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Patient Safety Learning

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  1. Patient Safety Learning
    The number of covid positive patients in English hospitals fell by 1,491 yesterday, by far the biggest decline recorded since the start of the pandemic.
    The previous record was set during the decline of the first wave, when numbers fell 1,055 on 17 April. The largest drop in the third wave before yesterday’s record was the 798 seen last Saturday.
    The national total of covid positive hospital patients now stands at 30,846, a drop of 9 per cent on the peak set on 18 January, but still 163 per cent of the mid-April peak.
    All seven English regions are now seeing a week-on-week decline in the number of their covid hospital patients for the first time.
    All have well established trends in falling admissions, with London and the south east seeing the running seven-day total fall by almost a third since a peak on 9 January. The east and south west have seen their admissions total decline by a fifth, while the midlands total has dropped 16 per cent in just five days and north east and Yorkshire nine in only four.
    Read full story (paywalled)
    Source: HSJ, 28 January 2021
  2. Patient Safety Learning
    Black people over the age of 80 were half as likely as their white peers to have been vaccinated against Covid by 13 January, a large study suggests. This is despite the fact black people are four times more likely to die with COVID-19 than their white counterparts.
    People living in deprived areas or who have severe mental-health conditions or learning disabilities were also less likely to have received a vaccination. The study was based on more than 20 million patient records in England.
    The OpenSafely study, by the University of Oxford and the London School of Hygiene and Tropical Medicine, found of the million of those over 80 but not living in a care home:
    43% of the white people had been given their first dose of the vaccine 30% of the Bangladeshi and Pakistani people had 21% of the black people had. Bangladeshi and Pakistani people are twice as likely to die with COVID-19 as white peple.
    Birmingham-based business owner Tru Powell told BBC Radio 5 Live of a "lack of trust between the government and people of colour".
    "People of colour have been subject to institutionalised racism within the healthcare system," she said.
    "We are five times more likely to be detained under the Mental Health Act and four times more likely to die in childbirth."
    Read full story
    Source: BBC News, 28 January 2021
  3. Patient Safety Learning
    The Healthcare Safety Investigation Branch (HSIB) has launched an investigation into the risks involved in prescribing, dispensing and administering medicines to children.
    The investigation was triggered after HSIB was notified of an incident including a child aged four years, who, after being diagnosed with a blood clot in her leg following a surgical procedure, received ten times the intended dose of anticoagulant on five separate occasions, over three days.
    This, HSIB said, was owing to errors that occurred during the prescription, dispensing and administration processes.
    The errors resulted in the child being admitted to the paediatric intensive care unit, with evidence of a bleed in her brain, where she stayed for three months until she was discharged with an ongoing care plan.
    HSIB said that studies showed that prescribing errors were the most frequent type of medication error in children’s inpatient settings.
    The investigation will look at this and other incidents to examine the role of multidisciplinary teamworking and checking in medication errors, as well as considering the risks associated with the implementation of electronic prescribing and medication administration (ePMA) systems in clinical areas using weight-based paediatric prescribing.
    “‘Wrong dose’ errors are a particular risk in children’s wards,” said Alice Oborne, consultant pharmacist in safe medication practice and medicines safety officer at Guy’s and St Thomas’ NHS Foundation Trust.
    Read full story
    Source: The Pharmaceutical Journal, 26 January 2021
  4. Patient Safety Learning
    The Department of Health & Social Care are working with Traverse, a research organisation, to appoint 15 people to a patient reference group. This group will work with DHSC as it develops and implements the Government’s response to the Report of the Independent Medicines and Medical Devices Safety Review (IMMDS Review).
    What will the group be doing?
    Meeting online to share experiences, ideas and recommendations. Helping to shape the Government’s response to the IMMDS Review, ensuring that patient voices are heard in the process. Providing advice, challenge, and scrutiny as the Government implements its response. They are looking for people who:
    Have a personal experience of or understand the context of the IMMDS Review. Are committed to improving the experience of patients. Want to engage with others on the group and DHSC representatives to support the development and implementation of the Government’s response to the IMMDS Review. Can consider complex and emotive issues in a balanced and sensitive way. Have good communication skills, and want to build strong working relationships with the rest of the group. They are also looking for a co-chair to support group members contribute to the group and make sure group members are heard. If you know the English healthcare system well and are comfortable working on sensitive issues, take a look at the recruitment pack to find out more about the co-chair role and how to apply.
    If you are interested in getting involved, contact IMMDSRPatientGroup@traverse.ltd for the recruitment pack and more information on how to apply.
  5. Patient Safety Learning
    There were 800 fewer cancer surgeries in the first two weeks of January than usually take place during the period, according to provisional data seen by HSJ.
    The bulk of this reduction came in London and the surrounding counties such as Essex, Bedfordshire, and Surrey.
    London and the south east have been severely hit by coronavirus pressures, causing widely reported mass cancellations of non-urgent elective surgery. However, the impact on cancer cases has, so far, been less clear.
    NHS England has insisted in the last week that urgent cancer cases should be given the same priority as coronavirus patients.
    Read full story (paywalled)
    Source: HSJ, 25 January 2021
  6. Patient Safety Learning
    NHS England has been urged to introduce routine recording of race and ethnicity data when people are given their covid vaccination.
    Documents seen by HSJ show Pinnacle, the IT system being used by GPs and mass vaccination centres to record jabs, does not directly require ethnicity to be recorded.
    Jabeer Butt, chief executive of the Race Equality Foundation, which promotes race equality in public services, told HSJ that making it a requirement would help establish the facts on uptake among different groups, more quickly.
    It is understood the NHS is able to ascertain data on vaccine uptake by ethnicity by connecting it with GP records, through the national immunisation management service, and potentially with other healthcare data. However, Mr Butt said this would provide only limited insight and take more time.
    He believes the absence of data may allow ”misconceptions” to take hold about lower uptake among some minorities, which can lead to stigma, when in fact, he said, the trend may so far simply be due to there being fewer black and Asian people in the oldest age groups, who are the first eligible for vaccination. 
    Read full story (paywalled)
    Source: HSJ, 24 January 2021
  7. Patient Safety Learning
    Two-thirds of women at the heart of a review into maternity services at a Welsh health board could have had very different outcomes if they had received better care, a report has found.
    The Independent Maternity Services Oversight Panel (Imsop) focused on the experiences of pregnant women at Cwm Taf Morgannwg health board.
    Its maternity services have been in special measures since "serious failings" were found two years ago. 
    Concerns emerged in late 2018 that women and babies may have come to harm because of staff shortages and failures to report serious incidents. This sparked a major independent review, which gave a damning verdict on maternity services in Cwm Taf Morgannwg health board.
    Published on Monday, the Imsop report focuses on the care of mothers between January 2016 and September 2018. It found that 19 reviews of maternal care (68%) revealed at least one factor where "different management would reasonably have been expected to alter the outcome".
    The panel's chairman, Mick Giannasi, said: "These findings will be concerning and potentially distressing for the women and families involved, and it will be difficult for staff."
    "Of the 28 episodes of care, we concluded that in 27 of them, our independent teams who reviewed the care would have done something differently. Put simply, what went wrong, might not have gone wrong if things had been done differently."
    Read full story
    Source: BBC News, 25 January 2021
  8. Patient Safety Learning
    A care home worker who was wrongly diagnosed with cancer said she thought it was a "cruel joke" when she was told doctors had made a mistake and she did not have cancer at all.
    Mum-of-four Janice Johnston said her "world crumbled" when she learned she had a rare form of blood cancer at Kent and Canterbury Hospital in 2017.
    She had 18 months of oral chemotherapy treatment, during which she experienced weight loss, nausea and bone pain, and had to give up her job as an auxiliary nurse. When the treatment did not appear to be working, she says, medics upped the dosage.
    In 2018, she sought alternative treatment at Guy's Hospital in London. It was there a specialist told her she did not have cancer at all but a different condition.
    Mrs Johnston was awarded £75,950 in damages after East Kent Hospitals University NHS Foundation Trust admitted liability. Staff at the hospital had failed to do the necessary ultrasound scan and bone marrow biopsy before diagnosing her.
    Read full story
    Source:  BBC News, 25 January 2021
  10. Patient Safety Learning
    The chief executive of a small acute trust has described the “terrifying situation” faced by ambulance crews and hospital staff in trying to provide adequate emergency care as coronavirus threatens to overwhelm the local NHS services.
    Susan Gilby, of Countess of Chester Hospital Foundation Trust, told HSJ staff are seeing “tragic and potentially avoidable” instances where patients with COVID-19 have reached the emergency department too late.
    She suggested this is due to a combination of patients waiting too long to call 999, and then having to wait long periods for an ambulance to arrive.
    Cheshire has been among the hardest hit areas in England during this third wave of coronavirus, with all four of its acute hospitals having very high covid occupancy rates.
    Dr Gilby, a former critical care consultant, said her trust has been at around 60 per cent covid occupancy for the last fortnight, which has made her increasingly fearful of the difficulties in admitting patients through the emergency department due to a lack of beds. This can then cause knock-on delays for patients arriving in ambulances, and ties those ambulance crews up for long periods, preventing them from responding to further 999 calls.
    She said ambulance turnaround times had been relatively good at the Countess of Chester, but she had spoken to paramedics handing over patients who were “really struggling” to get to people quickly enough.
    Read full story (paywalled)
    Source: HSJ, 22 January 2021
  11. Patient Safety Learning
    A special Crown Office unit set up to probe Covid-linked deaths is investigating cases at 474 care homes in Scotland, the BBC can reveal.
    The unit was set up in May to gather information on the circumstances of all deaths in care homes. Prosecutors will eventually decide if the deaths should be the subject of a fatal accident inquiry or prosecution.
    Care homes say the investigation is "disproportionate" and placing a huge burden on overstretched staff.
    The COVID-19 Deaths Investigation Team (CDIT) had received 3,385 death reports as of Thursday. The majority of them relate to people who lived in care homes.
    Behind the Crown Office statistics are hundreds of families grieving for loved ones who died in Scotland's care homes.
    Alan Wightman's 88-year-old mother Helen died in May last year during a Covid outbreak at Scoonie House in Fife
    Helen's death is part of the Crown Office probe and Mr Wightman's hopes for the investigation are that it looks "at the bigger picture and appreciates that on the ground people were doing the best they could".
    He added: "I thought that Scoonie House did the best they could in a very difficult situation, sourcing their own PPE and stopping people coming from hospital."
    "My own view is that care homes were put in an impossible situation because we had successive governments which did not properly prepare for a pandemic, you only have to look at the lack of PPE at the beginning of the pandemic to see that."
    Read full story
    Source: BBC News, 22 January 2021
     
  12. Patient Safety Learning
    In a new trial, cancer patients across the UK have been using the eRAPID technology system to help them manage their cancer symptoms.
    The system has been developed by the University of Leeds, and this is the first trial to offer automated advice to early-stage patients whose treatment aims to cure cancer. Hundreds of early-stage colorectal, breast, or gynaecological cancer patients took part in the trial which used computer algorithms to help manage their symptoms and improve their wellbeing. They were able to report online symptoms from home and receive instant advice on whether to self-manage or seek medical attention.
    Cancer can cause a range of different symptoms for patients living with the disease, as well as from the side effects of treatments such as chemotherapy, which are sometimes life-threatening and all of which lower a patients’ quality of life. Better monitoring and management of these symptoms can help in improving treatment delivery and reducing patients’ physical distress.
    All patients in the trial received their usual care, with 256 receiving the eRAPID system as additional care. The patients reported better symptom control and physical wellbeing in the early weeks of treatment, with the system preventing symptom deterioration in about 9% of patients after 12 weeks.
    Dr Kate Absolom, University Academic Fellow in the Leeds Institute of Medical Research at St James’s and the Leeds Institute of Health Sciences at the University of Leeds, said: “The encouraging results from this study will help pave the way for future development and refinement of these interventions in broader cancer settings. The COVID-19 pandemic highlighted the need and speeded a shift towards technology-enabled care, so these study results are very timely.”
    Programme lead Professor Galina Velikova, at the Leeds Institute of Medical Research at St James’s, University of Leeds, and the Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, said: “Rising numbers of cancer patients are receiving a range of anti-cancer treatments which means patients are living longer and require longer periods of care and monitoring.
    “Remote online monitoring options have the potential to be a patient-centred, safe, and effective approach to support patients during cancer treatment and manage the growing clinical workload for cancer care.”
    Read full story
    Source: Health Europa, 11 January 2021
  13. Patient Safety Learning
    Hospitals should ramp up their treatment of COVID-19 patients at home to free up more beds during the peak of the pandemic, under plans announced by NHS England/Improvement.
    All NHS trusts will receive up to 300 oximeters, which measure oxygen saturation levels and can be used to monitor COVID-19 patients in their own homes, rather than in hospital beds.
    NHSE has “recommended” that all areas of England “pursue immediate roll-out” given the “intense pressure on hospital beds right now”, according to a letter from medical director Steve Powis and two other national directors.
    Currently, nearly 60 trusts have COVID-19 patients in at least a third or more of their beds, and the total number of COVID-19 patients is peaking at around 37,000. There have been particular strains on hospital discharge, particularly of covid patients, whom many care homes are unable or unwilling to receive.
    The scheme, dubbed “covid virtual wards”, has been used at some trusts since the pandemic’s first wave.
    Read full story (paywalled)
    Source: HSJ, 19 January 2021
  14. Patient Safety Learning
    Doctors and midwives working in maternity services face higher levels of bullying than any other part of the NHS, MPs have been told.
    According to the General Medical Council, trainee doctors in maternity services report more than twice the level of bullying seen in the rest of the NHS while the Nursing and Midwifery Council said midwives were also more likely to be bullied.
    MPs on the Commons health select committee heard that the culture in some maternity units was a major barrier to improving safety and tackling poor care.
    In an evidence session as part of an ongoing inquiry into maternity care, MPs were also warned the lack of properly funded training was forcing some midwives to pay out of their own pocket.
    The inquiry by the committee was launched last year after repeated maternity scandals at the Shrewsbury and Telford Hospitals Trust and East Kent Hospitals University Trust.
    Giving evidence to the committee, Charlie Massey, chief executive of the General Medical Council said: “We do see in our data some quite troubling data around bullying."
    “If you are an obstetrics or gynaecology trainee, we see in our national training survey each year that some 14% report that they have experienced bullying – and that’s against an average for all trainees of 6%. You see more than double the rate of bullying in obstetrics and gynaecology than you do elsewhere.”
    Read full story
    Source: The Independent, 20 January 2021
  15. Patient Safety Learning
    There has been a sharp drop in the number of patients admitted to hospitals in England with heart attacks or heart failure in recent months, research reveals.
    Experts are worried that people who need urgent medical help are not seeking it. This was also the case during the first wave of the pandemic.
    The researchers included 66 hospitals in the study and compared daily admission rates in the year before the pandemic with those during the first and second waves in England, up to 17 November.
    During the first lockdown, daily admissions for heart attacks or heart failure decreased by more than 50%. They went up again in the summer, as coronavirus rates decreased in the UK and the NHS became less busy with the virus.
    From October, when coronavirus cases were rising again, heart admissions began to drop - by between 35% and 41% compared with pre-pandemic data, according to the study published in the Journal of the American College of Cardiology.
    Researcher Prof Chris Gale, from Leeds University, said: "Medical emergencies do not stop in a pandemic. I am afraid that we are seeing a re-run of one of the preventable tragedies of the first wave - people were either too afraid to go to hospital for fear of contracting COVIDd-19 or were not referred for treatment."
    "The message to patients needs to be clear. If they experience symptoms of a heart attack or acute heart failure, they need to attend hospital."
    Read full story
    Source: BBC News, 20 January 2021
  16. Patient Safety Learning
    The UK’s main gender identity development service for children is leaving thousands of vulnerable young people at risk of self-harm as they wait years for their first appointment, according to a highly critical report.
    The Care Quality Commission (CQC) took immediate enforcement action against the Tavistock and Portman NHS foundation trust when it completed the inspection in November, which rated the service overall “inadequate” and highlighted overwhelming caseloads, deficient record-keeping and poor leadership.
    The commission, which heard from young people using the service, parents, carers and staff in the course of its inspection, told the trust that services and waiting times in the Gender Identity Development Services (GIDS) in both their London and Leeds clinics “must improve significantly”, demanding monthly updates on numbers on waiting lists and actions to reduce them.
    The service has faced major scrutiny in recent years, with some former staff and campaigners raising concerns about the “overdiagnosing” of gender dysphoria, the consequences of early medical interventions and the significant increase in referrals of girls questioning their gender identity.
    Read full story
    Source: The Guardian, 20 January 2021
  17. Patient Safety Learning
    The family of a man who bled to death during kidney dialysis treatment at Royal Shrewsbury Hospital have said they believe lessons have been learned.
    Mohammed Ismael Zaman, known as Bolly, died after hospital staff failed to check the connection on his dialysis machine, despite it sounding an alarm after the catheter had become disconnected.
    During Mr Zaman’s treatment at the Royal Shrewsbury Hospital on October 18, 2019, his dialysis machine set off a venous pressure alarm.
    An unidentified member of staff reset the alarm without checking that the connection was still secure. As a result of the reset, Mr Zaman bled out for seven minutes losing 49% of his blood circulating volume.
    He was found unconscious in a pool of blood and despite resuscitation attempts, died two hours later.
    The coroner, Mr John Ellery concluded that the death was due to systems failure and individual neglect on the part of the unidentified staff member.
    Read full story
    Source: Shropshire Star, 16 January 2021
  18. Patient Safety Learning
    A London hospital is being forced to send patients back to ambulances for treatment due to an ‘overwhelming’ number of Covid patients on ICU wards, according to a frontline doctor.
    The medic, who asked to remain anonymous, said A&E staff are "running" into waiting ambulances to treat patients there until space becomes available.
    He said: "It’s not the fault of the staff, but the sheer numbers are so unprecedented and being full like this means that you just have to do your best to adapt. But it’s not the standard (of care) I signed up to."
    "It’s extremely stressful for us to be doing our best but knowing that significant patient harm is happening because there isn’t space and the patient load is too high." 
    He raised concerns that "significant patient harm" was occurring due to a lack of beds available and the emergency system means medics are limited in the care they can provide.
    Read full story
    Source: The Metro, 14 January 2021
  19. Patient Safety Learning
    The growth in covid positive hospital patients is rapidly slowing in every English region and appears to have stopped in the south east.
    The weekly increase in covid inpatients across England fell to 8% yesterday, the first time it had dropped to single figures since 12 December. A week earlier, on 10 January, the growth rate stood at 23%.
    There are now 33,352 covid hospital patients in English hospitals, an increase of 2,594 in the last seven days. The previous week had seen a rise of 5,801.
    The weekly growth rate of covid positive hospital patients in the seven English regions currently ranges from 26% in the south west to zero in the south east. In every region, the growth rate is seven to 20 percentage points lower than recorded on 10 January.
    London’s weekly growth rate is now three per cent and the east’s is 2%. There has been no substantive change in the south east total in the past week. It is likely covid patients will be seen to have peaked in these three regions between 13 to 15 January.
    The slowing in the growth of national covid patient numbers means the total is likely to peak during the next seven days at a level lower than many had feared and expected. HSJ has seen internal NHS England projections from last week that saw growth continuing into February and total covid patient numbers rising well above 40,000, this now seem very unlikely.
    Read full story
    Source: HSJ, 18 January 2021
  20. Patient Safety Learning
    Emergency legislation is needed to protect doctors and nurses from “inappropriate” legal action over critical Covid treatment decisions made amid the pressures of the pandemic, health organisations have argued.
    A coalition of health bodies has written to Matt Hancock, the health secretary, calling for the law to be updated so medical workers do not feel “vulnerable to the risk of prosecution for unlawful killing” when treating coronavirus patients “in circumstances beyond their control”.
    The letter, coordinated by the Medical Protection Society (MPS), states there are no legal safeguards for coronavirus-related issues such as when there are “surges in demand for resources that temporarily exceed supply”.
    The coalition, which includes the British Medical Association and Doctors’ Association UK, wrote: “With the chief medical officers now determining that there is a material risk of the NHS being overwhelmed within weeks, our members are worried that not only do they face being put in this position but also that they could subsequently be vulnerable to a criminal investigation by the police.
    “There is no national guidance, backed up by a clear statement of law, on when life-sustaining treatment can be lawfully withheld or withdrawn from a patient in order for it to benefit a different patient, and if so under what conditions. The first concern of a doctor is their patients and providing the highest standard of care at all times.”
    Read full story
    Source: The Guardian, 16 January 2021
  21. Patient Safety Learning
    A mental health trust prosecuted for failings after 11 patients died must make further safety improvements, the Care Quality Commission (CQC) said.
    Inspectors found safety issues on male wards and psychiatric intensive care units run by Essex Partnership University NHS Foundation Trust (EPUT).
    The Trust said it had taken "immediate action" to remedy the concerns.
    In November, EPUT pleaded guilty to safety failings related to patient deaths between 2004 and 2015.
    The CQC's report followed inspections in October and November last year at the Finchingfield Ward - a 17-bed unit in the Linden Centre in Chelmsford which provides treatment for men experiencing acute mental health difficulties.
    The CQC said the visit was prompted "due to concerning information raised to the commission regarding safety incidents leading to concerns around risk of harm".
    The inspection, which looked at safety only, found the following concerns:
    Some staff did not follow the required actions to maintain patient safety. Closed-circuit television showed staff who were meant to be observing were not present, and this contributed to an incident of patient absconding. Staff did not keep accurate records of patient care and managers did not check the quality and accuracy. of notes. Shifts were not always covered by staff with appropriate experience and competency Stuart Dunn, head of hospital inspection at the CQC, said EPUT had "responded quickly to concerns raised" including improving security measures.
    Read full story
    Source: BBC News, 14 January 2021
  22. Patient Safety Learning
    Advisers from the Scientific Advisory Group for Emergencies (Sage) have raised fresh concerns over Covid vaccine uptake among black, Asian and minority ethnic communities (BAME) as research showed up to 72% of black people said they were unlikely to have the jab.
    Historical issues of unethical healthcare research, and structural and institutional racism and discrimination, are key reasons for lower levels of trust in the vaccination programme, a report from Sage said.
    The figures come from the UK Household Longitudinal Study, which conducts annual interviews to gain a long-term perspective on British people’s lives.
    In late November, the researchers contacted 12,035 participants to investigate the prevalence of coronavirus vaccine hesitancy in the UK, and whether certain subgroups were more likely to be affected by it. Overall, the study found high levels of willingness to be vaccinated, with 82% of people saying they were likely or very likely to have the jab – rising to 96% among people over the age of 75.
    Women, younger people and those with lower levels of education were less willing, but hesitancy was particularly high among people from black groups, where 72% said they were unlikely or very unlikely to be vaccinated. Among Pakistani and Bangladeshi groups this figure was 42%. Eastern European groups were also less willing.
    “Trust is particularly important for black communities that have low trust in healthcare organisations and research findings due to historical issues of unethical healthcare research,” said the Sage experts.
    “Trust is also undermined by structural and institutional racism and discrimination. Minority ethnic groups have historically been underrepresented within health research, including vaccines trials, which can influence trust in a particular vaccine being perceived as appropriate and safe, and concerns that immunisation research is not ethnically heterogenous.”
    Read full story
    Source: The Guardian, 16 January 2021
  23. Patient Safety Learning
    The UK government’s new policy of distributing rapid coronavirus tests to local authorities in England has divided the medical and scientific community, with some calling for the tests to be halted because they could falsely reassure people and increase the spread of COVID-19.
    Critics are also concerned that the policy, announced on Sunday 10 January, was being rolled out without sufficient provision for people who test positive, such as putting them in hotels and compensating them financially. Supporters say the tests are a valuable additional tool in public health interventions to identify new cases and suppress further transmission.
    Launching the new testing drive, England’s health and social care secretary, Matt Hancock, said, “With roughly a third of people who have coronavirus not showing symptoms, targeted asymptomatic testing and subsequent isolation is highly effective in breaking chains of transmission. Rapid, regular testing is led by local authorities who design programmes based on their in-depth knowledge of the local populations, so testing can have the greatest impact.”
    Read full story
    Source: BMJ, 12 January 2021
  24. Patient Safety Learning
    Hundreds of senior midwives are to be given new training to help improve culture and leadership across 126 NHS trusts.
    Patient safety minister Nadine Dorries said a new £500,000 maternity leadership programme would be rolled out later this year aimed at giving senior staff running maternity wards the skills and knowledge they need to boost culture and safety.
    Its one step towards improving the working relationships between midwives and obstetricians and follows the damning report by the Ockenden inquiry into decades of poor care at Shrewsbury and Telford Hospitals Trust.
    The report, published last month, highlighted leadership on maternity wards as a key factor in cases at the trust which led to preventable baby deaths and cases of neglect over many years.
    Announcing the fund, Nadine Dorries said: “The shocking and tragic findings of the Ockenden Review highlighted the importance of strengthening maternity leadership and oversight as well as fostering more collaborative approaches within maternity and neonatal services.
    “I’m pleased to announce a new training programme for NHS maternity leaders, which will empower nurses, midwives and obstetricians to get the best out of their teams, and deliver safe, world-class care to mothers and their babies.”
    Read full story
    Source: The Independent, 12 January 2021
    Government press release
  25. Patient Safety Learning
    Private hospitals are ‘pushing back’ on requests from NHS trusts to send them more NHS patients, following a change to the national contract with the independent sector, and amid high pressure from COVID-19.
    Manchester University Foundation Trust, one of the largest NHS providers, has reported difficulties in accessing capacity at its local Spire, BMI and Ramsay hospitals this month.
    It comes as the NHS is facing “unthinkable” pressures from coronavirus patients, with dozens of hospitals on the brink of being overwhelmed.
    Throughout most of 2020, the bulk of private providers in England were on a national block contract whereby the NHS could use as much capacity as it needed.
    But a new contract, agreed with oversight from the Treasury last month, is now in place between January and April, and only offers trusts a minimum volume of activity which equates to activity provided in October and November.
    Pressures on the NHS have since intensified to unprecedented levels, with many areas now in far greater need of the private capacity than they were two months ago.
    And there appears to be a misunderstanding or lack of clarity in some areas about the extent to which they can now call on private capacity.
    Read full story (paywalled)
    Source: HSJ, 13 January 2021
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