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Archive - July/August 2010, vol 16 no 8

• Gifford, P. Individual and system failure ending in death. HCRR vol 16, no 8, pp6-7
  Great Western Hospitals NHS Trust was ordered to pay £75,000 plus costs of £25,000 after being found guilty of breaching the Health and Safety at Work Act over the death of 30-year old Mayra Cabrera in 2004.
• Gardner, J. Failure to return foetus for burial. HCRR vol 16, no 8, p8
  A foetus was not returned to its mother after it was sent to a laboratory for testing, in spite of her clearly expressed wish to bury it in accordance with her beliefs. She received compensation of £8,750.
• Gardner, J. Consent not obtained for hernia repair. HCRR vol 16, no 8, p8
  A man who underwent hernia repair surgery was left with scarring and penile numbness. He received £15,000 in compensation.
• Rimington, G. Failure to examine patient. HCRR vol 16, no 8, p9
  Compensation of £35,000 was secured after a GP failed to examine a teenage boy. The boy proved to have a slipped upper femoral epiphysis of the right hip.
• Tingle, J. Getting serious about patient safety culture in the NHS. HCRR vol 16, no 8, pp10-11
  The NHS annual staff survey shows that there is still some way to go in implementing a patient safety culture. In particular, it reveals a lack of teamwork and a lack of feedback to staff about changes made as a result of incidents that have harmed patients. The National Patient Safety Agency’s framework for reporting serious incidents should help to address this by ensuring a consistent national approach. However, the NPSA’s “never events” framework is of more dubious value, offering a punitive approach that does not fit the collaborative ethos of the NHS.
• Hancock, C, and Marchant, S. What does the CQC expect? The implications of regulations 11 and 17. HCRR vol 16, no 8, pp12-14
  Regulations 11 and 17 of the Regulated Activities Regulations cover safeguarding service users from abuse, and respecting and involving service users. These regulations represent two key aspects of modern healthcare – the safeguarding agenda and the personalisation agenda. Compliance with both these regulations is not easy. Regulation 17 is integral to the design and delivery of modern service provision and should be regularly audited. Compliance with this regulation is linked to compliance with regulation 11, by having a thorough understanding of the needs of individual patients, how they are protected using their individual risk profile, and how they and their families or carers are involved in their care.
  
• Anderson, P. Staffing and care of patients are key conditions in CQC registration. HCRR vol 16, no 8, pp15-16
  By 1 April this year, all 378 NHS trusts providing healthcare services in England had been registered with the Care Quality Commission. However, for 22 trusts, registration came with conditions attached. For acute trusts, the most frequently placed conditions concerned staffing, patient care, and the monitoring of care quality. Four mental health trusts, two primary care trusts and one ambulance trust also had conditions imposed. One mental health trust has now had its conditions removed on appeal.
• McIlwain, J. Consent: can a risk be unavoidable? HCRR vol 16, no 8, p17
  The Department of Health’s guidance on amending consent forms, issued after the Chester v Afshar case, advises referring to “unavoidable” risks as well as “serious” and/or “frequently occurring” risks. However, there appears to be a contradiction, as the term “unavoidable” involves certainty whereas “risk” means chance and so uncertainty. The introduction of a third adjective on a form will not necessarily make any lives or procedure safer and may even add to upset when litigation seeks to untangle what risks are avoidable and which are unavoidable.
• Marsden, E. Focusing on patient safety: looking beyond individual blame. HCRR vol 16, no 8, pp18-19
  Most incidents – even those that involve individual failings – are the result of system failures or weak systems coupled with human behaviour. The investigation of the death of a woman during routine surgery found long-standing organisational weaknesses that may have contributed to the patient’s death and made for an unsafe patient environment in the hospital on the day of her death. Recommendations have been made to help the hospital concerned to improve the quality and safety of its services.
• Anderson, P. National initiatives to improve safety in maternity care. HCRR vol 16, no 8, pp20-21
  This year has seen the publication of major guidance on maternity care from the National Patient Safety Agency, including an intrapartum scorecard, a care bundle for placenta praevia after caesarean section, and a pro-forma for review of intrapartum-related perinatal deaths. More support and guidance for NHS organisations is on the way, from the NPSA and other bodies including the King’s Fund and the Health Foundation.
• Alonzi, A. Understanding the roles of mental health and mental capacity advocates. HCRR vol 16, no 8, pp22-23
  Despite their similar titles, the roles of an Independent Mental Health Advocate (IMHA) and an Independent Mental Capacity Advocate (IMCA) are quite different. An IMHA represents people who are subject to the Mental Health Act, while an IMCA represents people who lack capacity in decisions about serious medical treatment or long-term changes of accommodation. Healthcare organisations need to understand the distinction and their duties towards service users. Additional responsibilities exist where an IMCA is instructed in relation to the deprivation of liberty safeguards.
  

Abstracts from Health Care Risk Report:

June 2010, vol 16 no 7

• Norris-Evans, T. Cerebral palsy due to birth injury. HCRR vol 16, no 7, pp6-7
  Negligent management of delivery resulted in brain damage to a newborn twin. At the age of 11 she received a lump sum of £1,956,466 plus periodical payments, including an annual sum against future loss of earnings.
• Gardner, J. Failure to provide care in labour. HCRR vol 16, no 7, pp7-8
  A claimant was left with permanent injury following substandard care during the birth of her second child. She secured £200,000 in compensation.
• Taylor, P. Failure to inform patient. HCRR vol 16, no 7, pp8-9
  A woman was not given the advice she needed about treatment and was left infertile. The case settled for £40,000.
• Sankey, P. Failure to diagnose lung cancer. HCRR vol 16, no 7, p9
  A claimant secured £137,500 in damages after abnormalities on his wife’s chest x-rays were overlooked, delaying her diagnosis of lung cancer by 14 months.
• Tingle, J. Delayed diagnosis of cancer: what happens and what could be done. HCRR vol 16, no 7, pp10-11
  Cancer is the leading cause of mortality in people under the age of 75 in the UK, and the UK lags behind other countries in treatment outcomes. Late or missed diagnosis has been suggested as a major contributor to the UK’s ranking. A National Patient Safety Agency review lists the factor contributing to delay in cancer diagnosis and makes five key recommendations for action. These include development of an accessible diagnostic tool for use in primary care, identification and dissemination of good practice in the process of ordering, managing and tracking tests and test results, and review and development of methods for empowering patients who may be on a cancer diagnostic pathway.
• The PIPS (Patient Involvement in Patient Safety) research team. Why professionals’ response is pivotal when patients speak up about safety. HCRR vol 16, no 7, pp12-14
  Strategies to reduce adverse events in healthcare have mainly focused on systems of care and professional behaviour, but there is a growing interest in involving patients in safety initiatives. The Patient Involvement in Patient Safety team has conducted a project with the overall aim of investigating how patients and carers might appropriately be involved in effectively promoting their own safety. We found that health care professionals’ attitudes and behaviour were vital in facilitating patient and carer involvement in safety. If patients feel more comfortable in their dealings with professionals, then it is more likely that patient roles in enhancing safety will occur as a matter of course.
• Dupont, D. How an IT-based system has improved handover safety at one hospital trust. HCRR vol 16, no 7, pp15-17
  In hospitals, handing information over regarding multiple patients and patients with complex needs has become increasingly fraught since the introduction of the European Working Time Directive. Salisbury NHS Foundation Trust has developed an advanced multi-professional IT handover system. In a recent audit, 98% of sick or deteriorating patients, reviewed trust-wide at night, had been identified and handed over prior to the night shift commencing. There has also been better information sharing between professionals and a reduction in time spent by junior doctors preparing for their ward rounds. Handover is now regarded as a reduced risk on the trust risk register.
• Hancock, C and Marchant, S. What does the CQC expect? Regulation 10: monitoring quality of services. HCRR vol 16, no 7, pp17-19
  A key Regulated Activities Regulation, number 10, requires service providers to protect service users, and others who may be at risk, against the risks of inappropriate or unsafe care or treatment by regularly assessing and monitoring the quality of services, and assessing and monitoring risk. This regulation has far-reaching implications for service providers and there are key questions that they need to ask themselves in order to ensure they comply with the Care Quality Commission’s requirements. These include whether assessment and monitoring are happening already, whether the organisation has a robust ability to learn from its mistakes, and whether reports about performance delivery are acted on or forgotten.
• McLeod, Norman. Identifying the inherent risk in “normal” hospital working patterns. HCRR vol 16, no 7, pp20-21
  In March 2006 a 49-year old woman bled to death in a UK hospital while recovering from breast cancer surgery. Whilst undoubtedly tragic and avoidable, the manner of her death calls into question the concept of patient safety in the routine daily work of a hospital ward. Three areas where effective processes of control were jeopardised were training, procedures and communication. Care was also delivered in a way that lacked the properties of effective teamwork.
• Grimshaw, S. Reducing stress and sickness absence. HCRR vol 16, no 7, p22
  In 2006/7 Blackpool Fylde and Wyre NHS Foundation Trust had a high sickness absence rate and high levels of stress among staff. With senior management support, it undertook a stress project which has led to a reduction in cases of work-related stress of almost 40% and a 10% improvement in sickness absence. The project also helped the trust achieve level 2 of the Clinical Negligence Scheme for Trusts. Staff time and money have therefore been freed up for patient care.
• Wellens, A. Ways to reduce slips, trips and falls. HCRR vol 16, no 7, p23
  Slips, trips and falls are a major concern for those working within the healthcare sector and reducing their occurrence is a challenge for risk managers. The Health and Safety Executive (HSE)’s “Shattered Lives” campaign aims to encourage risk managers to do more to prevent these types of incidents.
  

May 2010, Volume 16 no 6

• Gifford, P. Fatal stabbing of charity worker. HCRR vol 16, no 6, pp6-7
  Mental Health Matters Ltd, a registered charity, was fined £30,000 with costs of £20,000 after one of its employees was killed by a service user
• Moutran, A. Successful defence of claim. HCRR vol 16, no 6, p8
  A claimant alleged that negligence had caused adhesions after surgery. However, the trust involved was able to show that the procedure had not been negligent and the claim was dropped.
• Collier, J. Failure to complete TURP. HCRR vol 16, no 6, p8
  A man who underwent an incomplete transurethral resection of prostate (TURP) was mistakenly told that he had terminal cancer and suffered urinary symptoms. A claim settled for £112,500
• Tingle, J. Keeping patients safe and putting them at the centre of care. HCRR vol 16, no 6, pp10-11.
  Two publications have an important potential to safeguard patients and to articulate their rights in healthcare. The Ministry of Justice has published a summary of reports and responses under Rule 43 of the Coroners’ Rules and the Scottish Parliament has published the Patient Rights (Scotland) Bill. The Patient Rights (Scotland) Bill is important and innovative and if implemented will put patients at the very centre of healthcare. Such legislation could be usefully considered for England
• Limb, M. The CMO’s role in the long voyage towards patient safety. HCRR vol 16, no 6, pp12-13
  Sir Liam Donaldson, who leaves his post as chief medical officer this summer to take up chairmanship of the National Patient Safety Agency, has overseen a decade of transformation in the way patient safety is handled in the NHS. Many experts regard him as the guiding light for a penetrating series of reforms and initiatives that have tackled deep-rooted concerns head on and brought a long-neglected issue out of the shadows. However, few dispute that the journey still has a long way to go
• Dangoor, M. The RSM’s Patient Safety Section: an organisation that will use its memory. HCRR vol 16, no 6, pp14-15
  At the Royal Society of Medicine on 25 February 2010 we celebrated the launch of a new section of the society dedicated to Patient Safety. The section aims to bring RSM members from different disciplines together to focus on and promote patient safety. The former Association of Litigation and Risk Management (Alarm) has been incorporated into the RSM and the Patient Safety Section has been established through a joint initiative. The section is open to all RSM members and with the active participation of patients and carers, it offers a wealth of opportunities to make healthcare safer
• Parsons, H., Ashworth J., and Watson, L. Implementing Patient Safety First. HCRR vol 16, no 6, p16
  Patient Safety First is a voluntary campaign led by NHS clinicians and managers with the aim of encouraging trusts to effect measurable changes in practice and culture. Although it focuses largely on acute trusts, many of the interventions promoted can be adapted to suit a primary care trust’s needs. NHS Somerset and Somerset Community Health have brought in safety walkrounds, improved patient monitoring, and reduced inpatient falls since joining the campaign.
• Emslie, S. NHS boards and governance: guidance needs to cover all the bases. HCRR vol 16, no 6, pp17-18.
  When things go wrong in the NHS, inevitably the question is asked, or at least implied: “Where was the board?”. Guidance for boards published in February - the National Quality Board’s review of early warning systems for the NHS in England, and updated governance principles from the National Leadership Council - is very welcome. However, the latter publication’s evidence base appears incomplete, and boards are still left in need of more guidance on formulating strategy, and how to fulfil all of their responsibilities.
• Hancock, C., and Marchant, S. What does the CQC expect? Regulation 9(2) on planning for emergencies. HCRR vol 16, no 6, pp19-10
  The second part of regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 covers emergencies in healthcare settings. Unlike other parts of Care Quality Commission guidance about what is expected, emergency planning requirements are presented in a very complex way. Healthcare providers should ensure that they plan for emergencies, including fires and major incidents, and failures of utility supplies and equipment. It is possible they may be penalised under more than one Regulation if they fail to do so.
• Cifford, P. Sentences for corporate manslaughter. HCRR vol 16, no 6, p21
  In February 2010, just before the first case under the Corporate Manslaughter and Corporate Homicide 2007 Act was due to be heard, the definitive sentencing guideline was published. This deals with the seriousness of offences, financial penalties and the additional powers available to a court when imposing sentence. Public bodies such as NHS trusts are specifically covered.
• Alonzi, A. How case law is clarifying the deprivation of liberty safeguards. HCRR vol 16, no 6, pp22-23
  The deprivation of liberty safeguards are relatively new and in February, the Department of Health published details of three cases. One case dealt with the scope of a standard authorisation while the others clarified the relationship between the Mental Health Act and the Mental Capacity Act. Further guidance on deprivation of liberty can be found on the Department of Health website.

April 2010, volume 16 no 5

• Lawford, K. Death after liver biopsy. HCRR vol 16, no 5, p6
  A woman died from internal bleeding caused during a liver biopsy at the Churchill Hospital in Oxford, which went undiagnosed. An inquest was held and resulted in a retrospective internal investigation by the hospital. A subsequent clinical negligence claim settled for £100,000.
• Gifford, P. Fatal scalding to teenager. HCRR vol 16, no 5, pp7-8
  Lifeways Community Care Ltd was fined £100,000 with costs of £45,000 after a disabled teenager was lowered into a bath of scalding water and died from her injuries.
• Gifford, P. Breaches of radiation regulations. HCRR vol 16, no 5, pp8-9
  The Royal Free Hampstead NHS Trust was fined £4000 and paid £9704 costs for breaches under the Ionising Radiation Regulations 1999 (IRR 1999) relating to the work of a consultant physician.
• Tingle, J. A picture of care in two key areas: stroke and dementia. HCRR vol 16, no 5, pp10-11
  The National Audit Office (NAO) is an independent body that determines how well public money has been spent and makes recommendations to make the spending more effective. The NAO’s reports on stroke and dementia care, published in February and January 2010 respectively, give those who are involved in clinical risk, litigation and health quality important contextual insights into policy, challenges and opportunities in these care areas which affect large numbers of people in the NHS.
• Maddaford, C. Improving patient safety across NHS Western Cheshire. HCRR vol 16, no 5, pp12-13
  NHS Western Cheshire has established a risk management system for incidents, complaints, and patient advice liaison service contacts. This is underpinned by a system of reporting and analysis that engages the whole local health economy. The primary care trust shares information with providers in order to facilitate investigation, monitor incident trends, ensure actions are taken, identify learning and where appropriate change systems, processes and practice. This system-wide approach ensures effective outcomes from reporting of patient safety incidents.
• Anderson, P. Patient safety champions: achievements so far and potential for the future. HCRR vol 16, no 5, pp14-15
  Patient safety champions are engaging with the NHS and the Department of Health, and some are working with strategic health authorities as part of patient safety action teams. An evaluation of their work shows that the degree to which the NHS is prepared to involved them varies at the moment. However, a shared vision appears to be emerging is that champions’ involvement will become the norm, with a patient safety champion working with every healthcare organisation.
• Morgan, S. Making good risk decisions in mental health and social care. HCRR vol 16, no 5, pp16-17.
  A risk identified is a risk predicted and hence safely managed; but when this simplified course of events fails to happen then someone “is to blame”. This creates demand for risk assessment, which has become focused on the task of filling forms. Risk assessment is not a redundant activity, but we need a clearer articulation of how identifying, analysing and managing risk information in the context of individual circumstances should lead to good quality risk decisions. These detailed decisions put into action are what will bring about change in pursuit of safer practice and outcomes.
• Anderson, P. Why you need to read the Mid Staffordshire inquiry report. HCRR vol 16, no 5, pp18-19
  The report of the independent inquiry into care provided by Mid Staffordshire NHS Foundation Trust, chaired by Robert Francis QC, comes in two volumes. The first covers issues including patient experience, the culture of the trust, the experiences and perceptions of staff, governance, and the board. The second contains accounts of patient experiences (see box). The NHS chief executive has asked all trusts to read the report in full so that lessons can be learned elsewhere in the system.
• Hogan, A. The Jackson report and clinical negligence litigation. HCRR vol 16, no 5, pp20-21.
  In November 2008, Lord Justice Jackson was appointed to undertake a fundamental review into the cost of civil litigation and to come up with proposals for root and branch reform, to ensure that access to justice was achieved at proportionate cost. If his proposals are implemented, then there should be a sharp reduction in the cost of litigation to the NHS. The scope for those representing claimants to produce very substantial bills of costs particularly under no-win, no-fee arrangements will be significantly curtailed.
• Alonzi, A. Encouraging or assisting suicide: a new focus on healthcare professionals. HCRR vol 16, no 5, pp22-23.
  The director of public prosecutions (DPP) has issued a policy for crown prosecutors in February, guiding them on whether to prosecute for the new offence of encouraging or assisting suicide. Unlike the interim policy issued in 2009, this policy now has a specific reference to doctors, nurses and other healthcare workers – that is, if a someone assists suicide in their capacity as a healthcare professional, this may make prosecution more likely. Clinicians should be aware of the law and should continue to seek advice from their professional bodies.

March 2010, Volume 16 no 4

• Gifford, P. Deaths related to wheelchairs in ambulances. HCRR vol 16, no 4, pp6-7
  A 90-year old woman fell from an ambulance on to the road, while an 87-year old man fell backwards in his wheelchair during ambulance transport. Both subsequently died. In the first case the HSE prosecuted the county council involved and in both cases procedures have now been changed.
• Balen, P. Patient wrongly identified. HCRR vol 16, no 4, p8
  A patient with a history of allergic reaction to painkillers was prescribed ibuprofen by his GP, and died after taking one tablet. An inquest found that the GP surgery had mixed up his notes with those of a similarly-named patient.
• Rimington, R. Poor repair of vaginal tear. HCRR vol 16, no 4, p9
  A claim for a poorly performed repair of a second-degree vaginal tear settled for £27,000.
• Tingle, J. Saying sorry: a hard but worthwhile thing for the NHS to do. HCRR, vol 16 no 5, pp10-11
  In our daily lives we quite naturally apologise when we have accidentally caused somebody harm or distress and to do so is a natural social courtesy. However, to apologise effectively is not necessarily an easy thing to do and is an art to be mastered. A University of Michigan Health Systems Programme, aiming for open disclosure of adverse events, has led to a drop in litigation. In the UK, the National Patient Safety Agency has revised its Being open guidance along similar lines. Recent research has found that apologising yields better outcomes than offering money.
• Marchant S. The brave new world of healthcare regulation in England. HCRR, vol 16 no 5, pp12-13
  From next month, all NHS services in England should be registered with the Care Quality Commission (CQC). The CQC will take a more hands-on approach to concerns and risk than its predecessor. Managers will need to achieve a fine balance of making declarations so as to preserve CQC’s confidence in line with “setting the bar” whilst understanding that the regulatory response may not always be predictable.
• Hancock C. Regulations with teeth. HCRR, vol 16 no 5, p14
  One of the problems with maintaining acceptable standards of care within the NHS has been the absence of enforceable regulations policed by an organisation independent of the Department of Health. Could it be that the Health and Social Care Act (Regulated Activities) Regulations 2009, due to come into force on 1 April 2010, will prove to be exactly the sort of robust and transparent regulatory framework that is sorely needed?
• Power, R. “What is the cause of safety?” HCRR, vol 16 no 5, p15
  “What is the cause of safety?” asks Jessica Mesman, senior lecturer in science and technology studies at Maastricht University, the Netherlands.
  This may sound like asking what causes motherhood and apple pie, but Dr Mesman is serious about turning the world of patient safety research upside down. She says that asking this question shifts focus from absence to presence, errors or vulnerabilities to strengths, and formal issues to informal or unintended causes of safety.
• Anderson P. The 1000 Lives campaign’s work in primary and community care. HCRR, vol 16 no 5, pp16-17
  The NHS in Wales is in a particularly good position to promote patient safety in all the settings in which healthcare is delivered, as its seven local health boards (LHBs) encompass primary, community and hospital care. The 1000 Lives campaign, launched in April 2008, is actively promoting patient safety outside hospitals as well as inside. Its work in primary and community care includes a focus on anticoagulant medication, infection control, chronic heart failure, and safety improvement in primary care.
• Mayatt V. Reducing healthcare associated infections: the third PAC report. HCRR, vol 16 no 5, pp18-19
  In November 2009, the House of Commons Public Accounts Committee (PAC) produced its third report on healthcare-associated infections (HAIs). It makes recommendations for the Department of Health and NHS organisations. The PAC has accepted that it will never be possible to prevent all HAIs, but says that pursuing the aim of zero tolerance of avoidable infections attributable to poor practice, poor clinical care or poor antibiotic prescribing is the correct way for all to proceed.
• Morgan S. Positive risk-taking: a basis for good risk decision-making. HCRR, vol 16 no 5, pp20-21
  “Where is the risk assessment?” has become a bureaucratic mantra. However, risk assessment should be seen as one contributory part of a wider process for achieving good risk decisions. A balanced approach to risk includes appreciation of positive risk management (positive risk-taking), collaboration with the service user and others involved (such as carers), and recognition of and building on the service user’s strengths. At a team level, there must be consensus to think and work in this way, along with appropriate tools to support the process of individual and team risk decision-making.
• Antony J., and Walsh K. The theory of constraints and safety in healthcare: an overview. HCRR, vol 16 no 5, pp22-23
  The theory of constraints is being used in healthcare organisations in the UK and USA to improve efficiency and safety of patient care. It is a five-step process designed to identify “constraints” and bottlenecks in healthcare systems which lead to inefficient or less safe care. It has been a success in some organisations, but there are potential barriers to its implementation, and critical success factors can mean the difference between success or failure.

February 2010, Volume 16 no 3

• Rimington, Gillian. Failure to prevent eye damage. HCRR vol 16 no 3, p6
  A claimant secured a £100,000 settlement after pursuing a claim for failure to prevent severe corneal scarring whilst she was in intensive care.
• Anderson, Pat. Improved care could have reduced risks. HCRR vol 16 no 3, p7
  Two reports on homicides by mentally ill people have found that improved care by mental health services could have reduced the risk of acts of violence.
• Rimington, Gillian. Failure to prevent pressure ulcer. HCRR vol 16 no 3, p8
  A claimant received £20,000 in settlement of a claim regarding failure to prevent a pressure ulcer following a hip replacement.
• Collier, Janine. Delay in diagnosis of scaphoid fracture. HCRR vol 16 no 3, p9
  A serviceman brought a claim after a wrist fracture remained undiagnosed for eight months. The claim settled for £9,000.
• Collier, Janine. Inappropriate use of antipsychotic. HCRR vol 16 no 3, p9
  A claimant suffered persistent priapism leading to impotence due to prescription of chlorpromazine for mental illness. A resulting claim settled for £28,500.
• Tingle, John. Appropriate hospital care at the end of our lives. HCRR vol 16 no 3, pp10-11
  Our life journey begins most probably in the maternity unit of a hospital and will more than likely end in an acute hospital surrounded by high-tech equipment, with a cardiac arrest or similar team fighting to save our life. The hospital focus is on saving life and warding off death. Modern medicine has done well in postponing the inevitability of death and the problem is now, according to the National Confidential Enquiry on Patient Outcome and Death, that “...in so many instances, a timely death remains difficult to discuss and therefore perhaps less well managed than it might be”.
• Burnett, Susan. Why organisations respond differently to safety improvement programmes. HCRR vol 16 no 3, pp12-13
  There is an assumption in the NHS that organisations will respond in the same way to every piece of guidance, initiative or programme yet we still hear about both award-winning trusts and the scandals of very poor practice. Why do organisations respond in different ways to different initiatives? Research among hospitals participating in the Safer Patients Initiative has identified that greater “organisational readiness” means a better chance of success.
• Melville, Sara. Improving safety in critical care for children. HCRR vol 16 no 3, p14
  Making the safety of patients everyone’s highest priority is the primary purpose of Patient Safety First, the national campaign for patient safety improvement in England. Its aim is to create an NHS where there is no avoidable harm and no avoidable death. Patient Safety First promotes the implementation of evidence-based interventions that trusts can adapt to suit their individual needs. Alder Hey Children’s NHS Foundation Trust has successfully adapted the critical care intervention to focus on reducing central line infections.
• Taylor, Hannah. The Liverpool Care Pathway and key legal principles. HCRR vol 16 no 3, pp15-17.
  The Liverpool Care Pathway ("LCP"), designed to improve the care of patients in their final hours, has been the subject of emotive debate in the press. However, there has been little discussion of whether the latest version of the LCP addresses key legal principles such as consent, capacity, advance decisions and confidentiality. Without further explanation and expansion upon these principles, patients may suffer and healthcare professionals may open themselves up to liability.
• Rawson, Edwina. When medical treatment goes wrong: payouts and recent cases. HCRR vol 16 no 3, pp18-20
  The NHS Litigation Authority (NHSLA) report and accounts for 20091 show that the number of claims against the NHS for clinical negligence has risen by 11%, and £807m was paid in compensation and legal fees in 2008/2009. Both negligence and causation of injury must be proven for a claim for compensation to succeed. If successful, the patient will be compensated for the reasonable losses and suffering that have been caused by the negligence. Compensation comes under the headings of “general” and “special damages” and cases from 2009 illustrate the varying amounts paid out to claimants for different examples of negligence.
• Anderson, Pat. HSE wants to encourage NHS leadership on health and safety. HCRR vol 16 no 3, pp21-22
  Health and safety continues to be a serious issue in health and social care, with 5.1 million days lost to work-related ill health or injury in these sectors in 2007/8, and 15 worker fatalities and 309 fatalities to patients and service users reported under regulations between 2001/2 and 2007/8. The Health and Safety Executive’s director of field operations, David Ashton, tells HCRR that healthcare performance has “plateaued” and to make progress, NHS organisations have to provide better leadership on health and safety. He says HSE will help them to “light a fire from within”, and will also work with other regulators on patient safety.
• Rayner, Wendy and McAree, Mark. Auditing waste can help reduce risk. HCRR vol 16 no 3, p23
  Hospitals now have to conduct an annual audit of whether they are complying with Department of Health guidance on waste management. Performing these audits can help improve practice, save money and reduce risks to patients, staff and visitors.

December 2009 / January2010, Volume 16 no 2

• Gifford, Phil. Inadequate control of Legionella. HCRR vol 16 no 2, p6
  Following the deaths of two patients, unsafe levels of legionella were found in a hospital’s water supply system. It was prosecuted under the Health and Safety at Work etc Act 1974 for putting employees and the public at risk, fined £35,000 and ordered to pay costs of £12,862.

• Collier, Janine. Inappropriate size of bridge post. HCRR vol 16 no 2, p7
  A woman who attended her dentist for a bridge repair was fitted with a bridge post of the wrong size. A subsequent claim settled for £5,500.

• Mullarkey, Paddy. Injury during keyhole surgery. HCRR vol 16 no 2, p8
  A claimant received £45,000 in compensation after sustaining a serious vascular injury during a laparoscopic procedure. A joint consultation between the parties led to a resolution of the case by way of settlement.

• Gifford, Phil. Failure to remove ligature points. HCRR vol 16 no 2, p8
  Sylvan Money, an inpatient mental health service user, hanged herself from a curtain rail. A prosecution was taken under section 3(1) of the Health and Safety at Work etc Act 1974 for the local health board’s failure to remove such fixed ligature points. A fine of £30,000 was imposed by the Merthyr Tydfil Crown Court with £46,849.50 costs.

• Tingle, John. Paying attention to detail in managing patient information. HCRR vol 16 no 2, pp10-11
  The quality of record-keeping reflects the quality of professional practice, and proper use of records is a prerequisite to good, safe and professional care. The Care Quality Commission (CQC) has produced an important report on handling patient information, looking at whether healthcare organisations are meeting basic standards on information governance. The report shows that while broad systems are be in place to manage patient information adequately, some of the detailed elements that help to deliver safe, high quality care are missing.

• Sturgeon, Nicola. Scotland’s no-fault compensation review. HCRR vol 16 no 2, p12
  Patients in Scotland could benefit from a new simpler, less expensive and quicker system of medical compensation. An expert group was established by the Scottish Government, in June 2009, to consider the introduction of no-fault compensation north of the border. The group is chaired by Sheila Maclean, Director of the Institute of Law and Ethics in Medicine at Glasgow University. If introduced a system of no-fault compensation means that some patients would receive financial compensation without the need to go through the legal process.

• Campbell, Diane; Crofts, Sally; and Watson, Catherine. The use of critical care bundles to improve patient outcomes. HCRR vol 16 no 2, pp13-15
  Preventing ventilator-associated pneumonia (VAP) is a substantial challenge for intensive care units (ICUs). Since implementing a Scottish Patient Safety Programme care bundle in 2008, including the use of chlorhexidine gel for oral hygiene, one ICU has achieved a 70 per cent reduction in VAP. Plan-do-study-act (PDSA) cycles have been central to this achievement, ensuring staff ownership of practice changes. A co-ordinated multi-disciplinary approach has resulted in improvements that are reliable and sustainable.

• Forsyth, Donna; Fletcher, Martin. Improving incident investigation. HCRR vol 16 no 2, p16
  Patient safety cannot be improved without a range of valid reporting, analytical and investigative tools that identify sources and causes of risk in a way that leads to preventative action. In December 2008, the NPSA launched a new set of tools to assist NHS organisations to improve the credibility and thoroughness of root cause analysis (RCA) investigation reports. Overall, feedback from NHS staff using the tools has been positive and the NPSA will continue to review and develop them to promote learning.

• Iskander, Sandra; Vats, Amit; and Burnett, Susan. Surgical safety briefings: the challenges of implementation. HCRR vol 16 no 2, pp17-18
  In the operating theatre, a significant number of adverse events are due to poor communication between members of the multi-disciplinary team. The introduction of surgical safety briefings, bringing structure to team communication, was a key element of the Health Foundation-funded Safer Patients Initiative in 24 NHS hospitals. Evaluation of the initiative has found that while briefings take time to implement, staff say they are beneficial and believe that they will improve patient safety.

• Delgado, Pedro. Safety improvement in Northern Ireland’s health and social care services. HCRR vol 16 no 2, pp19-20
  Over the last five years, the patient and client safety improvement movement in Northern Ireland has seen unprecedented levels of planned and coordinated action. Front line staff have led efforts that reflect their own commitment to providing best care for patients and clients, as well as the commitment of trusts, commissioners, other health and social care agencies and the support of the Department of Health, Social Service and Public Safety (DHSSPS). Ultimately Northern Ireland’s vision is to become an exemplar for safety and quality improvement by 2020.

• Cresswell, Jackie. A firm research foundation for patient safety work in Spain. HCRR vol 16 no 2, pp21-22
  Spain’s patient safety strategy has been developing since 2005, spearheaded by its Ministry of Health and Consumer Affairs (MCHA) and the Spanish NHS Quality Agency. Studies at a national level have established a baseline picture of patient safety in hospitals, intensive care units and primary care. Alongside work at a national level, regional initiatives are focusing on topics including medication safety, pressure ulcers, and patient identification.

• Alonzi, A. Assisted suicide: what you need to know. HCRR vol 16 no 2, p23
  Following a House of Lords ruling, the Director of Public Prosecutions has issued interim guidance on whether someone who helps another person to commit suicide should be prosecuted. The guidance applies to healthcare practitioners as well as the public. It does not change the law, but lists factors weighing against prosecution, such as being motivated by compassion.

November 2009, Volume 16 no 1

• Rimington, Gillian. Failure to recognise fracture. HCRR vol 16 no 1, p6
  A physician assistant working in accident and emergency failed to diagnose an ankle fracture in a 40-year old woman. She was left unable to work for seven months and following this, still experienced pain and inability to undertake activities such as hillwalking or cycling. The case settled for £125,000.

• Gifford, Phil. Failure to reduce risk to employee. HCRR vol 16 no 1, p7
  A hospital employee was injured using a mechanical hoist to move a patient. The Court of Appeal unanimously held that the burden was on the employer to prove that it had taken appropriate steps to reduce risk to the employee. However, the employer was only liable for 50% of the damages.

• Gifford, Phil. Inadequate Legionella surveys at care homes. HCRR vol 16 no 1, p8
  Deba UK Ltd, a Berkshire-based water treatment company, was prosecuted for carrying out inadequate and misleading surveys at nursing homes in Blaenau Gwent and Powys.

• Tingle, John. A clearer picture of medication incidents and how to tackle them. HCRR vol 16 no 1, pp10-11
  The NHS is a very busy place and to some extent errors are an inevitable feature of professional practice, in a sense they are part of the cost of doing business. The National Patient Safety Agency (NPSA) has published an important review of medication incidents across England and Wales that offers safety advice and risk reduction strategies. The report addresses patterns of reporting, lessons from serious medication safety incidents, lessons to be learnt from incidents in clinical specialties including acute and primary care, and an overview of medication safety literature. Key features of the report include short reporting and learning system (RLS) case summaries which  reveal the essential nature of incidents involving medication errors, with patients dying in some instances.

• Emslie, Stuart. Getting boards on board with patient safety: why and how. HCRR vol 16 no 1, pp12-13
  The tone of any organisation is set at the top – or “the fish rots from the head”. The Patient Safety First Campaign in England has based its own “Leadership for Safety” intervention on the  “Boards on Board” approach set out by the Institute for Healthcare Improvement in the USA. “Leadership for Safety” provides a list of key questions and actions or interventions needed in order to answer these questions so that boards can develop an appropriate action plan with clear priorities and timescales. More pressure on boards will help them to achieve better outcomes for patients.

• Anderson, Pat. George Eliot’s patient safety story. HCRR vol 16 no 1, p15
  The George Eliot Hospital in Nuneaton, named after the novelist who was born and lived locally, has a dramatic patient safety story to tell. In 2005/6, its hospital standardised mortality ratio (HSMR) was 143 and the trust had high rates of C difficile infection and MRSA bacteraemia.  Now, the HSMR stands at 92 and there has been a 36% reduction in C diff infection and a “huge” reduction in MRSA rates. The trust calls this a “real success story for patients”.

• Burnett, Susan. Improving patient safety: learning from the Safer Patients Initiative. HCRR vol 16 no 1, pp16-17
  The Health Foundation’s Safer Patients Initiative, launched in 2004, has helped 24 organisations to build a safer NHS. Researchers from Imperial College London were recruited to aid the capture and dissemination of lessons from the initiative. The programme’s aim was to improve safety through improved reliability of clinical practices, developing a safety culture, and ensuring safety was a strategic priority through involvement of the chief executives. Its design included collaboration between organisations, partnership between senior management and clinicians, and teaching improvement science and measurement techniques.

• Anderson, Pat. The Productive Ward initiative and its effects on patient safety. HCRR vol 16 no 1, pp18-19
  The Productive Ward initiative, launched in January last year, has been enthusiastically embraced by NHS trusts. Nurses have been able to spend more time on direct patient care, with fewer interruptions, on wards where it has been introduced. There is anecdotal evidence that more time spent with patients, plus greater staff engagement in running of wards, is leading to safety improvements. Those involved with Productive Ward say that it is here to stay.

• Rawson, Edwina. Litigation matters: a claimant lawyer’s perspective on NHS claims. HCRR vol 16 no 1, pp20-21
  It may be difficult for trust managers and medical practitioners to accept that there is a common goal between them and claimant litigation lawyers, but there is.  Nobody wants to be the subject of a claim for compensation, but litigation, and the threat of it, improve and maintain standards.  The steps involved in bringing a claim are simple to express although litigation can be complex. Swift resolution can keep costs down and help patients to move on.

• Cattell, Don. MCA advocacy in acute care. HCRR vol 16 no 1, p22
  A study placed independent mental capacity advocates in two care of the elderly wards in an acute hospital for three hours a day over four weeks, to monitor admissions and advise staff unsure about their responsibilities under the Act. The presence of the advocate acted as a focus for the development of knowledge about IMCA and the MCA, and also highlighted training issues. Discharge co-ordinators came out of the study as particularly important individuals in that they liaise with all levels of staff, and are familiar with patients’ circumstances.

• Hancock, Charles. Could standardisation improve fire safety? HCRR vol 16 no 1, p23
  A  wide variation in standards of preparation and training for the management of emergencies within health and social care can only increase the risk of emergencies being managed wrongly, with potentially disastrous consequences. This is especially true of fire safety.

Editor Pat Anderson has selected her top ten hot reads from the HCRR 2006-07 archive:

• Investigation into the death of a child and lessons learned
  William Randell, vol 13 issue 8, (July/Aug 2007), pp18-19
• Creating the right environment for individual complaints resolution
  Jon Wigmore, vol 13 issue 7 (June 2007), pp22-23
• Preventing falls among older people with mental health problems
  Fiona Chaabane, vol 13 issue 6, (May 2007), pp14-15
• How patient safety walkrounds help to put safety first in healthcare delivery
  Pat O'Connor, vol 13 issue 5 (April 2007), pp18-19
• Safety in the operating theatre: what underpins attitudes and behaviour?
  Ruth McDonald and Justin Waring, vol 13 issue 4 (March 2007), pp12-14
• Why we need to speed up the pace of change in labour ward practice
  Brenda Ashcroft, vol 13 issue 2 (December 2006/January 2007), pp12-14
• Issues identified by the "Purple Card" reporting system: a two-year review
  Lezli Feeney, vol 12 issue 10 (October 2007), pp20-21
• How the NHS could better protect the safety of radiotherapy patients
  Katharine Tylko and Mitzi Blennerhassett, vol 12 issue 9 (September 2006), pp18-19
• Exploring the boundaries of risk within and between NHS organisations
  Dr Jeff McIlwain, vol 12 no 6 (May 2006), pp12-13
• Pandemic flu planning: what NHS risk managers need to know
  Dr Hilary Pickles and Siobhan Clarke, vol 12 issue 5 (April 2006), pp12-13

If you would like to read more articles like these then begin your HCRR journal subscription today.