Search Results

What happened with Martha's Case? Martha Mills, a 13-year-old, tragically lost her life to sepsis after the signs of her deteriorating condition were missed by healthcare professionals. Her ordeal began with a seemingly minor cycling accident during her summer holidays, which resulted in an injury to her pancreas. Despite being admitted to King's College Hospital in south London, her condition escalated into sepsis , a life-threatening response to infection that can lead to tissue damage, organ failure, and death. The inquest into Martha's death revealed that with prompt and appropriate medical intervention, her sepsis could have been treated, potentially saving her life. The hospital later issued an apology for the oversight in her care. This case underscored the critical need for heightened awareness and rapid response to the signs of sepsis in healthcare settings. It also brought to light the essential role that patients' families play in monitoring and advocating for their loved ones, especially in situations where healthcare professionals may overlook critical symptoms. The campaign led by Martha's parents for better recognition and response to sepsis has catalysed the introduction of "Martha's Rule" in NHS hospitals. This initiative aims to empower patients and their families, ensuring that concerns about a patient's worsening condition are promptly acted upon, with the hope of preventing similar tragedies in the future. What is Martha's Rule and how will it affect the NHS? Martha's Rule is a new initiative set to be introduced in NHS hospitals in England from April, aimed at providing seriously ill patients with easy access to a second opinion if their condition worsens. The scheme is backed by the government and will allow about two-thirds of hospitals, at least 100 initially, to apply for funding to participate. This system seeks to empower patients and their families by enabling them to directly request a "rapid review" of the patient's treatment from a team of critical-care medics. These reviews will be conducted by senior doctors or nurses who specialise in the care of patients who are deteriorating, ensuring an immediate reassessment of the patient's condition. Additionally, the scheme emphasises the formal recording of families' observations regarding the patient's condition or behaviour, acknowledging the vital role that patients and families can play in the monitoring process. The introduction of Martha's Rule reflects a significant shift towards enhancing patient safety and ensuring that concerns raised by patients or their families are promptly and effectively addressed. What is Sepsis and how it can affect children? Sepsis is a severe and potentially life-threatening condition triggered by the body's response to an infection. It arises when the body's defense system, in its attempt to fight off an infection, inadvertently turns on itself, causing widespread inflammation and clotting within the tissues and organs. This can lead to a cascade of changes that may damage multiple organ systems, leading them to fail. In the UK, sepsis is recognised as a medical emergency, with healthcare professionals trained to "think sepsis" when patients present symptoms indicative of severe infection. Early symptoms in children can include a high or low body temperature, chills and shivering, a fast heartbeat, and rapid breathing. In more severe cases, children may exhibit mottled, bluish, or pale skin, lethargy, a rash that does not fade when pressed, difficulty breathing, or convulsions/seizures. Diagnosing sepsis promptly is crucial, especially in children, as their condition can deteriorate quickly. In the UK, the NHS employs several diagnostic tools and protocols to identify and treat sepsis at the earliest possible stage. These include blood tests, urine or stool samples, respiratory secretion testing, and imaging studies such as X-rays, CT scans, or ultrasounds to identify the source of infection. Treatment for sepsis typically involves administering intravenous antibiotics, providing oxygen if levels are low, and ensuring fluids are given to prevent dehydration and maintain blood pressure. In severe cases, children may require admission to an intensive care unit for more specialised support. The UK's healthcare system emphasises the importance of early recognition and rapid response in the treatment of sepsis, aiming to reduce the risk of long-term complications and fatalities associated with the condition. NICE guidance / Sepsis Trust Guidance The National Institute for Health and Care Excellence (NICE) and the Sepsis Trust UK are pivotal organisations in the UK, providing comprehensive guidelines, resources, and support for managing and raising awareness of sepsis , including its impact on children. The National Institute for Health and Care Excellence (NICE) in the UK provides comprehensive guidance for the recognition, diagnosis, and early management of sepsis , including specific recommendations for children under 16 years old. This guidance, encapsulated in NICE guideline [NG51], emphasises the importance of early recognition of potential sepsis in anyone presenting with an infection, and it outlines steps for initial treatment, escalating care, and finding and controlling the source of infection. Key to this guidance is the notion of "thinking sepsis" early in the assessment process for individuals with suspected infection, especially given sepsis can present with non-specific symptoms and signs, sometimes even without fever. Healthcare professionals are advised to have a high index of suspicion for sepsis particularly in vulnerable groups such as those under 1 year or over 75 years of age, those who are pregnant, immunocompromised, have recently undergone surgery, or have a medical device or line in situ. High-risk individuals are recommended to receive broad-spectrum antibiotics and intravenous fluids in a hospital setting​​​​. The Sepsis Trust UK focuses on raising public and professional awareness of sepsis , advocating for improved care, and providing support to those affected by sepsis . For children, the Trust provides educational resources aimed at parents, caregivers, and professionals to help them recognise the early signs of sepsis , empowering them to seek medical attention swiftly. The Trust also engages in policy advocacy to enhance the standard of care and support for sepsis patients, including children, within the NHS and wider. Through its initiatives, the Sepsis Trust UK aims to reduce the incidence and mortality associated with sepsis by ensuring both the public and healthcare providers are informed and vigilant. For more detailed guidance and information, visiting the NICE website and the UK Sepsis Trust's official website would be beneficial. Conclusion In conclusion, the heart-wrenching case of Martha Mills has underscored the paramount importance of recognising and swiftly addressing sepsis , especially among children. The launch of Martha's Rule within the NHS marks a pivotal shift towards enhancing the responsiveness to sepsis in healthcare settings across the UK. This initiative, together with the crucial guidance provided by NICE and the advocacy efforts of the UK Sepsis Trust, signifies major progress in the fight against sepsis. As an expert witness company, we've provided advice and specialist opinion in a significant number of sepsis related cases, reflecting both the commonality of this condition and the complexities involved in its diagnosis and treatment. These instances starkly highlight the necessity for early detection and the pivotal role healthcare professionals play in averting the severe consequences of sepsis.

by Katherine Pierce Source The healthcare industry is a crucial part of the lives of everyone. Healthcare workers have always carried the great responsibility of caring for their patients. Over the last few years, doctors, nurses, and everyone on the frontlines of the pandemic dealt with incredibly difficult circumstances that required so much from them to the point of risking their own lives every day. Healthcare workers face many hardships during their long shifts and are overworked, often past their breaking point. It is no wonder healthcare managers experience continual employee turnover, and it’s a struggle to keep the healthcare team intact. Finding new employees to fill missing positions isn’t as easy as one might think, and you would need more resources to take on a new employee. But the retention of healthcare workers goes beyond the money and other resources the hospital spends to take on a new member. A quitting employee also means losing the experience and skill of a more seasoned member of the hospital’s healthcare team. You cannot easily replace those skills and expertise. Why is the Healthcare Industry Struggling to Retain its Employees? Employee retention is something all human resources managers think about, but especially so in such a demanding field like the healthcare industry. According to one study , healthcare providers face two significant challenges when retaining employees: structural and regulatory changes in the industry and departmental and individual discontent. Employees are stressed out, and some remain in these stressful environments at their own peril by force or feeling like they have no other option. These regulatory changes could involve incident reporting or how their higher-ups enforce specific policies. Many of the staff also feel stretched too thin and emotionally drained. Others have expressed developing mental health issues due to the strains of their job. The pressures of being in the medical field can be incredibly taxing. GPs have cited issues around job satisfaction and physical working conditions as critical factors in the increased GP turnover rate in the past decade. NHS workers have also reported workplace culture as why they leave their roles. In 2020, one in eight NHS staff has experienced discrimination at work. Reports of bullying, harassment, or abuse from managers and fellow colleagues have also been cited by the staff. Many healthcare employees also explained that the national shortage of medical professionals had left them with increased workloads. As a result, employees are burnt out and rushed, leaving patients with below-average care. Recently, healthcare professionals reported having intentions to leave the service. A common reason is exhaustion and stress. In a 2021 survey , 18% of doctors have considered leaving the profession, a leap from 12% in 2019. This is no surprise considering the demands they had to face. Nurses have also planned or considered leaving their roles due to feeling undervalued, exhausted, and under too much pressure. The Importance of Employee Retention in Healthcare The problems the healthcare organisations and workers face are multi-layered. It does not have straightforward solutions to solve everything entirely, but it can definitely guide the organization to the right path. Understandably, scheduling can be a difficult part of medical staffing. But employees will appreciate having control over their time. This gives them a more holistic life that includes time with loved ones. This can lead to healthier mental health that can help them feel more job satisfaction and stay in the organization for longer. Conducting interviews to listen to the employees’ pain points is also a great way to understand them. These interviews can help assess what management and the workplace can improve on. You can also remove frustrating obstacles and unnecessary challenges that may hinder them from performing their duties to the best of their abilities. You can implement new technology or streamlined services to help lessen their burden. This results in healthcare workers that feel more satisfied with their work as they can focus more on helping their patients. There is more balance between administrative and clinical work. And as NHS nurses have been vocal about in recent times, a well-compensated staff is crucial. NHS staff should have fair and reasonable pay and work conditions. Not addressing this aspect of the workforce crisis just aggravates the NHS staff crisis and puts patients at risk. Of course, recognition is always a great way to boost employee morale. Positive feedback, reinforcement, and a few kind words are always appreciated in the workplace. It also increases employee engagement and motivation. Developing a kinder workplace culture can also be incredibly helpful in keeping employees happy. Staff should be able to safely call out instances of bullying and racism and have proper measures enacted. With all the demands of the healthcare industry, sometimes people forget that healthcare workers are humans with breaking points too. It is crucial to provide support where they need it, to keep them in their hospitals and clinics, so they can continue serving their communities.

The realms of medical law and patient care in the United Kingdom have been significantly shaped by two landmark cases: Bolam v. Friern Hospital Management Committee (1957) and Bolitho v. City and Hackney Health Authority (1997) . These cases have established and then refined the tests for clinical negligence, setting precedents that continue to influence how medical professionals' actions are judged in the eyes of the law.    The Bolam Test: Establishing a Standard for Clinical Negligence The Bolam case arose from an incident in 1954 involving John Bolam , a patient who suffered fractures during electro-convulsive therapy (ECT) at Friern Hospital in London. At the time, it was not common practice to use muscle relaxants or restraints during ECT, nor was it standard to specifically warn patients of the risk of fractures. Bolam, alleging that the lack of these precautions constituted negligence, brought a case against the hospital.   The ruling of the case introduced what is now known as the "Bolam test" for establishing clinical negligence. Mr. Justice McNair, in his instructions to the jury, outlined that a doctor is not guilty of negligence if they have acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art. Simply put, if a significant number of esteemed practitioners would have acted in the same way under similar circumstances, the defendant would not be found negligent.   The essence of the Bolam test lies in its deference to clinical judgment and the recognition of differing opinions among professionals in the field. This standard emphasised the importance of peer approval and set a precedent that, for decades, would protect medical practitioners from negligence claims, provided their actions could be justified by a body of medical opinion.   The Bolitho Case The Bolitho case , decided forty years after Bolam , revisited and refined the criteria for assessing clinical negligence. The case involved Patrick Bolitho , a child who suffered catastrophic brain damage following a delay in intubation by a paediatric registrar, leading to his death. The Bolitho estate argued that if the child had been intubated earlier, he would have survived, claiming negligence on part of the health authority.   In this case, the House of Lords introduced a modification to the Bolam test , adding a layer of judicial oversight to the process. It was held that, while the medical profession's opinion is highly relevant, it is ultimately up to the court to decide whether the body of opinion relied upon is reasonable and responsible. The Bolitho ruling clarified that if the court concludes that the professional opinion is not capable of withstanding logical analysis, the court is entitled to find the defendant negligent.   This addendum to the Bolam test means that it is not enough for a group of medical practitioners to simply agree on a course of action. Their consensus must also be based on a foundation of logic and reasonableness when scrutinised by the court. The Bolitho ruling thus introduces a safeguard against unquestioning acceptance of medical opinions, ensuring that responsible and defensible reasoning underpins clinical decisions. Conclusion The Bolam and Bolitho cases collectively form the cornerstone of clinical negligence law in the UK, balancing the autonomy and expertise of medical professionals with the need to protect patients from substandard care. Bolam set the stage by establishing peer professional approval as a shield against negligence claims, while Bolitho refined this test by ensuring that such professional consensus must also be logically defensible. These legal frameworks ensure a nuanced approach to evaluating clinical negligence, respecting both the complexity of medical practice and the rights of patients to safe and informed care.

One pivotal aspect of nutritional support, as endorsed by NICE guidelines ( nice.org.uk ) is the effective screening for malnutrition risk.   The Malnutrition Universal Screening Tool ‘MUST’ stands out as a cornerstone in this effort. Developed by the British Association for Parenteral and Enteral Nutrition ( bapen.org.uk ), MUST is designed to help healthcare professionals identify adults who are malnourished or at risk of malnutrition.   Nutrition powers the body's healing processes. Adequate nutritional intake supports immune function, tissue repair, and overall recovery. Malnutrition can lead to weakened immunity, delayed wound healing, and increased susceptibility to infections. It's a vicious cycle where illness can diminish appetite or nutrient absorption, and inadequate nutrition can further impair health Recognising and addressing malnutrition is not just about improving health outcomes; it's about transforming patient care. Nutritional support can shorten hospital stays, reduce complications, and even decrease mortality rates.   The Vital Role of Good Nutrition in Wound Healing When it comes to healing wounds, whether they are minor cuts or major surgical incisions, the role of good nutrition cannot be overstated. Proper nutrition is foundational to the body's ability to repair itself. Every phase of the wound healing process requires specific nutrients to ensure a swift and efficient recovery. Here are several reasons why good nutrition is critical in wound healing: Protein Powers Repair: Protein is the building block of tissue and muscle. During the healing process, the body needs increased amounts of protein to repair damaged tissues. A deficiency in protein can lead to slower wound healing, increased risk of infection, and poorer outcomes. Foods rich in high-quality protein include lean meats, poultry, fish, eggs, dairy products, legumes, and nuts. Vitamins and Minerals – The Healing Catalysts: Certain vitamins and minerals play specific roles in healing wounds. Vitamin C, for example, is essential for collagen formation, a crucial component of skin tissue. It also helps with the absorption of iron, another important nutrient for wound healing. Zinc plays a critical role in maintaining skin integrity and is involved in the process of cell division, necessary for repairing damaged tissues. Sources of these nutrients include citrus fruits, strawberries, bell peppers, spinach, and pumpkin seeds. Hydration – The Unsung Hero of Healing: Adequate hydration is often overlooked in the wound healing process. Water is essential for all cellular functions and plays a pivotal role in delivering nutrients to the wound site, as well as in the removal of waste products from cells. Keeping the body well-hydrated ensures that the skin remains supple and resilient, which is vital for wound healing. Energy Needs: Healing wounds requires energy, which comes from calories. Consuming an adequate amount of calories is necessary to fuel the healing process. However, it's essential to source these calories from nutritious foods rather than empty calories from sugar-laden and highly processed foods. A balanced diet rich in fruits, vegetables, whole grains, healthy fats, and lean proteins provides the energy needed for efficient wound healing.  Immune System Support: Good nutrition strengthens the immune system, enabling it to fight off potential infections at the wound site. Nutrient-dense foods packed with antioxidants, vitamins, and minerals support the body's immune response, protecting the wound from complications that could delay healing.   Nutrition: A Key Factor in Preventing Pressure Sores Pressure sores, also known as bedsores or pressure ulcers, are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin. They often occur in individuals who are bedridden, use a wheelchair, or are unable to change their position frequently. While various factors contribute to the development of pressure sores, nutrition plays a pivotal role in their prevention.   Here's why nutrition is so crucial: Maintaining Skin Integrity: Healthy skin is the first line of defence against pressure sores. Nutrients such as protein, vitamins A and C, and zinc are essential for maintaining skin health and integrity. Protein is crucial for skin repair and regeneration, while vitamin C is involved in collagen production, which strengthens the skin. Vitamin A aids in skin cell turnover, and zinc promotes wound healing. A diet lacking these nutrients can lead to weakened skin, making it more susceptible to damage and the development of pressure sores. Supporting Immune Function: A well-nourished body has a stronger immune system, which is vital in preventing infections that can complicate pressure sores. Nutrients like vitamins C, E, and B6, along with minerals such as selenium and zinc, play significant roles in supporting immune health. Ensuring an adequate intake of these nutrients can help protect the body against infections and aid in the prevention of pressure sores. Enhancing Blood Flow: Proper nutrition supports cardiovascular health and enhances blood flow, ensuring that oxygen and nutrients necessary for skin health and wound healing are efficiently delivered throughout the body. Omega-3 fatty acids, found in fish, flaxseeds, and walnuts, are known to improve blood circulation, which is crucial for preventing pressure sores. Managing Body Weight: Both undernutrition and obesity can increase the risk of developing pressure sores. Undernutrition can lead to muscle wasting and decreased padding over bony prominences, making the skin more vulnerable to pressure sores. On the other hand, obesity can increase the pressure on certain areas of the body. A balanced diet helps in maintaining an optimal body weight, reducing the risk of pressure sores.   History and Development of MUST MUST was developed in the early 2000s as a practical response to the growing need for an easy-to-use, reliable screening tool for malnutrition. Recognising the prevalence of malnutrition in hospital and community settings and its impact on patient outcomes and healthcare costs, BAPEN aimed to create a tool that could be universally applied across care settings. The goal was to standardise the assessment of malnutrition risk, ensuring early identification and intervention.   How the MUST Works The MUST is ingeniously simple, designed for quick application while maintaining accuracy and reliability. It assesses three key parameters:   BMI (Body Mass Index): The first step in the MUST process is to calculate the patient’s BMI, a measure of weight in relation to height. A low BMI is a clear indicator of malnutrition risk. Unintentional Weight Loss: The second step assesses the percentage of unintentional weight loss, comparing the patient's current weight to their known weight at a previous time. This factor is critical as it indicates a recent deterioration in nutritional status. Acute Disease Effect: The final step considers the impact of acute disease on nutritional intake. If a patient is unable to meet their nutritional requirements due to illness (and has not received nutritional intake for more than 5 days), this is factored into their overall risk score.   Each component is scored, and the total score determines the patient's risk of malnutrition: A score of 0 indicates low risk. A score of 1 suggests medium risk. A score of 2 or more signals high risk.   The Relevance of MUST in Healthcare MUST has become an invaluable tool in healthcare settings for several reasons: Universal Applicability: It can be used in various settings, including hospitals, primary care, and community care, making it versatile. Early Intervention: By facilitating early detection of malnutrition risk, MUST allows healthcare professionals to intervene sooner, potentially preventing further decline in nutritional status. Improved Patient Outcomes: Early nutritional intervention can lead to better recovery rates, reduced complication risks, and shorter hospital stays. Cost-Effectiveness: Identifying and addressing malnutrition early can significantly reduce healthcare costs associated with prolonged treatment and complications.   Conclusion Adequate nutrition is paramount for both preventing illness and facilitating recovery in the event of illness. To ensure comprehensive care, healthcare providers must establish robust policies outlining the procedures for conducting nutritional assessments.   These assessments serve as crucial checkpoints before patients are referred to specialists, such as dieticians, ensuring timely intervention and tailored care plans. While the Malnutrition Universal Screening Tool (MUST) emerges as an exceptional aid in this process, it is important to remember that MUST is merely a tool and should never replace clinical judgement.   Despite its straightforward design, MUST enables early identification of malnutrition risk, empowering healthcare professionals to intervene effectively. By embracing MUST alongside clinical judgment, healthcare providers not only strengthen the foundation of healing but also uphold the principles of compassion and diligence integral to exemplary healthcare provision.

Introduction During the last 25 years nurses have been at the forefront in the treatment of non-surgical aesthetic procedures. These include the use of dermal fillers, the botulinum type A toxin cosmetically, chemical peels, and laser treatments. As well as treating patients many are instructing and mentoring their medical colleagues. Recognising that a new specialty brought with it responsibilities, a group of entrepreneurial nurses established a forum for aesthetic nurses. This afforded nurses networking and educational opportunities. They also published guidance for best practice, and the internationally acclaimed accredited competencies. Because their professional organisation felt that aesthetics was not part of mainstream healthcare, we founded the British Association of Cosmetic Nurses (BACN). Part of its remit is to educate and foster good practice so that patient safety in this new specialty may be safeguarded. The medicalisation of ageing and beauty There are many examples of conditions other than disease processes per se , which attract the attention of the medical and nursing professions, obesity and the menopause being the most obvious. Now the ageing process and the enhancement of beauty can be added to the list. It was during the Enlightenment that the idea of perfecting health began [1] . The Georgian public self-medicated, bought manuals and purchased products [2] which they hoped would help restore health. The 18th Century also saw the advent of marketing including advertising and product distribution. As the nation became more prosperous through an improved market economy, so people became more wealthy with an increase in disposable income. In addition to these factors anti-ageing treatments were crossing from America to the UK. Collagen which was used in the treatment of burns was found to restore skin integrity, and Drs A and A Carruthers were developing the use of the botulinum type A toxin cosmetically. Initially treatments were taken up by celebrities, and encouraged by the results, it was not long before the media promoted many of these treatments as ‘lunch time’ fixes. Alongside this was the realisation among some that physical appearance mattered in order to improve self-confidence, and secure a job or a partner. This too was encouraged by the media, and has become more potent with the advent of social media and the popularity of ‘selfies’. Although the public were initially cautious about anti-ageing treatments, the momentum rapidly increased resulting in the popularity of non-surgical treatments we are familiar with today. To cope with the increase in demand more practitioners are entering this field. There is therefore a requirement for education and training which is not delivered in the National Health Service. Education and training Currently education and training undertaken by doctors and nurses is product based, a format that seems set to change. The legal test for doctors and nurses is competence judged by the Bolam [3] /Bolitho [4] standard and underpinned by education and training. The BACN have updated their competency framework [5] which recognises the requirement for specialist knowledge and skills at different levels of practice [6] . The document provides a benchmark for good practice and is being used in the structuring of an educational framework for Higher Education Institutions in line with Department of Heath recommendations. As recommended in the Keogh report [7] , Heath Education England (HEE) is reviewing the qualifications required for non-surgical cosmetic procedures. Phase one established a proposed qualifications framework for five treatment modalities including non-surgical treatments. All practitioners will be expected to take part and there will be a range of entry points including accredited prior learning. A range of common themes including consent and ethics [8] will form part of the curriculum ranging from foundation to PhD level. Training will be competence based. The Department of Health will support HEE with legislation as at present non-medical personnel are undertaking these treatments. The legislation will ensure that all consultations for dermal filler treatments are undertaken by a member of the NMC or GMC. The treatment can then be undertaken ‘under supervision’ by an appropriately qualified practitioner [9] . It is hoped that this more formal model of education will reduce the high level of litigation in this specialty, currently running at 20%. Avoiding litigation While aiming to relieve distress medical treatments can cause iatrogenic harm. Non-surgical treatments are no exception and carry risks as well as benefits. In this field many clinical negligence cases which come before the courts do so because not enough attention has been paid to the consultation and the consent process. Many patients are vulnerable and can suffer from low self-esteem which adds to the pressure medical practitioners face in wanting to help them. Although these patients self refer, patient selection is key to a successful cosmetic outcome, and not everyone is suitable for treatment. Obtaining valid consent is an ethical, clinical and legal requirement. It must be free from coercion and the patient must have the ability to understand the information given. All risks must be explained and recently the importance of patient autonomy in a competent patient was clarified in Montgomery [10] . Although ignorance is no excuse in law, many practitioners are ignorant of the legal requirements of the consent process. Two way communication is key and practitioners have a responsibility to give as much information that patients need to make a decision. The amount of information is a matter for clinical judgement while respecting patient autonomy. Practitioners must also make every reasonable effort to ensure the patient has understood what has been said and it is helpful to give him a written information sheet. The signature on the consent form records the patient’s decision and that a discussion has taken place. It is not proof that consent is valid, neither does it take away legal liability if all aspects of the consent process are not covered. Finally it is advisable to check the medical history and obtain fresh consent before each treatment episode. Conclusion For nearly a quarter of a century nurses have led the way in the use of non-surgical procedures with a group of pioneering nurses being responsible for raising the profile of education and setting standards. Many factors have contributed to the medicalisation of the ageing process including those which directly impact on ageing and the way we approach it. These in turn have made people more aware of their appearance and the way others regard them. The way in which education is undertaken is changing. Training will be competence based and legislation will ensure all consultations are undertaken by medical or nursing staff. Finally, in order to reduce the incidence of litigation, those who are responsible for consultations and the consent process must be mindful of the legal requirements. [1] Porter R. Health for Sale. Quackery in England 1660-1850 , (1989). Manchester University Press, p39. [2] Porter R and Porter D. Patients’ Progress , (1989), Stanford University Press. Chapter 3. [3] Bolam v Friern Hospital Management Committee [1957] 1 WLR 582 at 587-588. [4] Bolitho v City & Hackney Health Authority [1998] AC 232 HL. [5] British Association of Cosmetic Nurses. An integrated career and competency framework for nurses in aesthetic medicine, (2014) RCN Accredited. [6] Ibid. pp20-21. [7] Department of Health. Review of the Regulation of Cosmetic Interventions, (2013), London. p7. [8] Spicer P. HEE, personal email 19/06/2014. [9] Rankin A. Working with Health Education England to change the future of the industry. Journal of Aesthetic Nursing, (2014), 3 (5), pp248-249. [10] Montgomery v Lanarkshire Health Board (Scotland) [2015] UKSC 11.

In a landmark ruling by the Court of Appeal on the 15 March 2024, the case of Thomas Hadley v. Mateusz Przybylo has reshaped the landscape of personal injury law in the United Kingdom, particularly concerning the ambit of recoverable costs in litigation. Stemming from a decision in the High Court presided over by Master McCloud, this appeal evaluated the inclusion of a fee earner's attendance at rehabilitation case management meetings within recoverable litigation expenses, leading to a significant judicial precedent. The Incident and Its Aftermath The origins of this legal journey trace back to a catastrophic road traffic accident on 8 June 2020, where Thomas Hadley's vehicle was stationary at a junction waiting to turn when he was hit from behind by Mateusz Przybylo's vehicle and shunted into another oncoming vehicle. Thomas Hadley suffered catastrophic injuries. The accident underscored not just the physical and emotional toll on Hadley , but also illuminated the complex web of medical, rehabilitative, and legal efforts required for his path to recovery.   Legal Controversy Unravelled Initially, Przybylo's admission of negligence might have seemed like a straightforward pathway to compensation. However, the real contention arose over the recoverability of costs related to Hadley's extensive rehabilitation. Specifically, Master McCloud's decision to disallow approximately £52,000 meant for the fee earner's attendance at rehabilitation case management meetings brought to the fore a pivotal legal query: Are such costs inherently unrecoverable as they do not contribute directly to the progression of litigation?   Deliberation in the Court of Appeal Tasked with this intricate legal question, the Court of Appeal, with Lord Justice Coulson at the helm alongside Lord Justices Dingemans and Birss, embarked on an exhaustive examination. The court endeavoured to bridge the gap between legal principles governing cost recoverability and the practical exigencies of rehabilitation following severe injuries.   The Ground breaking Judgment Challenging the erstwhile narrow confines of recoverable litigation costs, the Court of Appeal illuminated the essential role of rehabilitation in personal injury claims and the critical participation of legal professionals in this realm. Overturning Master McCloud's ruling, the court posited that, in principle, costs related to a fee earner’s attendance at rehabilitation case management meetings are recoverable. This pivotal decision was tempered with the understanding that such costs must still be justified as reasonable and proportionate upon closer scrutiny.   Wider Legal and Societal Ramifications This seminal ruling transcends the immediate legal context, signalling a judicial acknowledgment of the comprehensive needs of injury victims. It advocates for a broader interpretation of litigation costs, inclusive of necessary rehabilitation activities, thereby urging legal practitioners and personal injury stakeholders to thoroughly document and rationalise the extent of their engagement in the rehabilitation process. Forward-Looking Perspectives The Hadley v. Przybylo decision is poised to influence the trajectory of future personal injury litigation in the UK, especially concerning the perception and claims of legal costs tied to rehabilitation. This ruling embodies a progressive acknowledgment of the intertwined essence of legal advocacy and rehabilitative endeavours in the aftermath of personal injuries.

The media, in particular television loves medical drama and our screens are populated with the heroics of the uniformly attractive staff of Holby City and Casualty , the even more glamorous ER and the humorous Scrubs . However, after watching a recent episode of Call the Midwife I began to reflect on the dramatic advances in primary care nursing throughout the past sixty years. The nurses and midwives commanded huge respect from their patients and the community in general but, nurses’ roles have significantly changed as a consequence of the ever increasing pressure on NHS services. The current practice of a primary care nurse would be unrecognisable to a clinician from the age the television programme that I mention. When talking of Practice Nurses (PN) I refer to the wide range of nurses within General Practice from Health Care Assistants to Advanced Nurse Practitioners (ANP): all of whom have seen enormous changes in their scope of practice. Moreover, the expectation of further role advancement remains great. The catalyst for further rapid role change/adaption is the integration of health and social care services and the developing interface between primary and secondary care. The demand on primary care services has seen the development of the practice of ANPs who see and treat patients independently and offer services that were previously delivered by GP colleagues. Practice Nurses are specialists and often manage patients with chronic diseases and run their own clinics such as family planning, anticoagulation and travel health. Health Care Assistants have become skilled in treatment room duties and have been shown to have great value in promoting and supporting the general health of patients. The pace of change has been significant and arguably challenging. It is imperative that during this on-going revolution we embrace the numerous challenges but keep our practice safe and patient focused. The moot point is how we best achieve these aims and objectives. Arguably, education (of the clinicians and service users) is paramount. Again, the nurses referred to from a bygone era would be shocked and surprised to see the level of academic achievement attained by contemporary nursing practitioners. Due to their independent, autonomous status ANPs are often found to be independent prescribers and highly qualified both clinically and academically. In my role as an expert nursing witness I am often asked to comment on the care that has been afforded to patients within primary care settings. As a consequence, I believe that education alone will not equip nurses to rise to current challenges. The value of mentorship along with the development of a robust appraisal system will assist nurses to develop and maintain the necessary skills. In my opinion there also needs to be some kind of protection regarding the use of the title of ANP: at the present time it appears permissible for anyone to call themselves an ANP and I suggest that there needs to possibly be a separate part of the register for ANPs who have met minimum prescribed standards. As autonomous practitioners, we need to ensure that we work together and that our future role, as it develops is shaped from within inside the profession rather than having changes forced upon it. Sixty years ago the nurse was the doctor’s handmaiden and was praised for prompt and efficient following of orders. Thankfully, times have changed and a nurse is an independent practitioner who can offer their patients outstanding care. However, arguably, this development in nurses autonomy has not occurred because of recognition of nurses potential but is driven by a need to manage an ever increasing need on already over stretched services. The second pitfall is the continued cutting down of tall poppies and the fear that nursing colleagues are above themselves . The nursing profession needs to be careful that it does not allow itself to be merely dumped on by service managers. One wonders if the same opportunities would be offered to the nursing profession if primary care services were not so over stretched. I’m sure if those nurses and midwives of a bygone era were to look at the current state of the nursing and medical profession they would agree, that the NHS has developed and grown beyond everyone’s imagination. Despite radical political interference and reform it continues to be the most admired health care system in the world. The reason for the success of the NHS has been the dedication of the many doctors and nurses who have dedicated their lives to help others often in great need and dire circumstances. Importantly, it has never been more important for both the medical and nursing profession to stand and work together ensuring that patient need is always the first and overriding priority.

What is an indwelling urinary catheter? A urinary catheter is a medical device that is inserted through the urethra into the bladder to allow urine to flow. The catheter is a sterile thin plastic tube that has a balloon at the end which can be inflated inside the bladder to keep it insitu. It can be performed for any aged male but is more common in elderly patients.   Indications There are many reasons as to why a male patient may need a urinary catheter to be inserted. There are both acute and chronic conditions which can necessitate placement.    1. Urinary Retention One of the most common reasons for catheterisation is urinary retention, a condition where a person is unable to empty their bladder. This can result from obstructions in the urinary tract, such as those caused by benign prostatic hyperplasia (BPH), urethral strictures, or bladder stones. In addition, neurological disorders that affect the nerves controlling the bladder, including spinal cord injuries, multiple sclerosis, and Parkinson's disease can cause urinary problems.     2. Surgical Procedures Catheters are often used during and after certain surgical procedures to monitor urine output, which is a vital sign of kidney and overall health during surgery. Catheters are also used to manage urinary retention that may result from anaesthesia or the effects of surgery on the urinary tract, especially surgery involving the prostate, genitals, or lower abdomen.   3. Acute Medical Conditions Certain acute conditions may necessitate the temporary use of a catheter, such as critical illnesses or conditions where the patient is immobilised or in a coma, and natural urination is not possible. During critical illness, it is important that the fluid status of a patient is monitored and controlled.    4. Chronic Conditions Patients with chronic conditions that affect bladder control may require long-term catheterisation.   5. Urinary Incontinence For men who experience severe urinary incontinence and are unable to manage it through other means, it may be that the medical and nursing staff recommend a catheter placement.  For example, it could be used to prevent wound and skin contamination.   Contraindications If there is or suspected presence of trauma to the lower urinary tract then the patient and proposed procedure should be discussed with the urology team before it is attempted.  Insertion As a nurse I have inserted thousands of urinary catheters during my 30 years practice.  As a male nurse one of the first clinical skills that I was taught was how to insert a male catheter by another male nurse.  In my experience, patients can become a little uncomfortable during the procedure, but it is not usually a painful procedure.    Pre-Procedure Patient Communication: Thoroughly explain the procedure to the patient, ensuring they understand and consent to the process. Patient Positioning: Assist the patient into a supine position with legs apart to facilitate access to the urethral opening. Genital Prep: Remove any clothing obstructing the genital area and cover with a sterile towel, retracting the foreskin (if present) enough to clean the urethra.  Physical prep: Hands should be thoroughly cleaned and PPE worn/applied.   Procedure: Detailed Steps Aseptic Technique: Put on a disposable apron and sterile gloves and prepare the catheterisation pack on the sterile field. Genital Cleaning: Clean the penis with 0.9% sodium chloride, ensuring to handle the foreskin correctly. Lubrication: Apply anaesthetic gel within the urethra to minimise discomfort, waiting for the gel to take effect. Catheter Insertion: With one hand, hold the penis and with the other, introduce the catheter gently into the urethra until urine begins to flow, then advance it to the appropriate length. Balloon Inflation: Inflate the catheter balloon as per manufacturer's instructions to secure the catheter within the bladder. Connection the catheter bag and irrigation fluids: Attach the catheter bag to the correct port and start by slowly running in the irrigation fluid and carefully titrate to the required speed.   Post-Procedure Reposition Foreskin: This is critical; after catheter insertion, immediately reposition the foreskin (if present) to its natural state to prevent paraphimosis. Patient Comfort: Assist the patient to redress and ensure they are comfortable, with the catheter properly secured. Monitor and record urine and irrigation: record the urine output and irrigation amounts. Documentation: Log all pertinent details including the type, size, and length of the catheter, and the volume of water used for balloon inflation. Waste Disposal: Dispose of all used equipment and waste materials according to clinical waste protocols.   Complications The insertion of a male catheter, while generally safe when performed correctly, can sometimes lead to complications or issues. These can range from minor discomforts to more serious medical conditions. Here are some of the things that can go wrong with the insertion of a male catheter:   1. Urinary Tract Infections (UTIs) One of the most common complications is the development of urinary tract infections. The introduction of a catheter can introduce bacteria into the urinary tract, leading to infection if not managed properly. Symptoms include fever, painful urination, and cloudy or foul-smelling urine. The UTI could also progress to sepsis.    2. Urethral Injury The insertion process can cause trauma or injury to the urethra. This may result in bleeding, inflammation, or the formation of urethral strictures (narrowing of the urethra caused by scar tissue) over time, which can affect urinary function.   3. Bladder Spasms Some patients experience bladder spasms during or after catheter insertion. These spasms can be uncomfortable or painful and may cause leakage of urine around the catheter.   4. Difficulty Inserting the Catheter In some cases, particularly when there is an enlarged prostate or a urethral stricture, inserting the catheter can be challenging. This may lead to multiple attempts, which increase the risk of trauma or infection.   5. False Passage Repeated or incorrect attempts at catheter insertion can lead to the creation of a false passage—a new channel formed by the catheter as it mistakenly punctures the urethral wall. This can lead to significant complications, including bleeding and infection.   6. Hematuria The presence of blood in the urine (hematuria) can occur due to irritation or injury of the urinary tract tissues during catheter insertion. While often temporary and mild, it requires monitoring to ensure it resolves.   7. Catheter Blockage Catheters can become blocked by urinary sediment or crystals, especially if not managed correctly. Blockages can lead to inadequate drainage of the bladder, causing discomfort, urinary tract infections, or even bladder distention.   8. Allergic Reactions Some individuals may have an allergic reaction to the catheter material, typically latex. Symptoms can include itching, redness, and swelling in the urethral area.   9. Paraphimosis Paraphimosis is a common urological emergency that occurs in uncircumcised males when the foreskin becomes trapped behind the corona of the glans penis. When the catheter is inserted, the foreskin must be returned to its original position, if not, this can lead to strangulation of the glans and painful, vascular compromise, oedema and even necrosis.    Medico-Legal Considerations Male catheterisation, while clinically necessary in many instances, carries with it significant medico-legal responsibilities. Healthcare providers must navigate the intricate balance between clinical needs and legal obligations to ensure patient safety, dignity, and legal compliance. The following points highlight some of the key medico-legal considerations.   Informed Consent Of course, patients must be provided with clear, understandable information about the reasons for catheterisation, the procedure itself, potential risks, and alternative options if any. This consent should be obtained freely and documented appropriately before the procedure.   Competency and Training Only trained and competent healthcare professionals should perform catheter insertions. This requirement underscores the importance of proper education, training, and competency assessment in preventing complications. The legal ramifications of a poorly performed catheterisation can include negligence claims if the practitioner is deemed to have lacked the necessary skills or knowledge.   Adherence to Guidelines Following established clinical guidelines and best practices is vital for minimising the risk of complications. Healthcare practitioners are obligated to stay informed about current standards of care and to apply them in their practice. Deviation from these standards without valid reason can lead to medico-legal issues.   Documentation Comprehensive documentation is essential in the medico-legal context. Detailed records should include information on the informed consent process, the individual performing the catheterisation, the type of catheter used, how the procedure was performed, the amount of residual urine, the equipment used, any complications or difficulties encountered, and post-insertion care instructions. This documentation can be crucial in the event of legal scrutiny.   Managing Complications Should complications arise from catheterisation, timely and appropriate management is critical. This includes recognising symptoms of potential complications, such as infection or urethral injury, and taking prompt action. Failure to adequately address complications can lead to patient harm and legal liability.   Conclusion Male catheterisation, when executed correctly, is a low-risk procedure that provides critical relief and medical monitoring for patients. Understanding its purpose, method, and the care required afterwards is essential for healthcare practitioners. Continuous education and adherence to medical standards safeguard the well-being of patients and the legal integrity of medical practice. It's our responsibility as healthcare providers to perform catheterisation with the utmost precision and consideration and minimising potential complications.   My nursing expert witness practice includes provides opinions in many medico-legal cases when things have gone wrong for a patient having had a catheterisation procedure carried out.  My practice has involved cases where patients have developed severe infections, product allergic reactions, men requiring surgery due to trauma during the procedure, poor post operative fluid monitoring, health care practitioners using poor technique causing injury, failure to plan the long-term care and the development of paraphimosis.

Scott Lister talks to Matt Fowler about his current practice and his role as an advanced nurse practitioner (oncology and haematology) Scott – Matt, what is your current clinical role? Matt – I currently work as an Advanced Nurse Practitioner in Oncology and Haematology. I have worked at a senior level (Band 7 and above) within oncology, haematology and bone marrow transplant for over 8 years now amassing a wealth of clinical, managerial and academic experience. Scott – what do you enjoy about your current clinical role? Matt – I particularly enjoy my current role due to the level of autonomy and advanced clinical decision making skills I utilise on a daily basis. I care for cancer patients throughout all aspects of the illness trajectory including: pre-diagnosis, chemotherapy counselling, pre-treatment consultations, administration of cytotoxic chemotherapy and supportive products, management of cancer patients when they present as an emergency due to treatment toxicities/side effects, end of life treatment consultations Scott – what are your expertise? Matt – I am an expert within the field of chemotherapy administration and in particular the devices utilised to administer chemotherapy in order to minimise complications such as extravasation. I am an advanced Peripherally Inserted Central Catheter (PICC) placer using ultrasound and ECG to confirm lines are placed correctly. I am a non-medical prescriber and prescribe chemotherapy for all types of cancers. My particular areas of expertise are uro-oncology (including management of late effects of radiotherapy) colorectal oncology and bone marrow transplant nursing. As an experienced practitioner who has been administering chemotherapy since the late 1990s I have amassed a wealth of expertise and knowledge of chemotherapy in all tumour sites as well. Scott – where did you undertake your specialist training? Matt – Having initially completed my specialist cancer nursing training at the Royal Marsden in London I have continued to develop academically and am currently undertaking specialist training at Warwick Medical School in order to gain more in depth understanding of interpreting diagnostic results. I am also nearing completion of my MSc in nursing and will be looking to complete my PhD in the not too distant future. Scott – what medico-legal experience do you have? Matt – As a senior nurse I have a wealth of experience at managing complex situations both clinically and professionally. I have conducted disciplinary hearings, completed SUI investigations as well as functioned as a lead practitioner for clinical governance ensuring that any deviations in practice were appropriately risk assessed and actioned. I am articulate at report writing, and have extremely high standards of documentation to reflect the high standards of care I deliver on a daily basis. Scott – it must be very difficult practising as a nurse in your specialist area? Is it rewarding? Do you enjoy it? Matt – I feel very privileged to practice in my chosen speciality. I work with patients and their loved ones at various stages of the cancer journey and never underestimate how difficult this can be for individuals or their significant others. No two days are the same for me and I particularly enjoy the variety that my role brings; I also particularly enjoy coaching and developing new nurses to the speciality into expert practitioners.

‘Patient safety’ is an important (and topical) subject in all settings, with health departments of the respective UK governments repeatedly highlighting how the development of a patient safety culture across the NHS is vital. The publication of the report into the Mid-Staffordshire failings and the Berwick review in 2013 have both brought into sharp focus the need for a ‘safety’ to be at the top of the agenda for healthcare providers. It’s clear that many NHS organisations are able to demonstrate improvements, and the emphasis on developing a safety culture is bringing benefits; but a review of the key safety domains for healthcare providers in England , shows that there is still much to do. There is an understandable emphasis on some relatively obvious domains – safe staffing levels, infection prevention and control, safe surgical technique, and a robust incident-reporting culture – among others. But what about patient safety in mental health care? How do mental health nurses and other practitioners apply these principles to their own setting, and what constitutes the basics of ‘patient safety’ in mental health? Along with a number of other colleagues we have used the patient safety agenda to help promote and share a suicide prevention culture across a large NHS mental health trust , and this work has helped us to think about its application outside of the more traditional areas identified above. We have used the patient safety message as a way of addressing suicide prevention, building on the emerging evidence which suggests that organisations with a strong patient safety culture have fewer serious untoward incidents, including unexpected deaths. Our work has helped us develop a patient safety agenda to support suicide prevention, and as a result we have developed practical guidance for mental health clinicians. Here are examples of how we have framed and communicated the key messages, which I hope will also be of value to colleagues in other mental health settings. Patient safety tips for suicide prevention: Be clear about diagnosis and formulation Clarity regarding diagnosis, assessment of the person’s needs and a working formulation of the nature and context of their problems, means that accurate risk assessment and care planning can occur. Remember, that it is also equally important to be clear with the service user and their carer/family member about diagnosis and formulation. Target treatment on the priority problem – with clear goals Care planning and interventions should focus on the priority problem, or problems, and you need to set clear goals or aims in relation to this. Check that you have achieved some form of concordance with the person about the priority problem – do they agree with your assessment/formulation, and are they willing and able to work with you in managing risk? Talk to relatives/carers about risk Relatives and carers have a major role to play in relation to the assessment and management of risk. As well as acting as a source of valuable information that can inform accurate risk assessment, they will need to be aware of the plans made to manage the risks identified. This is particularly important for community-based teams and services, where the person is being cared for at home, and their family member may be responsible for providing the bulk of the person’s informal care. Be alert to changing risk Risk, by its very nature, is a dynamic concept, and the level and degree of risk demonstrated by the person can vary from moment to moment. When planning and implementing risk management interventions, take account of the factors, circumstances or situations that can cause the person’s risk profile to fluctuate. Be alert to risk at times of transition When service users are required to deal with and respond to transitions, then the level of risk can increase. Such transitions may include handovers of care from one team or service to another, discharge from a part of the service (in particular, discharge from inpatient care), and personal and interpersonal transitions or life events, such as bereavement and unemployment. Identify and work with hopelessness Individuals who express feelings of hopelessness and helplessness are at increased risk of suicide. Address this issue explicitly, talk to the person (and carer, if appropriate) about it directly. Identifying hopelessness can only be achieved by accurate and sensitive assessment and risk formulation practice. Take seriously previous attempts using high lethality methods Data and experience show that people who have acted on suicidal thoughts using violent methods (such as the use of weapons, jumping from a height, and hanging) are most likely to be at increased risk. Look at all risk indicators – not just stated intent Consider ALL risk factors when planning risk management interventions; treat with caution statements by the person that they have no plans to kill themselves, particularly when working with those people who have a number of other suicide risk characteristics. Access as much of the record as possible Key assessment and risk management information may be contained in previous health and social care records (including those records held by other care providers, such as GPs). Make all reasonable attempts to obtain this information as a way of informing assessment and care planning processes. Engagement, Engagement, Engagement!

Introduction The Health Services Safety Investigations Body (HSSIB) recently published a comprehensive report underscoring a crucial aspect of healthcare delivery within the NHS: the involvement of temporary staff in patient safety investigations. As the NHS leans heavily on temporary clinical staff to bridge workforce gaps, the report shines a light on the systemic challenges and offers actionable recommendations to ensure these vital contributors are integral to improving patient safety outcomes.   T he Underlying Challenges Temporary staff, including bank, agency staff, and locum doctors, play a pivotal role in the NHS’s daily operations. However, the HSSIB's investigation reveals that the engagement of these staff members in patient safety investigations is often limited, posing a risk to the depth and effectiveness of learning from incidents. The report outlines several barriers to their involvement, ranging from logistical challenges, such as access to incident reporting systems, to procedural issues, like the lack of direct communication channels.   Key Findings Limited Involvement in Safety Investigations : The exclusion of temporary staff from patient safety investigations restricts the learning potential and weakens the foundation for future safety enhancements. Barriers to Reporting Incidents : Temporary staff face obstacles in reporting safety incidents, impacting the development of an open reporting culture crucial for learning and improvement. Variability in Feedback and Learning Dissemination : There's an inconsistency in how findings from investigations are communicated back to temporary staff, hindering the collective learning process. Inadequate Support Post-Incident : Temporary staff often receive less support following safety incidents, affecting their welfare and potentially patient safety. Framework Agreements Lacking Reference to Patient Safety : Current NHS England framework agreements for agency staff do not explicitly address patient safety or the support for staff following safety incidents.   Recommendations for a Safer Future The HSSIB’s recommendations are a clarion call for systemic changes to better integrate temporary staff into the patient safety ecosystem. Key recommendations include: Enhanced Guidance for Involving Temporary Staff : NHS England is urged to include specific guidance on engaging temporary staff in learning responses following a patient safety incident. This effort should involve collaboration with temporary staff providers to ensure comprehensive incident investigations and learning. Updating Framework Agreement Criteria : The agency worker framework agreement criteria should be revised to mandate adherence to the NHS England Patient Safety Incident Response Framework's staff support principles, recognising the link between staff wellbeing and patient care delivery. Facilitating Involvement in Investigation Processes : Agencies providing temporary staff to the NHS can enhance patient safety by easing the participation of these staff in investigation processes, including interviews, in line with the Patient Safety Incident Response Framework.   A Path Forward The HSSIB report serves as a vital blueprint for rethinking how temporary staff are integrated into the processes that safeguard patient welfare. By addressing the highlighted challenges and implementing the proposed recommendations, the NHS can bolster its patient safety framework, ensuring that every member of the healthcare team, regardless of their employment status, is empowered and equipped to contribute to safer patient care. This call to action is not just about procedural adjustments; it’s a fundamental shift towards a more inclusive, learning-oriented culture within the NHS, where every voice is heard, and every experience is valued in the continuous journey towards excellence in patient safety. Conclusion The insights and recommendations from the HSSIB's investigation into the involvement of temporary staff in patient safety investigations illuminate a critical aspect of healthcare delivery that requires immediate attention. As the NHS evolves, the integration of temporary staff into the fabric of patient safety investigations will be paramount in fostering a culture of continuous learning and improvement.

Authors Scott Harding-Lister Scott is a qualified nurse and solicitor. He was a senior nurse within the NHS before leaving to pursue a career as a solicitor in City practices Matthew Fowler Matt is a qualified specialist oncology nurse and has been an Advanced Practitioner for 10 years . He is one of our most senior experts Mr Harding-Lister and Mr Fowler are both medico-legal experts providing opinions regarding iron infusions and in particular, iron extravasation injuries. In the realm of healthcare, the concept of informed consent is not merely a procedural formality; it is a fundamental patient right, underscored by the landmark Montgomery v Lanarkshire Health Board (2015) ruling. This pivotal judgement reshaped the understanding of informed consent within the UK and beyond, emphasising that healthcare providers/practitioners must ensure patients are aware of any material risks involved in a proposed treatment, as well as alternatives. The case of iron extravasation, a potential risk associated with iron infusions, is a prime example where the Montgomery ruling's principles are critically applied. The exact numbers of patients suffering an iron extravasation are unclear. The literature provides a wide range of possible numbers of patients that suffer this type of injury. We have recently made a Freedom of Information request to all of the NHS Trusts within the United Kingdom. To date we have responses indicating that 63% of responding Trusts have a specific leaflet regarding iron extravasation. Understanding the Montgomery Ruling The Montgomery decision marked a departure from the traditional "doctor knows best" approach, advocating instead for a patient-centred model of care. According to this ruling, patients must be given sufficient information to make informed decisions about their healthcare, including the disclosure of any significant risks and the existence of any reasonable alternative treatments. The judgement highlights the importance of considering the patient's perspective—what they would consider significant within their personal context. Why Written Information Matters in the Light of Montgomery Of course, the health care practitioner and patient conversation about the proposed treatment is paramount in which the patient can explore issues, options, and concerns with their care provider. The health care provider can provide information and identify any issues, risks and present reasonable treatment options for that individual. In addition to this, providing patients with detailed written information about iron infusion treatments and the risk of iron extravasation becomes not just beneficial but imperative for several reasons: Enhanced Patient Autonomy: Montgomery emphasises respecting patients' autonomy and their right to decide upon their medical treatment once adequately informed. Written materials ensure that patients have access to all the relevant information needed to make an informed choice, reflecting this ethos. Risk Communication: The ruling underscores the necessity of discussing material risks, which in the context of iron infusions includes extravasation. Written documents serve as a comprehensive resource for patients to understand these risks fully. Bolstering the Consent Conversation: Verbal discussions about consent are crucial but can be augmented by written information, ensuring patients can revisit the specifics of their treatment and risks at any time, facilitating a more informed and considered decision-making process. Legal and Ethical Compliance: Providing written information alongside verbal discussions ensures healthcare providers meet the standards set by Montgomery for informed consent, demonstrating a commitment to ethical practice and patient care. What Should Be Included? In our opinion, there is no right or wrong answer to what should be included as it will be dependent on the treating clinicians and the patient population. However, any written information is like to cover: Contact/Clinician Details: Contact details should be given for a clinician who is able to provide clarification and answer any questions that the patient may have before their treatment. This clinician needs to have the clinical knowledge and expertise to assist the patient in providing detailed information during the consent process. Procedure and Alternatives: Clear description of the iron infusion process, its benefits, and any reasonable alternatives. We imagine this to be a lengthy description, in clear language. Risks and Side Effects: Including the risk of iron extravasation, its symptoms, and how it is managed. Aftercare and Emergency Contacts: Instructions for aftercare and whom to contact in emergencies, ensuring ongoing support. Conclusion The Montgomery ruling has irrevocably changed the landscape of patient consent, placing the patient's right to information at the forefront of medical care. In providing written information about treatments like iron infusions and the associated risks such as iron extravasation , healthcare providers not only adhere to the legal and ethical mandates set forth by Montgomery but also honour the spirit of patient-centred care. This approach fosters trust, enhances patient autonomy, and ensures that decisions about healthcare are made in a truly informed context.