Professional Regulation Flashcards
What is the Bristol Royal Infirmary scandal? Why was nothing done?
Bristol has high paediatric cardiac mortality rates compared to other hospitals
- too many children died due to the failings of the hospital
nothing was done because of:
- ‘club culture’ = did not allow discussion of poor outcomes
- professional hubris
- lax approach to clinical safety
- low priority given to children’s services
- lack of external monitoring of NHS performance
= everyone thought it was someone else’s job to monitor quality of care
What was changed as a result of the Bristol Royal Infirmary scandal?
- independent external monitoring service to identify good and failing hospitals
- introduction of appraisal, CPD and revalidation for all healthcare professionals to ensure they keep their skills
up to date - patients and the public should be more involved in decisions about their treatment and care.
- more openness about clinical performance, allowing patients to access information about the relative performance of hospitals, services or consultant unit
- creation of national standards of care, both in clinical care and for hospitals
- changes to the consultant contract to make them more accountable to the trust hospital that employs them
What was the Alder Hey Organs scandal? Why did it happen?
organs were stripped without consent from babies who died at the hospital between 1988-1996
hospital staff also kept and stored 400 foetuses collected from hospitals around the north west of England
Alder Hey and Liverpool University knew there were risks in appointing Professor Van Velzen but failed to supervise him
- they failed to monitor his work or follow up complaints and missed numerous chances to discipline him
What was the Shipman Inquiry?
large quantities of CDs were prescribed by Harold Shipman
- was found to have killed 215 of his patients between 1975 and 1998.
= killed patients by administering large doses of opiates (diamorphine)
What was changed as a result of the Alder Hey Organs scandal?
independent commission to oversee cataloguing and return of 105,000 organs retained by hospitals in England
new law on informed consent
review of coroner’s system
trusts to employ bereavement counsellors
review by the education secretary of arrangements for joint hospital/university posts
What was changed as a result of the Shipman Inquiry?
- introducing new powers to enable Primary Care Trusts (PCTs) to suspend GPs or remove them from the local list
- introducing checks on the qualifications, professional history and police record of candidates for GP positions
- CD regulations
= revised valid period of prescription to 28 days
= advice to limit supply to 30 days
= CD prescription forms for private prescriptions
= proof of identity for collection of CDs
What was the Mid Staffordshire NHS Foundation Trust scandal? Why did it happen?
high mortality rates in patients admitted as emergencies
- appalling conditions and inadequacies at the hospital
- between 400 and 1200 more patients died between 2005 - 2008 than would be expected for the type of hospital
low staff numbers (understaffed)
poor staff morale
goal was to meet targets not providing care
What was the Francis Report?
made recommendations to the Secretary of State based on the lessons learnt from Mid Staffordshire scandal
What were the problem identified by the Francis Report?
problems
- too great a degree of tolerance of poor standards and of risk to patients
- failure of communication between the many agencies
- culture focused on doing the system’s business – not that of the patients
- failure to tackle challenges to the building up of a positive culture, in nursing in particular
What were the solutions brought forward by the Francis Report?
- foster a common culture shared by all in the service of putting the patient first
- develop a set of fundamental standards, easily understood and accepted by patients, the public and healthcare staff, the breach of which should not be tolerated
- ensure openness, transparency and candour throughout the system about matters of concern
- provide for a proper degree of accountability for senior managers and leaders
- enhance the recruitment, education, training and support of all the key contributors to the provision of healthcare
What was the Berwick Report (2013)?
says that the health system must:
- recognise the need for wide systemic change
- abandon blame as a tool and trust the goodwill and good intentions of the staff
- reassert the primacy of working with patients and carers to achieve health care goals
- use quantitative targets with caution - they should never displace the primary goal of better care
- recognise that transparency is essential and expect and insist on it
- ensure that responsibility for functions related to safety and improvement are established clearly and simply
- give NHS staff career-long help to learn, master and apply modern methods for quality control, quality improvement and quality planning
What was the Gosport scandal?
an independent panel found there was a “disregard for human life” at hospital
- where inappropriate use of strong painkillers was linked to the deaths of over 450 patients
Who was Beverly Allitt? What was the cause?
nurse
- convicted in 1993 of murdering 4 children and attempting to murder 3
- injected them with potassium and lignocaine
- the system was unable to detect things going wrong.
- healthcare professionals have duties not privileges
