Latest news with #HSSIB
Medscape
2 days ago
- Health
- Medscape
Safety Body Warns Over Post-Discharge Information Gaps
Communication failures between hospitals and community services after patient discharge can lead to serious medication-related harm, a new report has warned. The Health Services Safety Investigations Body (HSSIB) found that gaps in patient records, poor information sharing, and insufficient post-discharge support can delay or prevent medication being taken, with potentially life-threatening consequences. Case Study: Missed Insulin After Discharge The investigation examined the case of a 53-year-old man whose diabetes medication was changed during a hospital stay. Although he received some education on self-administering insulin, he later said he struggled to remember the instructions. A referral for district nursing support was made via his GP, but the district nursing team was not informed. Seventeen days after discharge, he told a nurse that he had not been taking insulin. His glucose levels were dangerously high, leading to an emergency hospital readmission. Key Failings Identified The HSSIB identified several failings: Conflicting records on admission made it unclear whether the patient had been taking diabetes medication. No documented evidence confirmed his ability to self-administer insulin after discharge education. Communication about the need for district nursing support was inconsistent between hospital teams and community services, and no specific support for insulin administration was arranged. The patient was discharged with two insulin pens, one of which was unnecessary, causing him confusion. District nursing demand often exceeded capacity, limiting visit times. Multiple providers used incompatible electronic patient record systems, preventing the sharing of critical information. Recommendations for Safer Discharges The report calls for local-level learning prompts covering hospital care, discharge planning, and community follow-up to prevent similar risks. It stressed the importance of ensuring patients are confident in managing their medication before leaving hospital and improving interoperability between hospital and community electronic systems. 'A Matter of Patient Safety' Rebecca Doyle, safety investigator at HSSIB, said that improving information flow and patient support at discharge is more than an administrative task. 'It's a matter of patient safety,' she said. 'While individual cases can be complex, this incident clearly highlighted persistent challenges with information sharing – an issue we continue to see in investigations that explore communication and the interaction of digital systems. This information sharing is critical to keep people safe at home, managing their medical conditions, and avoiding readmission to hospital.' The report is the third and final in a series of HSSIB investigations exploring why medications intended to be given to patients were not given. Priscilla Lynch is a freelance writer for Medscape, with over 20 years' experience covering medicine and healthcare. She has a master's in journalism and recently undertook a Health Innovation Journalism Fellowship with the International Center for Journalists.
Medscape
27-06-2025
- Health
- Medscape
Sepsis Diagnosis Delays Pose Urgent Safety Risk: HSSIB
The Health Services Safety Investigations Body (HSSIB) has warned that delays in diagnosing sepsis continue to pose an 'urgent and persistent safety risk' to NHS patients in England. In a new report, the independent body examined three cases where patients faced severe harm or death due to missed or late sepsis diagnoses. The findings highlight continued challenges faced by clinicians in identifying sepsis early. The UK Sepsis Trust told The Guardian that learning from such cases could help prevent up to 10,000 deaths each. Sepsis is associated with around 48,000 deaths and affects approximately 245,000 people each year in the UK. Key Issues Identified in Sepsis Care The HSSIB identified 10 areas for improvement. While based on the three cases reviewed, the recommendations may apply more broadly across the NHS. 'These reports show a consistent pattern of issues around the early recognition and treatment of sepsis,' said Melanie Ottewill, senior safety investigator at the HSSIB. Key areas for improvement included: Poor coordination of care, including inconsistent referral pathways, variation in clinical expertise, and access to medication. Weak communication between medical staff and across organisations. Failure to recognise early signs such as new-onset confusion or suspected infection. Case Studies Highlight Diagnostic Challenges The three HSSIB's investigations involved patients with a urinary tract infection, abdominal pain, and a diabetic foot infection. Two of the patients died. The third required an amputation and faced a long recovery. The report emphasised that sepsis symptoms can vary widely, with no single diagnostic tool reliably identifying the condition. Factors such as age, pre-existing health conditions, and immune function can alter how sepsis presents. In two of the three cases, new confusion — a known red flag — was not recognised. In one case, the patient's family told investigators they had raised concerns but felt they were not listened to. Barriers to Timely Treatment Each investigation uncovered different breakdowns in the system. One case showed that a lack of consistent referral processes and limited information sharing between hospitals contributed to delayed diagnosis. Another case identified the absence of a direct route of escalation from nursing staff to senior doctors for deteriorating patients. It also found that nurses were hesitant to begin a sepsis screen without confirmed signs of infection, which delayed escalation to senior clinicians. In the third case, a delay in prescribing by an out-of-hours GP using the electronic patient record system meant that a patient waited nearly 20 hours to receive antibiotics. 'These reports provide a valuable reiteration of how quickly sepsis can develop – and therefore how swift diagnosis and treatment must be,' said Dr Ron Daniels, founder and chief medical officer of the UK Sepsis Trust. 'We need a commitment from health ministers on the development and implementation of a 'sepsis pathway' – a standardised treatment plan that ensures patients receive the right care from the point at which they present their symptoms to a clinician through to receiving their diagnosis.' Ottewill added: 'The findings also highlight the imperative of listening to families when they express concerns about their loved one and tell us about changes in how they are.'
The Independent
26-06-2025
- Health
- The Independent
Early diagnosis of sepsis faces ‘ongoing challenges'
The Health Services Safety Investigations Body (HSSIB) has identified "ongoing challenges" in the early diagnosis of sepsis, labelling it an "urgent and persistent safety risk" in the UK. HSSIB's reports detail three cases where patients suffered severe harm or death due to delayed sepsis recognition, citing issues such as delayed medication, lack of doctor capacity, and inadequate patient transfers. A recurring concern highlighted by HSSIB is that family members are often not listened to when they express worries about a loved one's deteriorating condition, which can delay critical interventions. Experts, including the UK Sepsis Trust, advocate for swift diagnosis, consistent public awareness of symptoms, and the implementation of a standardised " sepsis pathway" to improve patient outcomes. NHS England states it is supporting initiatives like Early Warning Systems, Martha's Rule, and patient wellness questionnaires to aid in early deterioration detection and empower patients and their families to raise concerns.
The Guardian
26-06-2025
- Health
- The Guardian
Patients dying of sepsis because medics too slow to spot it, warns NHS watchdog
Sepsis is causing thousands of deaths a year, a charity has said, as the NHS's safety watchdog warned that doctors and nurses are too often slow to identify and treat it. 'The recognition of sepsis remains an urgent and persistent safety risk', despite previous reports highlighting the large number of deaths it causes when diagnosed too late, according to the Health Services Safety Investigations Body. Too often, relatives were ignored when they raised concerns about the condition of a loved one who later died of sepsis, the HSSIB said on Thursday. It urged NHS trusts and staff in England to learn from mistakes which the UK Sepsis Trust estimates play a key role in as many as 10,000 avoidable deaths every year UK-wide. Sepsis develops when an infection goes untreated and the body's immune response starts to target its own tissues and organs. Doctors refer to that process as 'organ dysfunction'. It causes more deaths than lung cancer and is the second biggest killer in England after heart disease, NHS England says. However, it is very hard to diagnose as many of its symptoms – such as confusion, breathlessness and blotchy skin – are also found with other conditions and there is no single sign or diagnostic test to identify it. The report from HSSIB is the latest in a series from bodies including the Parliamentary and Health Service Ombudsman (PHSO) and Care Quality Commission to reveal the large number of patients who die every year after NHS staff take too long to diagnose it. 'There have been initiatives to improve the recognition and timely treatment of sepsis over the last 20 years, yet it has persisted as a safety risk,' HSSIB said. It published reports of three cases involving patients – named only as Barbara, Ged and Lorna – for whom a delay in spotting sepsis had severe consequences. Two of the patients died and the third had to have her leg amputated below the knee after starting on antibiotics too late. The three incidents 'show a consistent pattern of issues around the early recognition and treatment of sepsis', said Melanie Ottewill, HSSIB's senior safety investigator. 'The experiences of Barbara, Ged and Lorna show the devastating consequences of sepsis. They also highlight the imperative of listening to families when they express concerns about their loved one and tell us about changes in how they are.' Lorna was admitted to hospital in England on 5 July last year with severe abdominal pain and a high heart rate. It took 30 hours before a doctor identified her sepsis and gave her antibiotics. However, her condition deteriorated and she died the next day. 'Lorna's family expressed concerns that they were unable to advocate for her wellbeing and that their concerns about how unwell she was were not always heard,' HSSIB said. Dr Ron Daniels, the founder and chief medical officer of the UK Sepsis Trust, said that since the success of hospitals in England in 2016-19 at identifying and promptly treating sepsis, the NHS's performance 'has slipped backwards considerably'. That is because a financial incentive offered to hospitals, to screen anyone who might have sepsis and give them antibiotics within an hour – the approach recommended by the National Institute for Health and Care Excellence – ended. 'The quality of care has returned to its pre-2016 level – that is, a postcode lottery in patients' chances of their sepsis being spotted. I'm appalled,' Daniels said. 'We estimate that of the 48,000 people a year who die of sepsis, at least 10,000 more lives could be saved if the NHS prioritised sepsis as an urgent clinical issue.' Rebecca Hilsenrath, chief executive of the PHSO, said: 'These reports highlight what we have been saying about sepsis for over a decade. Lessons are not being learned, recommendations from reports are not being implemented and mistakes are putting people at risk.' The NHS's culture needs to be one that is 'open, accepts mistakes and learns from them' in order to reduce the huge toll of avoidable death, she added.
Medscape
13-05-2025
- Health
- Medscape
Mental Health Units Repeating Safety Failings, Warns HSSIB
Mental health inpatient services in England continue to ignore critical safety recommendations, putting patients and staff at risk, according to a new report. The Health Services Safety Investigations Body (HSSIB) based its findings on multiple investigations into inpatient mental health care between September 2024 and January 2025. The report highlighted persistent systemic failures that have persisted despite previous warnings. Duplication and Confusion The report warned that in many cases, there is no clear responsibility for implementing recommendations. Guidance is often duplicated across organisations, causing confusion. A recurring barrier is the sheer volume of similar recommendations. This has led to a box ticking culture and tokenistic approach to making improvements. One example cited is a 2023 investigation by the HSSIB into the transition from children's to adult mental health services. Despite clear recommendations made to NHS England, the HSSIB found no evidence of follow-up action. Furthermore, longstanding recommendations to improve the physical health of people with severe mental illness remain unfulfilled, the HSSIB report stated. Premature deaths continue to occur as a result. Adults with severe mental illness remain significantly more likely to die prematurely—before the age of 75—than those without, in every upper-tier local authority in England. Culture of Blame Hindering Progress A culture of fear and blame continues to hinder progress, according to the report. Staff told investigators they felt punished or singled out when things went wrong. In one case, a senior leader likened their experience to 'being the naughty child on the naughty step' following a patient death. Fragmented Systems and Poor Accountability The report highlights deep fragmentation between health and social care services. Investigators found that delivery of mental health care services is hindered by poor integration and often depends on personal relationships and misaligned goals. This lack of integration leads to poor accountability and ultimately harms patient outcomes. The HSSIB has called on the Secretary of State for Health and Social Care to develop a national strategy to define patient safety roles and responsibilities across integrated care systems. Flawed Suicide Risk Assessments The report also raises concerns about how suicide risk is assessed. Clinical language and tick-box checklists can leave patients feeling dismissed or fearful. This discourages open discussion of distress and undermines safety. In contrast, compassionate conversations based on trust are more likely to improve outcomes, the report noted. Additional System Problems The HSSIB report identified further areas of concern: Physical health: Patients with severe mental illness often receive inconsistent physical health checks. Symptoms may be misattributed to psychiatric causes, delaying treatment. Data access: Integrated care boards lack quality data to plan or respond effectively. Workforce: Staff shortages in inpatient and community settings continue to threaten care quality. Digital systems: Poorly integrated IT systems hamper coordination across services. Call for Change The central message of the report is that repeated recommendations are failing to produce meaningful change. 'Too often, we see well-intentioned recommendations fall through the cracks – not because people don't care, but because systems don't support sustained change,' said Craig Hadley, HSSIB's senior safety investigator. 'Our findings call for a more joined-up approach to improvement to ensure that mental health services are safe, effective, and patient-centred.'
