search.noResults

search.searching

dataCollection.invalidEmail
note.createNoteMessage

search.noResults

search.searching

orderForm.title

orderForm.productCode
orderForm.description
orderForm.quantity
orderForm.itemPrice
orderForm.price
orderForm.totalPrice
orderForm.deliveryDetails.billingAddress
orderForm.deliveryDetails.deliveryAddress
orderForm.noItems
PATI ENT SAFE T Y


First Do No Harm: a hard-hitting review


Kate Woodhead RGN DMS discusses the harrowing findings of a review by Baroness Cumberlege into the harm caused to patients and lessons that must be learnt. She highlights some of the important patient safety findings that are a must read for all those working in healthcare.


A recent report which represents two year’s work by Baroness Cumberlege is some of the most harrowing and appalling reportage I have ever read of failings in the delivery and follow up of care in the NHS. It documents the severe suffering caused by three treatments and the pain and suffering experienced by the patients, most of whom were women, for years without being heard. The three interventions are: l Sodium valproate, an epilepsy medication that causes harm to unborn children when their mother, unaware of the risks, takes it during pregnancy.


l Pelvic mesh, used to treat prolapsed pelvic organs and urinary incontinence, has caused extreme complications in many women.


l Primodos, a hormone pregnancy test, taken by women between 1950s and the late 1970s is associated with damage to children born with lesser or malformed limbs, who still need care as adults.


The report is critical of the healthcare system as ‘disjointed, siloed, unresponsive and defensive’ and highlights the need to change medical care to include more pre-market


Harm1


testing, post-market surveillance and long-term monitoring of pharmaceuticals and medical devices. The Cumberlege Review First Do No was published at the beginning


of July. It correctly identifies that the timing of such a report is serendipitous as there is a reform of the medical device regulation in hand to manage post Brexit requirements. The Medicines and Medical Devices Bill 2019-2021 is described by the parliamentary website as ‘A Bill to confer power to amend or supplement the law relating to human medicines, veterinary medicines and medical devices; make provision about the enforcement of regulations, and the protection of health and safety, in relation to medical devices; and for connected purposes.’2


It is due for its second


reading in the House of Commons at the beginning of September 2020. Baroness Cumberlege and her small team travelled the length and breadth of the country interviewing more than 700 past patients and their families for over two years; they also received a great deal of written evidence from those working within the system, including regulators, professional bodies, policy makers and manufacturers. Baroness Cumberlege said: “I have conducted many reviews and inquiries over the years, but I have never encountered anything like this; the intensity of the suffering experienced by so many families, and the fact that they have endured it for decades. Much of this suffering was entirely avoidable, caused and compounded by failings in the health system itself.” Challenges to the patient safety culture were reported by the CQC3


in 2018 when


they reviewed the safety culture in the NHS and demonstrated a clear need for transformation. Their review included input from arms-length bodies, Royal Colleges and professional regulators, who have a


22 l WWW.CLINICALSERVICESJOURNAL.COM SEPTEMBER 2020


©Chinnapong - stock.adobe.com


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76  |  Page 77  |  Page 78  |  Page 79  |  Page 80  |  Page 81  |  Page 82  |  Page 83  |  Page 84  |  Page 85  |  Page 86  |  Page 87  |  Page 88  |  Page 89  |  Page 90  |  Page 91  |  Page 92