💯If it doesn’t start well and is ignored or minimised, it won’t end well.
When the NHS causes avoidable harm to a patient, why isn't that patient automatically given additional safeguards against further harm?
An apology isn't enough. A Duty of Candour letter isn't enough. An investigation report isn't enough.
Once a healthcare organisation knows that a patient has been harmed, surely it has an additional responsibility to protect them.
That should mean:
- A named senior clinician accountable for coordinating their care.
- An independent assessment of the harm and any ongoing risks.
- Enhanced monitoring and safeguards against further failures.
- Full, honest disclosure to the patient.
- A documented plan to address the harm.
- Staff empowered and expected to speak up when care is unsafe.
- Independent verification that lessons have actually been learned.
Why should a patient who has already been failed have to rely on the same systems, with no additional safeguards, to prevent it happening again?
Patient safety should not end with incident reporting.
We talk endlessly about learning from mistakes. But what about protecting the person who has already suffered the consequences?
Duty of Candour should be accompanied by a duty of continued protection.
Not preferential treatment because one patient's life matters more than another's, but additional safeguards because an identified failure has created additional responsibilities.
Acknowledging harm is not the same as putting it right.
And no patient should have to suffer further harm before an organisation takes those responsibilities seriously.
A culture of territorialism permeates health & social services, with deep ‘them and us’ battle lines drawn by staff. The cult is impenetrable.
This is the greatest obstacle to a better NHS. Not funding. No amount of funding can fix it, only a change in culture.
JM Reid retweeted
This would give people in hospitals or care homes the right to nominate someone they lave and trust as thei Health and Care Partner. That person's access would be protected and their care and advocacy valued. It really matters but no one knows about it. Please RT
Late last night in the House of Lords @LordPhilofBrum introduced 4 amendments to the #HealthBill - these reflect the right to a #HealthAndCarePartner. We thank him, along with #BaronessFinlay #BaronessTyler @Tanni_GT for speaking @JohnCampaign @CovidJusticeUK #RightsForResidents
youtu.be/nA0PhONwRx0?si=1yJJ…
JM Reid retweeted
This is a joke, many NHS managers who've retired early have been offered such positions in exchange for an annual payment of £13500
While there is a committment to read a few reports remotely over a day or two, it is viewed as a stepping stone until their state pension kicks in
Plus dietitian, speech & language and social work.
Real input, not ward rounds without seeing or speaking to the patient.
Not box-ticking or minimal/no records.
Key to it all - compassion and MDT communication .
A house of card can collapse with just one card removed.
JM Reid retweeted
Before an older relative leaves hospital in England, NICE guidance on moving between hospital and home for adults with social care needs lists what should happen.
One health or social care practitioner should be responsible for coordinating the discharge. The person should be given a complete list of their medicines. The hospital doctor should make sure the GP receives the discharge summary within 24 hours.
A GP or community nurse should phone or visit people at risk of readmission 24 to 72 hours after they leave.
If you do not know who is coordinating the discharge, ask the ward.
This needs to be said over and over again. Every failure can’t be clocked up to “error”. Laziness and negligence are not errors. And they can and do cause death, often of the most vulnerable patients.
Neglect of nutrition, hydration and other basic physical and mental needs are common in care of the elderly, even in facilities proclaiming to specialise in elderly care and can be difference between life and death.
Another finding of neglect (Safeguarding investigation) against Mid and South Essex, with poor records criticised by coroner
"not fed and hydrated properly"
Death of 86 Jill Rose, former nurse
Can't find published PFD yet
Condolences to family
yellowad.co.uk/nhs-trust-und…
JM Reid retweeted
No screening means no numbers. No numbers means no problem, as far as the board can see.
A hospital that does not measure delirium has no way to show how much it has, or whether its care is improving.
A damning statistic indeed & begs the Q, what are the statistics for others not qualifying as people - the very elderly/frail, mentally impaired, just anyone very vulnerable & unable to self-advocate, whereupon medical power may trump the right to adequate care and even life.
💯 Medics wield immense power and influence through their notes. They’re not the place for playing fast & loose with the facts or making wild guesses & character judgements with inappropriate words, snap scores and wee crosses +. Definitely not the place for exclamation marks ‼️
#Oliverscampaign
A bit of advice for medics when writing up a patients notes, don't write something you wouldn't say to the patients face,
STOP with the mother blame
If you wouldn't write it about your loved ones. Don't write it about your patient.
Keep to the facts
JM Reid retweeted
"Denies pain" means little from a patient who is unable to say where it hurts.
In dementia and delirium, pain shows up as agitation or silence.
Use an observational pain tool, treat, reassess.
Painkillers before tranquillisers.
#delirium
JM Reid retweeted
The delirium checklist that fits on a glove: PINCH ME.
Pain, INfection, Constipation, deHydration, Medications, Environment.
Then add what it can miss: sodium, glucose, calcium and oxygen.
#delirium
ALT Card headed "BEFORE THE SCAN" and "PINCH ME". Pain. INfection. Constipation. deHydration. Medications. Environment. Footer: "Six bedside checks, then add sodium, glucose, calcium and oxygen." @think_delirium
If Michelle O’Neill’s understanding of the law is akin to that of a medieval monarch, it’s because she stands against a medieval anti-Catholic coat-trailing klan that in any healthy modern society would be consigned to history.
But nice gaslighting.
What has happened in Portadown over the last 48 hours has ramifications which will echo for years. Michelle O’Neill has shown an understanding of constitutional law which is closer to that of a medieval monarch than a democratic government minister.
belfasttelegraph.co.uk/comme…
One of many important questions that nobody asks.
It’s as if it doesn’t matter but it matters very much. It determines how they are treated and very often it results in them being treated as a lost cause.
In hospital, ask early: what could this person do two weeks ago?
That baseline should guide mobility, delirium assessment, discharge planning and rehabilitation.
#geriatrics
JM Reid retweeted
In hospital, ask early: what could this person do two weeks ago?
That baseline should guide mobility, delirium assessment, discharge planning and rehabilitation.
#geriatrics
JM Reid retweeted
Every time inquiry learnings come to a board meeting (which is every single day) respondents should imagine that there is a public gallery filled with those harmed by the original events, watching. Maybe that would stop them being no more than an item on a very busy agenda
JM Reid retweeted
An older person can survive the acute illness yet leave hospital less able to walk, wash or think clearly.
Preventing avoidable decline is part of the treatment.
#hospitalcare pubmed.ncbi.nlm.nih.gov/3265…
