Clinical negligence cases in the English NHS: uncertainty in evidence as a driver of settlement costs and societal outcomes

The cost of clinical negligence claims continues to rise, despite efforts to reduce this now ageing burden to the National Health Service (NHS) in England. From a welfarist perspective, reforms are needed to reduce avoidable harm to patients and to settle claims fairly for both claimants and society. Uncertainty in the estimation of quanta of damages, better known as financial settlements, is an important yet poorly characterised driver of societal outcomes. This reflects wider limitations to evidence informing clinical negligence policy, which has been discussed in recent literature. There is an acute need for practicable, evidence-based solutions that address clinical negligence issues, and these should complement long-standing efforts to improve patient safety. Using 15 claim cases from one NHS Trust between 2004 and 2016, the quality of evidence informing claims was appraised using methods from evidence-based medicine. Most of the evidence informing clinical negligence claims was found to be the lowest quality possible (expert opinion). The extent to which the quality of evidence represents a normative deviance from scientific standards is discussed. To address concerns about the level of uncertainty involved in deriving quanta, we provide five recommendations for medico-legal stakeholders that are designed to reduce avoidable bias and correct potential market failures

From Expert to Experiential Knowledge:Exploring the Inclusion of Local Experiences in Understanding Violence in Conflict

Critical peace and conflict scholars argue that to understand fully conflict dynamics and possibilities for peace research should incorporate ‘the local’. Yet this important conceptual shift is bound by western concepts, while empirical explorations of ‘the local’ privilege outside experts over mechanisms for inclusion. This article explores how an epistemology drawing on feminist approaches to conflict analysis can help to redirect the focus from expert to experiential knowledge, thereby also demonstrating the limits of expert knowledge production on ‘the local’. In order to illustrate our arguments and suggest concrete methods of putting them into research practice, we draw on experiences of the ‘Raising Silent Voices’ project in Myanmar, which relied on feminist and arts-based methods to explore the experiential knowledge of ordinary people living amidst violent conflict in Rakhine and Kachin states

Defining the Enablers and Barriers to the Implementation of Large-scale, Health Care-Related Mobile Technology: Qualitative Case Study in a Tertiary Hospital Setting

BACKGROUND: The successful implementation of clinical smartphone apps in hospital settings requires close collaboration with industry partners. A large-scale, hospital-wide implementation of a clinical mobile app for health care professionals developed in partnership with Google Health and academic partners was deployed on a bring-your-own-device basis using mobile device management at our UK academic hospital. As this was the first large-scale implementation of this type of innovation in the UK health system, important insights and lessons learned from the deployment may be useful to other organizations considering implementing similar technology in partnership with commercial companies. OBJECTIVE: The aims of this study are to define the key enablers and barriers and to propose a road map for the implementation of a hospital-wide clinical mobile app developed in collaboration with an industry partner as a data processor and an academic partner for independent evaluation. METHODS: Semistructured interviews were conducted with high-level stakeholders from industry, academia, and health care providers who had instrumental roles in the implementation of the app at our hospital. The interviews explored the participants' views on the enablers and barriers to the implementation process. The interviews were analyzed using a broadly deductive approach to thematic analysis. RESULTS: In total, 14 participants were interviewed. Key enablers identified were the establishment of a steering committee with high-level clinical involvement, well-defined roles and responsibilities between partners, effective communication strategies with end users, safe information governance precautions, and increased patient engagement and transparency. Barriers identified were the lack of dedicated resources for mobile change at our hospital, risk aversion, unclear strategy and regulation, and the implications of bring-your-own-device and mobile device management policies. The key lessons learned from the deployment process were highlighted, and a road map for the implementation of large-scale clinical mobile apps in hospital settings was proposed. CONCLUSIONS: Despite partnering with one of the world's biggest technology companies, the cultural and technological change required for mobile working and implementation in health care was found to be a significant challenge. With an increasing requirement for health care organizations to partner with industry for advanced mobile technologies, the lessons learned from our implementation can influence how other health care organizations undertake a similar mobile change and improve the chances of successful widespread mobile transformation

A family of process-based models to simulate landscape use by multiple taxa

Context: Land-use change is a key driver of biodiversity loss. Models that accurately predict how biodiversity might be affected by land-use changes are urgently needed, to help avoid further negative impacts and inform landscape-scale restoration projects. To be effective, such models must balance model realism with computational tractability and must represent the different habitat and connectivity requirements of multiple species. Objectives: We explored the extent to which process-based modelling might fulfil this role, examining feasibility for different taxa and potential for informing real-world decision-making. Methods: We developed a family of process-based models (*4pop) that simulate landscape use by birds, bats, reptiles and amphibians, derived from the well-established poll4pop model (designed to simulate bee populations). Given landcover data, the models predict spatially-explicit relative abundance by simulating optimal home-range foraging, reproduction, dispersal of offspring and mortality. The models were co-developed by researchers, conservation NGOs and volunteer surveyors, parameterised using literature data and expert opinion, and validated against observational datasets collected across Great Britain. Results: The models were able to simulate habitat specialists, generalists, and species requiring access to multiple habitats for different types of resources (e.g. breeding vs foraging). We identified model refinements required for some taxa and considerations for modelling further species/groups. Conclusions: We suggest process-based models that integrate multiple forms of knowledge can assist biodiversity-inclusive decision-making by predicting habitat use throughout the year, expanding the range of species that can be modelled, and enabling decision-makers to better account for landscape context and habitat configuration effects on population persistence

The impact of the COVID-19 pandemic on patterns of attendance at emergency departments in two large London hospitals: an observational study

Abstract Background Hospitals in England have undergone considerable change to address the surge in demand imposed by the COVID-19 pandemic. The impact of this on emergency department (ED) attendances is unknown, especially for non-COVID-19 related emergencies. Methods This analysis is an observational study of ED attendances at the Imperial College Healthcare NHS Trust (ICHNT). We calibrated auto-regressive integrated moving average time-series models of ED attendances using historic (2015–2019) data. Forecasted trends were compared to present year ICHNT data for the period between March 12, 2020 (when England implemented the first COVID-19 public health measure) and May 31, 2020. We compared ICHTN trends with publicly available regional and national data. Lastly, we compared hospital admissions made via the ED and in-hospital mortality at ICHNT during the present year to the historic 5-year average. Results ED attendances at ICHNT decreased by 35% during the period after the first lockdown was imposed on March 12, 2020 and before May 31, 2020, reflecting broader trends seen for ED attendances across all England regions, which fell by approximately 50% for the same time frame. For ICHNT, the decrease in attendances was mainly amongst those aged < 65 years and those arriving by their own means (e.g. personal or public transport) and not correlated with any of the spatial dependencies analysed such as increasing distance from postcode of residence to the hospital. Emergency admissions of patients without COVID-19 after March 12, 2020 fell by 48%; we did not observe a significant change to the crude mortality risk in patients without COVID-19 (RR 1.13, 95%CI 0.94–1.37, p = 0.19). Conclusions Our study findings reflect broader trends seen across England and give an indication how emergency healthcare seeking has drastically changed. At ICHNT, we find that a larger proportion arrived by ambulance and that hospitalisation outcomes of patients without COVID-19 did not differ from previous years. The extent to which these findings relate to ED avoidance behaviours compared to having sought alternative emergency health services outside of hospital remains unknown. National analyses and strategies to streamline emergency services in England going forward are urgently needed

Marking out the pitch: a historiography and taxonomy of football fiction

Football, or soccer as it is more commonly referred to in Australia and the US, is arguably the world’s most popular sport. It generates a proportionate volume of related writing. Within this landscape, works of novel-length fiction are seemingly rare. This paper establishes and maps a substantial body of football fiction works, explores elements and qualities exhibited individually and collectively. In bringing together current, limited surveys of the field, it presents the first rigorous definition of football fiction and captures the first historiography of the corpus. Drawing on distant reading methods developed in conjunction with closer textual analyses, the historiography and subsequent taxonomy represent the first articulation of relationships across the body of work, identify growth areas and establish a number of movements and trends. In advancing the understanding of football fiction as a collective body, the paper lays foundations for further research and consideration of the works in generic terms

Identification and validation of a novel pathogenic variant in GDF2 (BMP9) responsible for hereditary hemorrhagic telangiectasia and pulmonary arteriovenous malformations

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant multisystemic vascular dysplasia, characterized by arteriovenous malformations (AVMs), mucocutaneous telangiectasia and nosebleeds. HHT is caused by a heterozygous null allele in ACVRL1, ENG, or SMAD4, which encode proteins mediating bone morphogenetic protein (BMP) signaling. Several missense and stop-gain variants identified in GDF2 (encoding BMP9) have been reported to cause a vascular anomaly syndrome similar to HHT, however none of these patients met diagnostic criteria for HHT. HHT families from UK NHS Genomic Medicine Centres were recruited to the Genomics England 100,000 Genomes Project. Whole genome sequencing and tiering protocols identified a novel, heterozygous GDF2 sequence variant in all three affected members of one HHT family who had previously screened negative for ACVRL1, ENG, and SMAD4. All three had nosebleeds and typical HHT telangiectasia, and the proband also had severe pulmonary AVMs from childhood. In vitro studies showed the mutant construct expressed the proprotein but lacked active mature BMP9 dimer, suggesting the mutation disrupts correct cleavage of the protein. Plasma BMP9 levels in the patients were significantly lower than controls. In conclusion, we propose that this heterozygous GDF2 variant is a rare cause of HHT associated with pulmonary AVMs

A family of process-based models to simulate landscape use by multiple taxa

Acknowledgements: We would like to thank all the volunteer surveyors who contributed data to the BTO/RSPB/JNCC Breeding Bird Survey and those who contributed data to the Field Survey within the BCT’s National Bat Monitoring Programme, without whom validation of the bird and bat models would not have been possible. We would also like to thank all the volunteer surveyors of Surrey Amphibian and Reptile Group, who kindly contributed their common lizard sightings and enabled validation of the reptile model. Finally, we would like to thank the regional ARGs and all the Toad Patrol volunteers, supported by Froglife, who took the time to fill in the toad habitat use questionnaire, so enabling validation of the amphibian model. EG acknowledges funding from a Research Programme Fellowship provided by the Natural Environment Research Council through UK Research and Innovation’s Landscape Decisions Programme (NE/V007831/1).Abstract Context Land-use change is a key driver of biodiversity loss. Models that accurately predict how biodiversity might be affected by land-use changes are urgently needed, to help avoid further negative impacts and inform landscape-scale restoration projects. To be effective, such models must balance model realism with computational tractability and must represent the different habitat and connectivity requirements of multiple species. Objectives We explored the extent to which process-based modelling might fulfil this role, examining feasibility for different taxa and potential for informing real-world decision-making. Methods We developed a family of process-based models (*4pop) that simulate landscape use by birds, bats, reptiles and amphibians, derived from the well-established poll4pop model (designed to simulate bee populations). Given landcover data, the models predict spatially-explicit relative abundance by simulating optimal home-range foraging, reproduction, dispersal of offspring and mortality. The models were co-developed by researchers, conservation NGOs and volunteer surveyors, parameterised using literature data and expert opinion, and validated against observational datasets collected across Great Britain. Results The models were able to simulate habitat specialists, generalists, and species requiring access to multiple habitats for different types of resources (e.g. breeding vs foraging). We identified model refinements required for some taxa and considerations for modelling further species/groups. Conclusions We suggest process-based models that integrate multiple forms of knowledge can assist biodiversity-inclusive decision-making by predicting habitat use throughout the year, expanding the range of species that can be modelled, and enabling decision-makers to better account for landscape context and habitat configuration effects on population persistence. </jats:sec