recorded in a narrative verdict that there had been repeated failings by the Swansea University Health Board and local council. She said multiple system failures had contributed to Kim’s death and warned of more deaths if they were not addressed. Jane is speaking out now, with her son’s permission, after a Sunday Times investigation highlighted the scale of mental health-related killings in Britain. There have been at least 233 reported since 2020 and there have been repeated warnings about NHS services failing to provide crisis care. Read full story (paywalled) Source: The Times, 1 June 2024 -
EventTraining to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations. Being open and apologising when things go wrong. Challenges/complexities associated with cases where there is more than one investigation. Effective communication, including dealing with conflict and difficult conversations. Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation. Sharing findings. Signposting and support: including loss, trauma and stress. WHO SHOULD ATTEND Lead investigators conducting patient safety incident investigations. Executive and service lead for duty of candour. Executive and service lead for patient safety. Executive and service lead for the supporting response to patient safety incidents. Investigators supporting patient safety incident investigations. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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News Article
Parents call for inquiry into maternity services
Patient Safety Learning posted a news article in News
The families of nine babies who died at a scandal-hit NHS trust over a three-year period have called for a public inquiry into the standard of its maternity care. A collective letter has been sent to each of the families' MPs after they lost babies at hospitals run by the University Hospitals Sussex NHS Foundation Trust. Of the nine bereaved mothers, four said they too almost died as a result of "poor standards of care" from maternity teams between 2021 and 2023 The trust said it had recruited more midwives and "changed" how it supported families, with outcomes now better "than most other trusts in the country". But the Sussex-based families said they had called for a public inquiry into its maternity services to ensure accountability for "systemic failures", and so the trust learns from past mistakes. In the letter to the MPs, the parents said: "With the volume and repetition of errors in maternity care by the trust, we believe that babies and potentially mothers will continue to unnecessarily die under the trust’s care unless there is additional intervention." Read full story Source: BBC News, 4 June 2024 -
Content ArticleIn this Byline Times article, the family of 18 year-old Mollie McAinsh describe her treatment in an NHS hospital after they sought help for her life-limiting ME. Millie developed the condition after a viral illness in 2019 and became increasingly unwell. When she was no longer able to feed herself, she was admitted to the Royal Lancaster Infirmary, where her family believed she would have a feeding tube fitted and then be sent home. However, while in hospital her mother was banned from visiting and Millie was sectioned under the Mental Health Act. The article looks at the issues facing people with severe ME and examines the history of how the illness has been perceived, which many believe has resulted in the wrong treatment being offered to ME patients.
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EventThis conference brings together leading experts at the forefront of Martha’s Rule implementation and offers a comprehensive and practical guide for clinical staff to seamlessly integrate Martha’s Rule into their daily practice. The conference delves into the caregiver’s perspective, principles and implications of Martha’s Rule, legal and patient safety considerations, effective communication strategies, and the use of technology in the adoption of Martha’s Rule. Throughout the day, there will be interactive sessions, small breakout groups, and collaborative exercises, fostering a dynamic learning experience. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/marthas-rule-patient-safety or email aman@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for the discount code. Follow on X @HCUK_Clare #MarthasRule
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Content ArticleClive Treacey, who had a learning disability, epilepsy and complex mental health needs, died in 2017 aged 47, having spent his adult life in residential social care and inpatient settings. In 1993, he was placed by Staffordshire County Council into the David Lewis Centre in the borough of Cheshire East, where it is alleged he was sexually abused by a member of staff. Cheshire East Safeguarding Adults Board (CESAB) and Staffordshire and Stoke-on-Trent Adults Safeguarding Partnership Board (SSASPB) jointly commissioned a Discretionary Safeguarding Adults Review (D-SAR) to look at Clive's case. Authored by Professor Michael Preston-Shoot, the review relates to historical incidents of abuse and examines what is now in place to protect adults at risk since adult safeguarding became a statutory duty under the Care Act in 2014. The SAR makes 14 recommendations to the boards.
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Content ArticleHealthcare services improvisation relies heavily on collaborating with patients and caregivers by acknowledging their feedback to enhance quality and safety. The 2023 World Patient Safety Day underscores the significance of co-production with patients in safety strategies. In accordance with this, a crucial tool that involves patients and caregivers is the “Patient-reported experience measures (PREMs)” that help in assessing healthcare delivery in terms of quality, safety and performance. These tools for various healthcare processes offer valuable insights into treatment effectiveness and areas needing improvement. PREMs are surveys used to assess patients' care experiences objectively, aiding in pinpointing the areas for improvement. Unlike patient satisfaction measures, which reflect only subjective evaluations, PREMs offer an objective view of care encounters. In view of the importance of a standardised tool for Indian health care organisations, CAHO in collaboration with various stakeholders and patients unveil the White paper on Patient-Reported Experience Measures (PREMs) tool development process. This white paper was released by the honourable governor of West Bengal, Dr C.V Ananda Bose at the recently concluded CAHOCON 2024 at Biswa Bangla, Kolkata.
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Content ArticleMeasures exist to improve early recognition of, and response to, deteriorating patients in hospital. However, deteriorating patients continue to go unrecognized. To address this, interventions have been developed that invite patients and relatives to escalate patient deterioration to a rapid response team. To systematically review articles that describe these interventions and investigate their effectiveness at reducing preventable deterioration.
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Content ArticleMeasures exist to improve early recognition of, and response to deteriorating patients in hospital. Despite these, 7% of the deaths reported to the National Reporting and Learning System from acute hospitals in 2015 related to a failure to recognise or respond to deterioration. Interventions have been developed that allow patients and relatives to escalate patient deterioration to a critical care outreach team. However, there is not a strong evidence base for the clinical effectiveness of these interventions, or patients’ ability to recognise deterioration. The aims of this study were to (a) identify methods of involving patients in recognising deterioration in hospital, generated by health professionals, and (b) to develop and evaluate an identified method of patient involvement in practice, and explore its feasibility and acceptability from the perspectives of patients. The preliminary findings suggest that patient-reported wellness may predict subsequent improvement or decline in their condition as indicated by objective measurements of physiology (NEWS). Routinely recording patient-reported wellness during observation shows promise for supporting the early recognition of clinical deterioration in practice, although confirmation in larger-scale studies is required.
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Content ArticleChildren being subjected to lethal medical experiments sounds like the plot of a dystopian horror film. Yet that is exactly what happened in the UK in the 1970s and 80s. New documents seen last week by the BBC reveal the extent to which children with haemophilia and other blood clotting disorders were enrolled in clinical trials, often without their parents’ consent. Most of them were infected with HIV or hepatitis C as a result of being treated with blood products that doctors knew could kill them. At one boarding school for boys with haemophilia used by the doctors conducting these trials, Treloar College in Hampshire, 75 out of the 122 pupils who attended between 1974 and 1987 have died as a result of their HIV or hepatitis C infections. The independent inquiry on the contaminated blood scandal estimated that 1,250 people contracted both HIV and hepatitis C as a result of these agents, and between 2,400 and 5,000 people hepatitis C alone. Others contracted these viruses after receiving blood transfusions following surgery or childbirth; it is thought that up to 100 people were infected with HIV this way, and 27,000 people with hepatitis C. Around 2,900 people have died so far. One gets a sense of the horrific trauma the state inflicted on people by reading the evidence those affected gave the inquiry.
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News Article
GPs and patients invited to share views on legal ‘duty of candour’
Patient Safety Learning posted a news article in News
The Government is inviting views on how well GP practices and other NHS organisations are complying with their legal duty of candour when things go wrong. Patients and health professionals are being asked whether the statutory duty is well understood and adequately regulated by the CQC. Under the statutory duty of candour, introduced for all CQC-registered providers in 2015, GP practices must be open and honest with their patients when something goes wrong and has caused harm. In December, the Department of Health and Social Care (DHSC) announced a review into whether healthcare providers are following the duty of candour rules. This was in response to concerns that the duty is not always being met and that there is variation in how the rules are being applied. The DHSC has published its ‘call for evidence’ to gather views on how well the duty of candour obligation is working for both patients and health professionals. Patients have been asked whether GP practices and other providers ‘demonstrate meaningful and compassionate engagement’ with patients who have been affected by an incident. The call for evidence also asks for views on whether the criteria for triggering the duty are appropriate and well understood by staff. Read full story Source: Pulse, 16 April 2024 -
Content Article
Consumer perspectives enable a broader understanding of how harm occurs. This webpage by Te Tāhū Hauora, the Health Quality & Safety Commission of New Zealand, contains guidance on engaging patients and consumers who have experienced harm and wish to be involved in learning and improvement in the healthcare system. It describes how patients and family will be supported to work in partnership with health care workers.
