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Over half of incidents resulting in death reported by Welsh health boards came from Betsi

More than half of all incidents resulting in death reported by health boards in Wales came from troubled Betsi Cadwaladr. The 53% figure from a Welsh Government safety report came to light during First Minister Questions in the Senedd yesterday.

Plaid Cymru Leader Adam Price said there had been “an alarming rate” of patient safety incidents in the Betsi Cadwaladr University Health Board area and that between December 2018 and November 2019 there were 40 incidents resulting in death registered within Betsi. Between November 2017 and November 2019 there were 520 incidents within Betsi that resulted in death or serious harm - higher than all the other health boards in Wales combined.

Mr Price questioned whether there is an issue with Betsi itself, or whether there is an issue of "under-reporting of serious incidents" in the rest of Wales.

Defending the figures, the First Minister said that reporting incidents and learning from them has become part of the culture of a health board that they “want to see everywhere in Wales”.

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Source: North Wales Live, 29 January 2020

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Better tech: not a ‘nice to have’ but vital to have for the NHS

In a keynote speech at the Healthtech Alliance on Tuesday, Secretary of State for Health and Social Care, Matt Hancock, stressed how important adopting technology in healthcare is and why he believes that it is vital for the NHS to move into the digital era. 

“Today I want to set out the future for technology in the NHS and why the techno-pessimists are wrong. Because for any organisation to be the best it possibly can be, rejecting the best possible technology is a mistake.”

Listing examples from endless paperwork to old systems resulting in wasted blood samples, Hancock highlights why in order to retain staff and see a thriving healthcare, embracing technology must be a priority.

He also announced a £140m Artificial Intelligence (AI) competition to speed up testing and delivery of potential NHS tools. The competition will cover all stages of the product cycle, to proof of concept to real-world testing to initial adoption in the NHS.

Examples of AI use currently being trialled were set out in the speech, including using AI to read mammograms, predict and prevent the risk of missed appointments and AI-assisted pathways for same-day chest X-ray triage.

Tackling the issue of scalability, Hancock said, “Too many good ideas in the NHS never make it past the pilot stage. We need a culture that rewards and incentivises adoption as well as invention.”

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Nurse begs hospital bosses to ‘see for themselves how unsafe it is’

An advanced nurse practitioner working in primary care services at Grimsby Hospital has called on the hospital senior leadership to ‘see for themselves how unsafe it is’.

The nurse, who has penned a letter to bosses at Northern Lincolnshire and Goole NHS Foundation Trust says they are having “worst experience to date” in their career and fears somebody will die unnecessarily unless something is urgently done.

“I have never in my whole career seen patients hanging off trolleys, vomiting down corridors, having ECGs down corridors, patients desperate for the toilet, desperate for a drink. Basic human care is not being given safely or adequately," says the nurse.

Hospital bosses say they are taking the letter seriously and are investigating. Earlier this month it was revealed that some hospitals were being forced to deploy ‘corridor nurses’ in a bid to maintain patient safety while dealing with unprecedented demand.

Dr Peter Reading, Chief Executive, said: “I can confirm we have received this email and that the hospital and North East Lincolnshire CCG are taking these concerns seriously. The person who raised the concerns with us has been contacted and informed that we are jointly investigating what they have told us.

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Source: Nursing Notes, 22 January 2020

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Top hospital downgraded amid safety fears and whistleblowing inquiry

The hospital at the centre of a whistleblowing inquiry has been downgraded by the care watchdog and issued with a warning notice amid concerns over leadership and patient safety.

West Suffolk Foundation Trust has been rated requires improvement by the Care Quality Commission (CQC) in a damning report having previously been rated outstanding since 2017.

The trust, whose Chief Executive Stephen Dunn received a CBE for services to patient safety in 2018, has faced criticism after bosses threatened senior doctors with a fingerprint and handwriting analysis to try and identify a whistleblower.

In a new report published today, the CQC inspectors said they had significant concerns about the safety of mothers and babies in the trust’s maternity unit and the criticised the culture of the trust leadership referencing what they called “threatening” actions.

In the West Suffolk hospital maternity unit the CQC found staff had not completed key safety training, did not protect women from domestic abuse, and staff did not always report safety incidents. They also found maternity staff were not taking observations and the unit lacked enough staff with the right qualifications to keep women safe.

The trust was issued with a warning notice by the trust demanding it make improvements before the end of this month.

On the trust leadership the CQC report said: “The style of executive leadership did not represent or demonstrate an open and empowering culture. There was an evident disconnect between the executive team and several consultant specialities."

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Source: The Independent, 30 January 2020

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Seriously ill wait more than an hour for ambulance

Heart attack, stroke and burns victims are among the seriously ill and injured patients waiting over an hour for an ambulance to arrive in England and Wales, a BBC investigation shows.

The delays for these 999 calls - meant to be reached in 18 minutes on average - put lives at risk, experts say.

The problems affect one in 16 "emergency" cases in England - with significant delays reported in Wales.

NHS bosses blamed rising demand and delays handing over patients at A&E.

Rachel Power, Chief Executive of the Patients Association, said patients were being "let down badly at their moment of greatest need" and getting a quick response could be "a matter of life or death".

She said the delays were "undoubtedly" related to the sustained underfunding of the NHS.

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Source: BBC News, 29 January 2020

 

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Ministers reject calls for immediate compensation for infected blood victims

Calls for immediate compensation for thousands of victims contaminated by infected NHS blood have been rejected by ministers at a meeting with campaigners and survivors – but more health support may be made available.

Despite one person dying every four days on average from HIV, hepatitis C or other conditions, the government on Tuesday turned down a request for a national compensation scheme.

There are estimated to be between 5,000 and 7,000 victims still alive who acquired viral infections through transfusions from the health service. Many are haemophiliacs who need regular transfusions to help their blood clot.

Products supplied by the NHS in the 1970s and 1980s came from the US using blood obtained from prisoners and drug addicts who were paid for their donations. Imported products were inadequately screened.

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Source: The Guardian, 28 January 2020

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Urgent inquiry ordered into 'witch-hunt' at West Suffolk hospital

The government has ordered an urgent inquiry into the local hospital of the health secretary, Matt Hancock, after the Guardian revealed its unprecedented “witch-hunt” for a whistleblower.

The Department of Health and Social Care (DHSC) has told NHS England to commission a “rapid review” of the actions of bosses at West Suffolk hospital.

They are under fire for demanding that staff give fingerprints and samples of their handwriting to help identify who wrote to a family alerting them to failings in care that contributed to a patient’s death.

Unusually, the investigation has been instigated by Edward Argar, a junior minister at the DHSC, because Hancock and another health minister, Jo Churchill, are both local MPs who have close ties to the hospital.

Argar has made clear to NHS England that the inquiry must be undertaken by independent experts, given those existing relationships.

Announcing the review, Argar made clear that he wanted hospital personnel to speak openly. “I want all staff to feel that they can speak up and have the confidence that anything they raise will be taken seriously,” he said.

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Source: The Guardian, 28 January 2020

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Nearly 35,000 patients overdue follow-ups at single trust

Nearly 35,000 patients are overdue a follow-up appointment at North Lincolnshire and Goole Foundation Trust, HSJ has learned.

Almost 20% of the 34,938 follow-up appointments are in ophthalmology. A paper from the trust’s November board meeting said the “backlog of follow-up appointments… clearly remains a risk”.

The report also said the service was failing some of the quality guidelines set out by the National Institute for Health and Care Excellence (NICE).

The trust told HSJ it had introduced a clinical harm review process last year to address the backlog. It has reviewed “more than 5,000 patients”, out of the 34,938 cases to date, according to Chief Operating Officer Shaun Stacey.

He said the trust had initially identified 83 patients who could have come to “potential harm”.

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Source: HSJ, 28 January 2020

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NHS is ‘losing its memory’ warns new report on patient safety alerts

In a report published today, AvMA, the charity Action Against Medical Accidents, reveals serious delays in NHS trusts implementing patient safety alerts, which are one of the main ways in which the NHS seeks to prevent known patient safety risks harming or killing patients.

The report, authored by Dr David Cousins, former head of safe medication practice at the National Patient Safety Agency, NHS England and NHS Improvement, identifies serious problems with the system of issuing patient safety alerts and monitoring compliance with them. Compliance with alerts issued under the now abolished National Patient Safety Agency and NHS England are no longer monitored – even though patient safety incidents continue to be reported to the NHS National Reporting and Learning System.

David said: “The NHS is losing it memory concerning preventable harms to patients. Important known risks to patient safety are being ignored by the NHS. The National Reporting and Learning System, the NHS Strategy and new format patient safety alerts, all managed by NHS Improvement, now ignore the majority of ‘known/wicked harms’ which have been the subject of patient safety alerts in the past and have now been archived."

“Implementation of guidance in new Patient Safety Alerts can be delayed, for years in some cases. The Care Quality Commission that inspects NHS provider organisations also no longer appear to check that safeguards to major risks, recommended in patient safety alerts, have been implemented, or continue to be implemented, as part of their NHS inspections.

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Source: AvMA, 28 January 2020

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Up to 100,000 on antipsychotics with no review

A national strategy is needed to tackle health risks linked to antipsychotic drugs because current policy is letting tens of thousands of people fall through the gaps, commissioners in London are warning.

Commissioners and clinicians in City and Hackney found more than 1,000 patients in their area who were on these drugs without having regular medication reviews or health checks. They warned that, if their findings applied across England, 100,000 patients could be in the same position. 

Although NHS England funds GP practices to carry out regular health checks on patients who are on the serious mental illness register, this excludes patients who are prescribed antipsychotics without having an SMI diagnosis — which typically covers psychoses, schizophrenia or bipolar active disorder. 

An audit by City and Hackney Clinical Commissioning Group, carried out in July 2019 and shared with HSJ, found 1,200 patients in the area were taking antipsychotics but did not have a formal SMI diagnosis.

The audit found most of these patients were not receiving regular health checks and a significant number may have benefited from having their medication reduced. 

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Source: HSJ, 27 January 2020

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Hundreds recalled as consultant accused of ‘unnecessary’ surgery

A surgeon has been accused of carrying out “unnecessary” shoulder operations on several NHS patients at a private hospital linked to the Ian Paterson scandal, with 217 patients recalled.

HSJ has been told at least five patients, all commissioned by the NHS, have instructed solicitors to take legal action against Habib Rahman, a consultant orthopaedic surgeon at Spire Parkway Hospital in Solihull.

Mr Rahman is accused of undertaking “unnecessary or inappropriate surgical procedures at Spire Healthcare hospitals” . Spire has confirmed it has recalled 217 patients over the concerns.

The allegations come weeks before the findings are due from an independent inquiry into disgraced surgeon Ian Paterson – who was found guilty of wounding with intent after giving hundreds of patients unnecessary breast surgeries in Spire hospitals across the Midlands.

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Source: HSJ, 24 January 2020

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Morecambe Bay inquiry chief voices criticisms over East Kent hospital scandal

The failure to pass a damning report about a scandal-hit hospital trust to the care watchdog has been criticised by the man who led the inquiry into baby deaths at Morecambe Bay.

On Friday, a coroner ruled that the death of baby Harry Richford in 2017 resulted from neglect in the maternity unit of East Kent Hospitals NHS Trust.

A report by the Royal College of Obstetrics and Gynaecologists (RCOG) completed a year earlier had warned of issues that contributed to Harry’s death, including senior doctors not showing up for their shifts. However, the report was never passed on to the Care Quality Commission (CQC), despite the recommendation of the Morecambe Bay inquiry in 2015 that relevant external reviews should be passed on to the watchdog.

Bill Kirkup, who chaired the inquiry into deaths of mothers and babies at Furness General Hospital in Barrow-in-Furness, told The Independent: “When there is sufficient concern about a service to prompt an external review, the report must be available immediately to those responsible for assuring the quality of the service. That was the reason for the recommendation of the Morecambe Bay investigation, and it is disappointing that the Care Quality Commission apparently had no sight of this report until now.”

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Source: 26 January 2020

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Health secretary to investigate allegations of women denied epidurals

Women in labour are being denied epidurals by NHS hospitals, amid concern that a “cult of natural childbirth” is leaving rising numbers in agony.

Last night, Matt Hancock, the Health Secretary, promised an investigation, and action to ensure women’s choices were respected, pledging to make the NHS maternity services the world-leader.

An investigation by The Sunday Telegraph found hospitals refusing clear requests from mothers-to-be, in breach of official guidelines from the National Institute for Health and Care Excellence (NICE).

Mr Hancock said all expectant mothers should be able to make an informed choice, knowing their choice would be fully respected.

“Clinical guidance clearly state that you can ask for pain relief at any time – before and during labour – and as long as it is safe to do so this should never be refused. I’m concerned by evidence that such requests are being denied for anything other than a clinical reason,” he said.

“It's vital this guidance is being followed right across our NHS, as part of making it the best place in the world to give birth. Women being denied pain relief is wrong, and we will be investigating.”

One mother, describing her experience at one NHS Hospital said: "It made me feel unsafe psychologically - I couldn't speak up, I couldn’t say what I wanted to say, I couldn’t advocate for myself medically because people were ignoring or belittling me. It feels that in childbirth, it’s a given that the doctor is taking their personal beliefs with them to the table, whereas in any other area of healthcare that would be unacceptable."

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Source: The Telegraph, 26 January 2020

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Justice is being denied to too many families

Harry Richford's death underlines the need for the health secretary to bring back the national maternity safety training fund – and there are other issues that require urgent attention – The Independent reports. 

Harry Richford had not even been born before the NHS failed him. An inquest has concluded he was neglected by East Kent University Hospitals Trust in yet another maternity scandal to rock the NHS. His parents and grandparents have fought a tireless campaign against a wall of obfuscation and indifference from the NHS. In their pursuit of the truth they have exposed a maternity service that did not just fail Harry, but may have failed dozens of other families.

As with the family of baby Kate Stanton-Davies at Shrewsbury and Telford Hospitals Trust, or Joshua Titcombe at the University Hospitals of Morecambe Bay Trust, it has taken a family rather than the system to expose what was going wrong. It is known that there are about 1,000 cases a year of safety incidents in the NHS across England, including baby deaths, stillbirths and children left brain damaged by mistakes.

Last week, the charity Baby Lifeline, joined The Independent to call on the Department of Health and Social Care (DHSC) to reinstate the axed maternity safety training fund. This small fund was used to train maternity staff across the country. Despite being shown to be effective, it was inexplicably scrapped after just one year. 

There are other issues that also need urgent attention. The inquest into Harry’s death, which concluded on Friday, lasted for almost three weeks. Without pro bono lawyers from Advocate, Brick Court Chambers and Arnold & Porter law firm, the family would have faced an uphill struggle. At present, families are not automatically entitled to legal aid at an inquest, yet the NHS employs its own army of lawyers who attend many inquests and can overwhelm bereaved families in a legal battle they are ill-equipped to fight. Even the chief coroner, Mark Lucraft QC, has called for this inequality of legal backing to end, but the government has yet to take action.

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Source: The Independent, 26 January 2020

 

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England's poorest 'get worse NHS care' than wealthiest citizens

England’s poorest people get worse NHS care than its wealthiest citizens, including longer waiting for A&E treatment and worse experience of GP services, a new study has shown.

Those from the most deprived areas have fewer hip replacements and are admitted to hospital with bed sores more often than people from the least deprived areas. With regard to emergency care, 14.3% of the most deprived had to wait more than the supposed maximum of four hours to be dealt with in A&E in 2017-18, compared with 12.8% of the wealthiest. Similarly, just 64% of the former had a good experience making a GP appointment, compared with 72% of those from the richest areas.

Research by the Nuffield Trust and Health Foundation thinktanks found that the poorest people were less likely to recover from mental ill-health after receiving psychological therapy and be readmitted to hospital as a medical emergency soon after undergoing treatment.

The findings sparked concern because they show that poorer people’s health risks being compounded by poorer access to NHS care.

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Source: The Guardian, 23 January 2020

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East Kent hospitals: Care watchdog inspects trust after baby death apology

England's care watchdog has carried out a no-notice inspection of an NHS trust at the centre of concerns over the possible preventable deaths of babies. The Care Quality Commission (CQC) is investigating East Kent Hospitals NHS Trust but has not yet decided whether to prosecute.

It comes as the trust is likely to be heavily criticised at an inquest into the death of baby Harry Richford.

On Thursday, the BBC revealed significant concerns have been raised about maternity services at the trust, and a series of preventable baby deaths may have occurred there. On Wednesday and Thursday this week, the trust's maternity services were subject to an unannounced inspection from the CQC.

On Thursday night, East Kent Hospitals University NHS Foundation Trust said in a statement: "We are truly sorry for the death of baby Harry and our thoughts and deepest sympathies go out to Harry's family. We accept that Harry's care fell short of the standard that we expect to offer every mother giving birth in our hospital and we are fully cooperating with the CQC's investigation into Harry Richford's death."

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Source: BBC News, 24 January 2020

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Cancer care backlog may cost 30,000 lives, Boris Johnson told

Scores of MPs and former ministers have urged the prime minister to tackle a backlog in NHS cancer care that threatens to lead to thousands of early deaths over the next decade.

More than 100 MPs have written to Boris Johnson after the coronavirus lockdown caused severe disruption to cancer diagnoses and treatments. They have called on him to deliver an emergency boost to treatment capacity.

One senior oncologist has claimed that in a worst-case scenario the effects of the pandemic could result in 30,000 excess cancer deaths over the next decade.

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Source: The Times, 22 August 2020

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LloydsPharmacy launches pilot programme to help and support mental health patients

LloydsPharmacy is piloting an innovative new service that offers extra help and support to mental health patients. Funded by The National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre (NIHR GM PSTRC), which is a partnership between The University of Manchester and Salford Royal, the pilot is being carried out in ten community pharmacies in Greater Manchester.

The new service, referred to as AMPLIPHY, enables pharmacists to provide personalised support to people who have been newly prescribed a medicine for depression or anxiety, or those who have experienced a recent change to their prescription.

The pilot programme has been funded and designed by researchers at the NIHR GM PSTRC in collaboration with LloydsPharmacy. Central to the programme is the ability for patients to lead the direction of support they receive. They set their own goals and objectives and the pharmacist supports them in these. 

Professor Darren Ashcroft, Deputy Director of the NIHR Greater Manchester PSTRC, said: "The NIHR Greater Manchester PSTRC focuses on improving patient safety across four themes, which include Medication Safety and Mental Health. AMPLIPHY covers two of these areas and we believe it has the potential to make a difference to patients, by providing enhanced support for their care in the community."

The pilot is set to run until April 2020 when its impact will be evaluated before a decision is made on the next steps.

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Source: News-Medical.net, 22 January 2020

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Whorlton Hall: Care regulator ‘was wrong’ to bury whistleblower’s report into failings at hospital where patients were abused

The Care Quality Commission (CQC) missed multiple opportunities to identify abuse of patients at a privately run hospital and did not act on the concerns of its own members, an independent review has found.

Bosses at the CQC have been criticised in an independent report by David Noble into why the regulator buried a critical report into Whorlton Hall hospital, in County Durham, in 2015.

His report published today said the CQC was wrong not to make public concerns from one of its inspection teams in 2015.

“The decision not to publish was wrong,” his report said, adding: “This was a missed opportunity to record a poorly performing independent mental health institution which CQC as the regulator, with the information available to it, should have identified at that time.”

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Source: The Independent, 22 January 2020

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East Kent hospitals: Baby deaths 'could have been prevented'

At least seven preventable baby deaths may have occurred at one of the largest groups of hospitals in England since 2016, a BBC investigation has found.

Significant concerns have been raised about maternity services at the trust.

East Kent NHS Foundation Trust has apologised, saying it has "not always provided the right standard of care".

The trust has struggled to improve maternity care for years, despite repeatedly being made aware of the problems.

In 2015, the medical director asked experts from the Royal College of Obstetricians and Gynaecologists to review maternity care, amid "concerns over the working culture". Their review, seen by the BBC, found poor team working in the unit, a number of consultants operating as they saw fit, a lack of performance management of the consultant body and out of date clinical guidelines.

It highlights consultants who:

  • failed to carry out labour ward rounds, review women, make plans of care or attend out of hours when requested
  • rarely attended CTG training
  • were reported "as doing their own thing rather than follow guidelines".

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Source: BBC News, 23 January 2020

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Earlier recognition of aortic dissection needed to prevent deaths

Up to half of all patients who suffer an acute aortic dissection may die before reaching crucial specialist care, according to a new Healthcare Safety Investigation Branch (HSIB) report.

The report highlights the difficulty which can face hospital staff in recognising acute aortic dissection. The investigation was triggered by the case of Richard, a fit and healthy 54-year old man, who arrived at his local emergency department by ambulance after experiencing chest pain and nausea during exercise. It took four hours before the diagnosis of an acute aortic dissection was made, and he spent a further hour waiting for the results of a CT scan. Although Richard was then transferred urgently by ambulance to the nearest specialist care centre, he sadly died during the journey.

The report has identified a number of risks in the diagnostic process which might result in the condition being missed. These include aortic dissection not being suspected because patients can initially appear quite well or because symptoms might be attributed to a heart or lung condition.

It also highlighted that, once the diagnosis is suspected, an urgent CT scan is required to confirm that an acute aortic dissection is present. 

Gareth Owens, Chair of the national patient association Aortic Dissection Awareness UK & Ireland, welcomed the publication of HSIB’s report, saying: “HSIB’s investigation and report have highlighted that timely, accurate recognition of acute Aortic Dissection is a national patient safety issue. This is exactly what patients and bereaved relatives having been telling the NHS, Government and the Royal College of Emergency Medicine for several years."

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Source: HSIB, 23 January 2020

 

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Hundreds of serious incidents recorded at struggling small trust

One of the country’s smallest trusts recorded 277 serious incidents over a two-year period, HSJ can reveal.

Delays in treatment, missed diagnoses, adverse media coverage and “suboptimal” care were among the hundreds of serious incidents reported at the struggling Isle of Wight Trust from the start of 2018 and up to November 2019.

There were also two never events in 2019 — a “wrong site” surgery and an incident in which a patient was mistakenly connected to an air flow meter, rather than an oxygen supply.

The trust said the level of incidents did not neccessarily reflect poor care, and did not mean patients had come to harm.

The trust was placed in special measures in April 2017 after it was rated “inadequate” by the Care Quality Commission due to “significant” concerns over patient safety. It was upgraded to “requires improvement” in September 2019, but remains in special measures. 

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Source: HSJ, 22 January 2020

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Dementia patients being 'dumped in hospital'

Dementia patients are being dumped in hospitals in England because of a lack of community care, a charity says.

The Alzheimer's Society called for action, highlighting data showing one in 10 dementia patients spends over a month in hospital after being admitted.

The figures also suggested the overall number of emergency admissions among people with dementia is rising - with some patients yo-yoing back and forth.

Ministers said they were "determined" to tackle the problems. Central to this, the government said, would be plans for reforming the social care system, which encompasses care home places and support in people's homes.

Alzheimer's Society Chief Executive Jeremy Hughes said people were falling through the "cracks of our broken social care system".

"People with dementia are all too often being dumped in hospital and left there. Many are only admitted because there's no social care support to keep them safe at home. They are commonly spending more than twice as long in hospital as needed, confused and scared."

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Source: BBC News, 22 January 2020

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Cosmetic nurse leaders issue warning over Scottish regulation plans

Proposals by the Scottish Government to give a licence to unregistered professionals to carry out cosmetic procedures are “fundamentally flawed” and put lives at risk, leading nurses in the field have warned.

A consultation has been launched seeking views on plans for a new regulatory regime of non-surgical aesthetic treatments that pierce or penetrate the skin like dermal fillers or lip enhancements. Ministers want to bring non-health professionals under existing legislation allowing them to obtain a licence to perform these procedures in unregulated premises such as beauty salons and hairdressers.

The move comes after a UK-wide review carried out in 2013, by then NHS medical director Sir Bruce Keogh, identified that little regulation existed within the cosmetic industry. Since then there has been growing concern that people are coming to physical and psychological harm from treatments gone wrong.

Leaders at the British Association of Cosmetic Nurses (BACN) told Nursing Times that they were “totally opposed” to non-medical practitioners carrying out injectable beauty procedures.

BACN Chair Sharon Bennett said holding a medical, nursing or dentistry qualification should be a “basic prerequisite” before being accepted to an aesthetics training course. SHe said BACN believed even clinically trained practitioners, including nurses, needed further training in aesthetics before working in this “specialist” area.

“[This is] because there is no educational framework, training or statutory provision to establish or task beauty therapists to detect disease, care for patients or carry out medical treatment, so to do so would breach public health safety and endanger lives.”

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Source: The Nursing Times, 20 January 2020

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Patient had wrong eye injected after software error

Herefordshire clinicians injected a patient in the wrong eye after a technical blunder, board papers have revealed.

The Wye Valley Trust patient was injected with an antivascular endothelial growth factor to treat age-related macular degeneration. They did not come to harm as a result of the incident.

The mistake occurred after the ophthalmology department deleted a poor quality image of one of the patient’s eyes. This shifted up the other images, which were stored sequentially using software called IMAGEnet6, which led to the mistake. 

Although initially reported as a “never event,” the incident was downgraded to a “serious incident” after a review by the Herefordshire Clinical Commissioning Group (CCG). 

The trust, which is still using the software, is updating its standard operating procedure and has installed new technology that can take higher quality images. A spokesman said: “Patient safety is the trust’s priority. While no harm was caused to this patient, the trust has taken this incident seriously.”

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Source: HSJ, 21 January 2020

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