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Patient Safety Learning

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  1. Patient Safety Learning
    COVID-19 could be causing lung abnormalities still detectable more than three months after patients are infected, researchers suggest.
    A study of 10 patients at Oxford University used a novel scanning technique to identify damage not picked up by conventional scans. 
    It uses a gas called xenon during MRI scans to create images of lung damage. Lung experts said a test that could spot long-term damage would make a huge difference to Covid patients. The xenon technique sees patients inhale the gas during a magnetic resonance imaging (MRI) scan.
    Prof Fergus Gleeson, who is leading the work, tried out his scanning technique on 10 patients aged between 19 and 69.
    Eight of them had persistent shortness of breath and tiredness three months after being ill with coronavirus, even though none of them had been admitted to intensive care or required ventilation, and conventional scans had found no problems in their lungs.
    The scans showed signs of lung damage - by highlighting areas where air is not flowing easily into the blood - in the eight who reported breathlessness.
    The results have prompted Prof Gleeson to plan a trial of up to 100 people to see if the same is true of people who had not been admitted to hospital and had not suffered from such serious symptoms. He is planning to work with GPs to scan people who have tested positive for COVID-19 across a range of age groups.
    The aim is to discover whether lung damage occurs and if so whether it is permanent, or resolves over time.
    Read full story
    Source: BBC News, 1 December 2020
  2. Patient Safety Learning
    The government has admitted the NHS in England does not have enough nurses and doctors to keep all its services running if there is a third spike in coronavirus cases as leaked figures show the number of staff off work because of the virus rising.
    An analysis of the impact of coronavirus, released by Downing Street on Monday, warned that even with a 6% growth in NHS staff since August 2019 and extra funding “there is a trade-off between the NHS’s ability to deliver COVID-19 and non-Covid-19 care in the event that COVID-19 hospitalisations rise”.
    It also warned of the psychological effects on staff saying: “It would be expected that higher rates of post-traumatic stress disorder (PTSD) would be seen amongst health and social care staff.”
    New leaked NHS data for England on Monday shows more than 82,000 NHS staff are absent from work with more than two-fifths, 42 per cent, linked to coronavirus either due to sickness or because they need to self-isolate.
    This includes almost 27,000 nurses and 4,000 doctors absent from NHS wards.
    Hospital leaders reiterated the strain the NHS was under in a briefing to MPs ahead of the vote on local tier restrictions today.
    Read full story
    Source: The Independent, 1 December 2020
  3. Patient Safety Learning
    Two hospitals in Cumbria must take "rapid" action "to keep people safe", the health watchdog has announced.
    There had been "escalating" concerns about Carlisle's Cumberland Infirmary and the West Cumberland Hospital in Whitehaven, the Care Quality Commission (CQC) said.
    North Cumbria Integrated Care (NCIC) has been issued with a warning.
    The trust, which was already rated as requiring improvement, admitted the pace of change had been "too slow". The warning notice requires the organisation "to take action to minimise the risk of patients being exposed to harm".
    During checks in August and September, inspectors found:
    Emergency department patients "were not always receiving timely and appropriate" treatment Significant delays in admitting people to wards "Insufficient numbers" of qualified, competent and experienced staff Professor Ted Baker, chief inspector of hospitals, said "rapid improvements" were needed.
    Read full story
    Source: BBC News, 27 November 2020
  4. Patient Safety Learning
    There are serious concerns over the funding and staffing numbers available for new ‘long-covid’ clinics, while patient groups ‘remain in the dark’ over their locations.
    Last month, NHS England announced there would be 40 clinics around the country, to start opening at the end of November, with £10m of funding to cover set-up and operational costs until March 2021.
    But several speakers at HSJ’s inaugural virtual respiratory forum last week said there were still uncertainties and concerns about the capacity to provide the clinics.
    Dr Jon Bennet, a respiratory consultant and chair of the British Thoracic Society, said staffing the respiratory rehabilitation services within the clinics would be challenging, as “there isn’t at the moment sufficient capacity”.
    Read full story (paywalled)
    Source: HSJ, 29 November 2020
  5. Patient Safety Learning
    Nearly 100 trusts have no ‘very senior managers’ (VSM) who are declared to be from a black, Asian or minority ethnic background, HSJ analysis has revealed.
    According to data obtained from every NHS provider in England, 96 out of 214 (45%) did not have any VSMs declared as being from a BAME background.
    This includes several large providers, such as The Newcastle upon Tyne Hospitals Foundation Trust — where around 9 per cent of the workforce and 15 per cent of the city’s population are BAME — and Liverpool University Hospitals FT.
    Jon Restell, chief executive of the Managers in Partnership trade union, said the underrepresentation of BAME staff in leadership positions has “dangerously damaged” the NHS’ response to coronavirus, labelling it the “ultimate wake-up call”.
    Read full story (paywalled)
    Source: HSJ, 30 November 2020
  6. Patient Safety Learning
    New Covid guidance for hospitals could see more patients receiving face-to-face visits from loved ones.
    NHS Wales has given health boards and hospices flexibility to allow visits based on local levels of COVID-19. Until now accompanying people to medical appointments and hospital visits have not been allowed, with a few exceptions. 
    It also allows for pregnant women in low Covid rate areas to take their partners to maternity appointments.
    The Welsh Government said the new flexibility was "due to the changing picture of coronavirus transmission across Wales, with significant variations in community transmission across different parts of the country and differences in the rate of nosocomial transmission".
    Read full story
    Source: BBC News, 30 November 2020
  7. Patient Safety Learning
    Mistakes by Great Ormond Street contributed to the death of a five-year-old boy, the children’s hospital has admitted – just months after it concluded a legal case with his family in which it denied responsibility.
    The world-renowned children’s hospital failed to flag results of a crucial blood test, showing that Walif Yafi had a dangerous infection, to doctors at King’s College Hospital where he had been receiving treatment. He died a few weeks later, in September 2017.
    In September this year, Walif’s parents agreed an out-of-court settlement with Great Ormond Street, which admitted negligence but denied liability for the boy’s death. However, this week the hospital admitted an expert had reviewed the case ahead of the settlement and concluded its actions did contribute to Walif’s death. The hospital said it had been under no duty to share these results with Walif’s parents at the time.
    Walif had a liver transplant in 2012 after suffering cancer shortly after his birth, and was being overseen by Great Ormond Street as an outpatient, as well as by the transplant team at King’s College Hospital, in south London. 
    On 24 August 2017, he had a routine blood test at Great Ormond Street, which showed he had an adenovirus infection – something that is common in children whose immune system is being suppressed by drugs, as Walif’s was because of his transplant. If untreated, the infection can be deadly.
    But the blood test result was not communicated to the team at King’s College Hospital. Shortly afterwards, Walif’s health deteriorated and he was admitted to hospital. He was transferred to King’s College Hospital a week later, and it was not until 7 September that the infection was confirmed. 
    By this stage, he was severely unwell and, though he began anti-viral therapy, Walif suffered multiple organ failure from the spread of the infection. On 30 September, he suffered cardiac arrest and died.
    It was only when approached by The Independent this week that the trust revealed its expert had, in the course of negotiating the settlement with Walif’s parents, determined the hospital did materially contribute to the child’s death.
    Read full story
    Source: The Independent, 29 November 2020
  8. Patient Safety Learning
    Health inspectors in England have been moving between care homes with high levels of COVID-19 infection without being tested, raising fears they have put more residents at risk of catching the virus, leaks to the Guardian have revealed.
    In recent weeks all care home inspections carried out in the north of England have been of infected homes, including a facility where 38 of the 41 people receiving care and 30 staff – almost half of the workers – had tested positive, internal documents from the Care Quality Commission (CQC) show.
    Over the last two months inspectors have been checking infection control procedures and care standards in up to 600 care homes, many of which were dealing with outbreaks of COVID-19, but the Department of Health and Social Care (DHSC) has yet to provide testing. The CQC said on Friday it was expecting to start testing inspectors “in the coming weeks”.
    Weekly Covid deaths in care homes have been rising. In the week to 20 November, 398 people were notified to the CQC as having died from Covid, up from 138 a month earlier. The death toll remains lower than at the peak of the pandemic, when more than 2,500 people were dying a week in late April.
    The situation has sparked “very real anxieties about contracting the disease” and spreading it between infected homes, the leaked memos reveal. One inspector described work to his managers as like “going into the eye of the storm”.
    Read full story
    Source: The Guardian, 27 November 2020
  9. Patient Safety Learning
    A mother fighting for a public inquiry into the death of her son and more than 20 other patients at an NHS mental health hospital in Essex has won a debate in parliament after more than 100,000 people backed her campaign.
    On Monday, MPs in the House of Commons will debate Melanie Leahy’s petition calling for a public inquiry into the death of her son Matthew in 2012, as well as 24 other patients who died at The Linden Centre, a secure mental health unit in Chelmsford, Essex, since 2000.
    The centre is run by Essex Partnership University NHS Trust which has been heavily criticised by regulators over the case.
    A review by the health service ombudsman found 19 serious failings in his care and the NHS response to his mother’s concerns.
    This included staff changing records after his death to suggest he had a full care plan in place when he didn’t.  
    Matthew was detained under the Mental Health Act but was found hanged in his room seven days later. He had made allegations of being raped at the centre, but this was not taken seriously by staff nor properly investigated by the NHS.
    The trust has admitted Matthew’s care fell below acceptable standards.
    In November, it pleaded guilty to health and safety failings linked to 11 deaths of patients in 11 years.
    Read full story
    Source: The Independent, 29 November 2020 
  10. Patient Safety Learning
    The Care Quality Commission (CQC) has criticised a new trust’s leadership after issuing it with a warning notice to improve care in its two emergency departments.
    The watchdog warned North Cumbria Integrated Care Foundation Trust that patients were not always receiving timely and appropriate care, while delayed transfers of care had “resulted in significant delays in admitting patients on to wards”.
    The CQC — which carried out focused inspections at the trust in August and September after concerns were raised about risks to patient and staff safety — added there was evidence of “insufficient numbers of suitably qualified, skilled, competent and experienced clinical staff”.
    The CQC also said there was a lack of an effective system to mitigate risks, including infection control in the emergency department escalation areas and on some medical wards.
    Of the trust’s Cumberland Infirmary and West Cumberland hospitals, the CQC said: “People could not access the urgent and emergency care and medicine service when they needed them and often had long waits for treatment.”
    The CQC’s inspection report, published today, also said the trust had an “inexperienced leadership team” which “did not always have the necessary skills and abilities to lead effectively”. It added there were “few examples of leaders making a demonstrable impact on the quality or sustainability of services”.
    Read full story (paywalled) 
    Source: HSJ, 30 November 2020
  11. Patient Safety Learning
    The death of a premature baby in 2001 led to a "20-year cover-up" of mistakes by health workers, an independent inquiry has found.
    Elizabeth Dixon, from Hampshire, died due to a blocked breathing tube shortly before her first birthday. The government, which ordered the inquiry in 2017, said the mistakes in her care were "shocking and harrowing".
    The inquiry report by Dr Bill Kirkup said some of those involved had been "persistently dishonest".
    Elizabeth, known as Lizzie, died from asphyxiation after suffering a blockage in her tracheostomy tube while under the care of a private nursing agency at home.
    Dr Bill Kirkup, who was appointed by the government to review the case, said her "profound disability and death could have been avoided".
    He said: "There were failures of care by every organisation that looked after her, none of which was admitted at the time, nor properly investigated then or later."
    "Instead, a cover-up began on the day that she died, propped up by denial and deception."
    Read full story
    Source: BBC News, 26 November 2020
    Patient Safety Learning's statement on the Dixon Inquiry report
  12. Patient Safety Learning
    A network of specialist surgical mesh removal centres is to be set up around England, with a launch planned for April 2021.
    The move implements a recommendation of the review, chaired by the Conservative peer and former health minister Julia Cumberlege, into three treatments which caused avoidable harm. These included the use of transvaginal tape and pelvic mesh to treat pelvic organ prolapse and urinary incontinence.
    The review, which published its report in July, heard “harrowing” stories about women left with serious complications. The mesh is hard to remove and only a few surgeons in the UK are able to carry out the procedure.
    Read full story (paywalled)
    Source: BMJ, 25 November 2020
  13. Patient Safety Learning
    NHS trust chief executives have told HSJ  they need more clarity the Pfizer-BioNTech covid vaccine is safe to reassure their worried staff. 
    Trusts were told last week they need to be ready to start vaccinating their staff from early next month. On Tuesday, it was confirmed that they would initially be asked to use the covid vaccine produced by Pfizer and BioNTech, assuming it is granted a licence by the Medicines and Healthcare products Regulatory Agency.
    Speaking at the HSJ Provider Virtual Summit, St George’s University Hospitals Foundation Trust chief executive Jacqueline Totterdell said there was a lot of “anxiety” around the vaccine among her staff. Leeds Community Healthcare Trust chief Thea Stein added leaders in her city feel “anxious and uncertain”.
    Ms Totterdell said: “As a responsible officer for 9,000 staff, I also need to be clear that the vaccination is safe. That bit of narrative just needs to come out from the centre, about the reasons why they think it is safe.
    “I think there is a lot of anxiety, and some of the polls we’ve done around south west London show that as little as 50 per cent of people are willing just to have it without any of that [assurance]."
    Northumbria Healthcare FT chief executive Sir Jim Mackey, who also spoke at the summit, admitted he was “a bit surprised” by some staff who said they were not going to get the vaccine.
    The former NHS Improvement chief added: “I think when it actually comes to it, and we get the messaging right about it, not just the responsibility for you but also your responsibility for the people you work with… then the vast majority of people will get it and take confidence in the fact that it’s been developed really quickly and effectively.
    “These things don’t get signed off if they’re dangerous, so we need to embrace it as the thing that’s going to get us back to normal.”
    Read full story (paywalled)
    Source: HSJ, 26 November 2020
  14. Patient Safety Learning
    Ministers are to invest millions in making Britain's maternity wards safer, it was announced on Wednesday after The Independent exposed a series of cases in which mothers and babies had suffered avoidable harm during childbirth.
    The new money, almost £10m, was announced as part of the spending review unveiled by Rishi Sunak, the chancellor, in the Commons and will deliver new pilots of what the Treasury called “cutting-edge training” to improve practice during childbirth.
    Significant failings in maternity safety units across the NHS have devastated families and left some babies needing tens of millions of pounds to look after them in later life.
    In November last year, The Independent joined with the charity Baby Lifeline to call for a new fund to be set up after exposing the single largest maternity scandal in NHS history at Shrewsbury and Telford Hospitals Trust, where dozens of babies have died or been left with brain damage.
    The new funding will also cover the final year of the independent investigation into the Shrewsbury trust.
    Read full story
    Source: The Independent, 26 November 2020
  15. Patient Safety Learning
    Emergency care leaders are warning it will take up to six more months to determine whether pilots of a radical change to accident and emergency are working, even though it is due to go live nationally next week, HSJ  has learned.
    HSJ understands the new “111 First” system — where walk-in patients not in medical emergencies call 111 to “book” urgent care — is set to “go live” across England from next week following pilots in acute trusts which have been run since the summer.
    From 1 December, people will be able to call NHS 111 from anywhere in the country and have urgent care “booked” for them if needed, it is understood. NHS England has been pursuing the 111 First model to help reduce overcrowding and the risk of nosocomial infections in A&Es. The service is also intended to be able to book them into GP practice appointments.
    Well-placed sources confirmed most acute trusts have now implemented some form of 111 First and the model is set to be part of their standard operations when the national system “goes live” next week. A national advertising campaign is expected to promote the approach.
    But the Royal College of Emergency Care Medicine said there was a “vocal minority” of clinicians who are “vehemently against” 111 First as they believe it will increase demand in emergency departments.
    Read full story (paywalled)
    Source: HSJ, 25 November 2020
  16. Patient Safety Learning
    While both ME and long Covid, or post-Covid syndrome, are long-term illnesses, they aren’t the same thing. But, there are ways in which our knowledge of ME has helped experts treat long Covid. It’s also helped those with the illness understand what they’re going through. Evan was diagnosed with ME in 2017, and she believes her experience can help her support those living with long Covid.
    Watch video
    Source: BBC News, 26 November 2020
  17. Patient Safety Learning
    NHS Test and Trace chief Baroness Dido Harding will be interviewed by HSJ editor Alastair McLellan at 9am tomorrow  as part of HSJ’s virtual provider summit.
    HSJ’s subscribers working in the NHS or a non-profit organisation can register to attend the summit here.
    Other speakers will include new Health Education England chief executive Navina Evans and King’s Fund chief executive Richard Murray. The subjects due to be covered include how the NHS will tackle the drive to recover routine care, the service’s workforce challenges and how forthcoming legislation may impact the governance of the service.
    Full details of the programme can be seen here.
  18. Patient Safety Learning
    Across Britain, intensive care nurses and doctors are being pushed to their limits as they try to save lives from coronavirus. During 12-hour shifts in sweltering conditions, they are faced with technical and emotional challenges that many have never faced as they tackle a virus that has swept across the globe in a matter of days, threatening to kill tens of thousands in the UK.
    Britain has yet to even hit the peak of infections, but intensive care specialists are already asking how long they can keep working relentlessly.
    “We are trained for and used to dealing with difficult and emotional scenarios, but this is like a major incident that never ends,” says critical care nurse Karin Gerber.
    As an advanced nurse practitioner in critical care outreach, the 47-year-old sees patients in hospital who are getting sicker and may need to be admitted to intensive care. She says she has never seen anything “at this intensity”.
    The Royal London Hospital is at the forefront of the capital’s fight against the virus and has created more than 200 extra beds at its Whitechapel site in east London. They are filled with COVID-19 patients.
    Simon Richards, senior charge nurse at the Royal London’s critical care unit, tells The Independent: “In 20 years as a nurse this situation is by far the worst I have ever seen and totally unexpected, but the team spirit that people have shown has been amazing.
    “It’s extremely difficult, we are working so hard. The whole team is being pushed to their limit and you do wonder how long can this be sustained for? I wish we could see light at the end of the tunnel.”
    Read full story
    Source: The Independent, 24 November 2020
     
  19. Patient Safety Learning
    Hospital trusts have been put on notice that the challenging storage requirements of the first covid vaccines are likely to mean the vaccination of their staff will have to form the vanguard of the planned roll-out next month due.
    HSJ reported last week that healthcare staff would share priority with “care home residents and staff” in the vaccine roll-out. 
    However, a letter sent to trust chief executives by NHS England seeks to clarify the situation by stressing that “different vaccines are likely to be better suited to different settings because the vaccines are likely to have different storage, reconstitution and administration requirements”. 
    “Given what we currently know about the first expected vaccine, the imperative is that NHS trusts are ready to start vaccinating from the beginning of December.” 
    Trusts are one of several components of the vaccination programme that includes primary care-run sites, mass vaccination centres, and “roving” visits to those who need them. Local systems and regional teams will decide “the most appropriate combination of models required to deliver the vaccine to their local populations based on local needs” the letter says. However, during the early stages of the roll-out this is likely to be dictated by the vaccine types that become available.
    Read full story (paywalled)
    Source: HSJ, 25 November 2020
  20. Patient Safety Learning
    Former health secretary and chair of the Commons health committee Jeremy Hunt has criticised Great Ormond Street Hospital after it was accused of covering up errors that may have led to the death of a toddler.
    Writing for The Independent, Mr Hunt, who has set up a patient safety charity since leaving government, said it was “depressing” to see how the hospital had responded to the case of Jasmine Hughes, which has now been taken to the Parliamentary Health Service Ombudsman for a new investigation.
    Mr Hunt said the hospital had chosen to issue a “classic non-apology apology of which any politician would be proud” and added he was left angry over the hospital’s “ridiculous decision” to stop talking to Jasmine’s family and the refusal to apologise for what went wrong.
    The MP for South West Surrey said the case was symbolic of a wider problem in the health service of a blame culture that prevents openness and transparency around mistakes.
    Read full story
    Source: The Independent, 24 November 2020
  21. Patient Safety Learning
    Matt Hancock has called for British people to routinely get tested for the flu, saying covid diagnostic capacity should be kept and used for “everything” once the pandemic dies down.
    Speaking at the Commons health and social care committee this morning, the health and social care secretary said the nation “must hold on to” the mass diagnostic capacity it has created for coronavirus.
    Going further, he called for a change in culture to one of “if in doubt, you get a test”, and for a long-term expansion of diagnostics.
    Mr Hancock said: “Why in Britain do we think it’s acceptable to solider on when you have flu symptoms or a runny nose, and go in [to work] and make everyone ill?
    “If you have flu-like symptoms you should have a test for it and find out what is wrong with you and stay at home. We are peculiar outliers in soldiering on and going to work and that… culture, that should change.”
    Read full story (paywalled)
    Source: HSJ, 24 November 2020
  22. Patient Safety Learning
    The NHS’ current plan for the covid vaccine rollout — dependent on the arrival of supplies — would see the whole adult population able to begin receiving it before the end of January, according to leaked documents seen by HSJ.
    Under the plan, everyone who wants to would have been vaccinated by early April.
    NHS England’s draft COVID-19 vaccine deployment programme, seen by HSJ,  reveals when each cohort is likely to begin receiving it, based on its plans to create huge capacity across GP-run facilities, “large scale mass vaccination sites”, NHS trusts, and “roving models” for those who cannot travel.
    It relies on a range of assumptions including that there will be 75% takeup, outside of residential settings like care homes and prisons, where 100% is expected.
    The plan also relies on supplies, including more than 7 million doses being available in December. It is not clear what impact a delay to this would have on the rollout. With most doses due to be administered between early January and  mid March — at a rate of 4-5 million every week — a small delay may not make a huge impact to the overall schedule.
    The document is dated 13 November and was shared among some senior NHS regional leaders yesterday.
    Read full story (paywalled)
    Source: HSJ, 23 November 2020
  23. Patient Safety Learning
    A care agency which left people "at risk of avoidable harm" by not ensuring staff had been properly trained has been put into special measures.
    Stars Social Support, which provides personal care to people living in their own home, was inspected by the Care Quality Commission earlier this year.
    Inspectors found safe recruitment procedures were not in place to make sure suitable staff were employed.
    A report following the inspection states that "safe recruitment procedures were not in place to ensure only staff suitable to work in the caring profession were employed."
    It said people's references had not been followed up after they had been requested, according to the Local Democracy Reporting Service. The report added: "When the disclosure and barring service (DBS) identified concerns, a risk assessment had not been completed to assess staff suitability."
    Inspectors also found not all staff who provided care had received appropriate training or training updates to ensure they were competent.
    Read full story
    Source: BBC News, 21 November 2020
  24. Patient Safety Learning
    Coronavirus antibodies last at least six months and offer protection against a second infection, a study of healthcare workers suggests.
    Staff at Oxford University Hospitals were regularly tested both for COVID-19 infections and for antibodies revealing a past infection.
    The more antibodies people had, the lower their chances of re-infection.
    A separate study found pre-existing immunity from other coronaviruses also protected against Covid.
    Infection consultant Dr Katie Jeffery described the Oxford findings as "encouraging news" ahead of forthcoming Covid vaccines.
    They indicated that having the virus once "provides at least short-term protection" from getting it again, she said.
    Read full story
    Source: BBC News, 21 November 2020
  25. Patient Safety Learning
    More than a million patient operations could be delayed because of widespread shortages of anaesthetists in the NHS – with 9 out of every 10 hospitals reporting at least one vacancy.
    As coronavirus paralysed the NHS earlier this year, more than 140,000 NHS patients have already waited over a year for treatment. 
    The Health Foundation has warned that 4.7 million fewer patients have been referred for treatment because of the impact of coronavirus on NHS services.
    The Royal College of Anaesthetists (RCOA) told The Independent the scale of the vacancies was getting worse and labelled it a “workforce disaster” that could cost patients’ lives and have a widespread impact on hospital services.
    Read full story
    Source: The Independent, 22 November 2020
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