Health Management and Policy Alert

Healthcare provision in prisons: emergency care response

Health Services Safety Investigations Body (HSSIB) - 

Ambulance crews spend significant time diverting resources to 999 callouts in prisons that are cancelled or not a serious emergency. The HSSIB estimates that these calls use 1,250 hours of ambulance crew time per year. There is a particular need to improve communication and collaboration.

• Report
• Press release

Workforce and patient safety: temporary staff – integration into healthcare providers

Health Services Safety Investigations Body (HSSIB) - 

The NHS regularly uses temporary staff to fill gaps in its workforce. This investigation report reveals there is widespread discrimination against temporary staff in the NHS and this creates a culture of fear that stops them speaking up about patient safety.

• Report
• Press release

Digital tools for online consultation in general practice

Health Services Safety Investigations Branch -
This report identifies that online tools are not always accessible and easy to use, and do not always allow general practices to collect the necessary information they need to make decisions about a patient’s care. It concludes that patient safety must be prioritised as online consultation tools in general practice continue to be implemented.

• Report
• Health Services Safety Investigations Branch - news

Patient Safety Commissioner annual report 2023-24

Department of Health and Social Care -
This report summarises the work of the Patient Safety Commissioner during the financial year 2023 to 2024. It is aimed at all those with an interest in patient safety.

• Report
• Department of Health and Social Care - publications

Corridor care: unsafe, undignified, unacceptable

Royal College of Nursing -
This report reveals that more than 1 in 3 (37 per cent) nursing staff working in typical hospital settings delivered care in inappropriate settings, such as corridors, on their last shift. The report shares the results of a survey of almost 11,000 frontline nursing staff across the UK. It calls for mandatory national reporting of patients being cared for in corridors, to reveal the extent of hospital overcrowding, as part of a plan to eradicate the practice.

• Report
• Royal College of Nursing - press release

Infected Blood Inquiry: the report

Infected Blood Inquiry -   

This is the report, published in seven volumes, of the independent public statutory inquiry established to examine the circumstances in which men, women and children treated by National Health Services in the United Kingdom were given infected blood and infected blood products, in particular since 1970.

• Overview & recommendations
• Other volumes

 

National learning report: factors affecting the delivery of safe care in midwifery units

Maternity & Newborn Safety Investigations -
This report looks at common themes of 92 maternity investigation reports, where the safety incident under investigation included care provided in a midwifery unit. It identifies four main themes and findings, which include issues relating to: work demands and capacity to respond; intermittent auscultation; how prepared an organisation is for predictable safety-critical scenarios; and telephone triage.

• Report
• Maternity & Newborn Safety Investigations - publications

Investigation report: nutrition management of acutely unwell patients in acute medical units

Health Services Safety Investigations Body -
The purpose of this investigation was to support improvements in the identification of malnutrition and management of nutritional needs for patients within acute medical units (AMUs). AMUs are the first point of entry for patients referred to hospital as an acute medical emergency by their GP and those requiring admission from the emergency department. The investigation uses, as an example, a real patient safety incident in which a man’s nutritional needs were not met for 19 days stay in hospital, of which 13 days were in AMU resulting in him losing up to 26% of his body weight within a six-week period.

• Report
• Health Services Safety Investigations Body - publications

The King’s Fund submission to the Health and Social Care Committee inquiry on NHS leadership, performance and patient safety

The King's Fund -
This submission focuses on: how leadership intersects with the NHS’s productivity challenge; the evidence for associations between leadership and productivity; and what national leaders and politicians should do with this insight.

• Report
• The King's Fund - publications

Long waits and excess deaths

Royal College of Emergency Medicine - 

The idea of emergency care services experiencing seasonal spikes in demand – so called ‘Winter Pressures’ are fast becoming a thing of the past. Instead, long waits have become the new norm year-round, and staff are caring for patients in unsafe conditions on a daily basis. It is well established that long waits are associated with patient harm and excess deaths. Last year the UK government published Delivery plan for the recovery of urgent and emergency care (UEC) services. A year on, far too many patients are still coming to avoidable harm.

• Briefing
• Press release