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Patient Safety Learning

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  1. Patient Safety Learning
    Care homes have been ordered to destroy a batch of faulty COVID-19 test kits after it was discovered that the swabs could break off while being used to gather samples from residents’ tonsils and noses.
    Care home managers were told on Sunday not to use the tests because they had “brittle stems at risk of snapping”. The kits were manufactured by Citotest, a company based in China, and were distributed by the government’s COVID-19 care home testing programme. It is tasked with providing tests for all staff and residents in care settings, not just people displaying symptoms.
    The affected batch should be destroyed or kept in a safe area clearly marked with warnings not to use them, officials said, adding that the problem emerged on Saturday and they were working as quickly as possible to resolve it.
    The Department of Health and Social Care (DHSC) said the batch could have contained tens of thousands of tests and that a complaint had been raised with the manufacturer, with whom discussions were ongoing.
    “We are aware of an issue with one batch of swab sticks which are being replaced where needed but this does not affect any tests, or the results of tests, previously taken,” a DHSC spokesperson said. “Testing is unaffected and people should still arrive for their booked tests.”
    Read full story
    Source: The Guardian, 15 June 2020
  2. Patient Safety Learning
    Demand for oxygen from COVID-19 patients recovering at home is set to place the NHS under strain, the health service has warned.
    NHS England has issued guidance to out-of-hospital health providers on the extra demands likely to be placed on them given the number of people recovering after a hospital stay with the coronavirus. It warns that the provision from its home oxygen services and community respiratory teams across the NHS is expected to be an issue as the scale of demand increases.
    Andrew Whittamore, a practising GP and clinical lead for the Asthma UK and British Lung Foundation partnership, said concerns about the potential for hospitals to be overwhelmed in the early part of the pandemic had led to community oxygen teams being primed to take on more patients – but he described that ramping up as “a short-term fix”.
    “We don’t know how long people are going to need oxygen or other services for,” he said. “There are definitely going to be extra patients added on to our community teams’ workloads.”
    The Taskforce for Lung Health – of which the British Lung Foundation is a member – has raised particular concerns about access to pulmonary rehabilitation. An education- and exercise-based treatment, which is proven to be more effective for lung patients than many drug-based treatments, and face-to-face classes have been suspended during the pandemic. It may be that such treatment would also be helpful for some patients recovering from COVID-19.
    Jackie Eagleton, policy officer at the British Lung Foundation, said there had been issues with access to pulmonary rehabilitation for a long time, but the need to offer this form of support to people with lung conditions “has never been more pressing than it is now”.
    Read full story
    Source: The Independent, 16 June 2020
  3. Patient Safety Learning
    The architects behind the new NHS Race and Health Observatory have vowed that it will deliver actionable recommendations within months to tackle the structural racism that exists throughout healthcare.
    Victor Adebowale and Mala Rao called for an observatory to tackle the ethnic health inequalities in the UK in a special issue of The BMJ that they co-edited in February (bmj.com/racism-in-medicine) and NHS England confirmed at the end of the May that the centre would go ahead.
    Speaking at a meeting to discuss the aims of the observatory on 12 June, Adebowlae told more than 20 assembled stakeholders that he wanted the new centre “to fire on all cylinders,” making recommendations for changes to services that are likely to affect the health outcomes of people from black and ethnic minority backgrounds “within a couple of months.”
    Read full story
    Source: BMJ, 15 June 2020
  4. Patient Safety Learning
    When Dan Scoble came down with the coronavirus in March, all the classic symptoms landed in one fell swoop. “I had everything under the sun: a fever, temperature, fatigue and chest pain,” he said. “My head felt like a balloon.”
    The 22-year-old, a personal trainer from Oxford who normally breezed through 10-mile runs, suddenly found himself bed-bound. He presumed it would soon blow over, but 12 weeks after falling ill as the country went into lockdown, he is still not back to normal.
    Dan has left his house just five times in three months — twice to see his GP and three times to hospital. He still suffers from crippling fatigue, recurrent migraines and a persistent sore throat, as well as abdominal and musculoskeletal pain.
    Read full story (paywalled)
    Source: The Times, 14 June 2020
  5. Patient Safety Learning
    Unlawful 'do not resuscitate' orders are being placed on patients with a learning disability during the coronavirus pandemic without families being consulted.
    National charities have successfully challenged more than a dozen unlawful do not resuscitate orders (DNRs) that were put in place because of the patient’s disability rather than due to any serious underlying health risk.
    Turning Point said it had learned of 19 inappropriate DNRs from families while Learning Disability England said almost one-fifth of its members had reported DNRs placed in people’s medical records without consultation during March and April.
    In one example, a man in his fifties with sight loss was admitted to hospital after a choking episode and was incorrectly diagnosed with coronavirus. He was discharged the next day with a DNR form giving the reason as his “blindness and severe learning disabilities”.
    Marie-Anne Peters, whose brother Alistair has epilepsy but no other health conditions, overturned a DNR on her brother which included instructions for him not to be taken to hospital.
    Both charities fear other people with learning disabilities who are vulnerable could be wrongly denied life-saving treatment. They have now launched a new checklist for families and care workers to challenge illegal DNRs.
    Read full story
    Source: The Independent, 13 June 2020
  6. Patient Safety Learning
    Dozens of hospitals are running short of scrubs in the latest problem to hit the NHS over the supply of personal protective equipment (PPE) during the coronavirus pandemic.
    The shortages are revealed in a survey of UK doctors undertaken by the Doctors’ Association UK (DAUK), which found that 61% said that the hospital where they worked was facing a shortage of scrubs.
    In recent months, many more NHS staff have begun wearing scrubs, which are usually used mainly by surgical staff, to protect themselves against COVID-19. The prevalence of coronavirus in hospitals has prompted many to switch from wearing their own clothes at work to using scrubs, and handing them in to be washed at the end of their shift. However, the big increase in demand for scrubs from doctors, nurses, physiotherapists and occupational therapists has left many hospitals unable to keep up and also put unprecedented pressure on hospital cleaning services.
    Some staff have even worn pyjamas intended for patients when scrubs have run out.
    “Protective clothing must be considered to be at a par with other PPE by Public Health England and must be provided to staff by the NHS," said said Dr Samantha Batt-Rawden, the president of the DAUK.
    She added: “A failure to adequately supply scrubs to staff may risk further community spread of Covid-19.”
    Read full story
    Source: The Guardian, 15 June 2020
  7. Patient Safety Learning
    Ambulance services have been urged to look at how suspected overdose and poisoning cases are prioritised after paramedics took 45 minutes to reach a woman with known mental health problems.
    Helen Sheath, 33, had been discharged from a mental health unit in early July last year and was still waiting for an outpatient appointment with a psychological assessment and treatment service when she took a fatal dose of sodium nitrate on 20 August.
    Her father called an ambulance at 6.20pm when she had locked herself in a bathroom and was threatening to take the sodium nitrate. But Bedfordshire and Luton senior coroner Emma Whitting said her father could not tell whether or not she had taken it, and that in view of her history of suicidal ideation, the call should have been treated as a category two – with an 18 minutes response target – rather than a category three incident.
    The first ambulance which was sent to her was diverted on route and it was only after a second call to the East of England Ambulance Service at 6.48pm, that the call was upgraded to category two – when the call handler selected a different set of questions, after being told she had ingested the chemical. A rapid response vehicle arrived at 7.05pm and the mental health street triage team attended six minutes later. Shortly afterwards she became acutely unwell and was taken to Bedford Hospital, where she received treatment but died shortly afterwards.
    In a prevention of future deaths report Ms Whitting said: “If the first call had been coded as a category two, it seems likely that the rapid response vehicle, mental health street triage team (and even possibly the double staffed ambulance) would have arrived on scene much earlier (potentially just before or just after Helen had ingested the sodium nitrate) which could potentially have altered the outcome.” 
    The case comes just months after two other ambulance trusts were criticised in cases involving suspected or threatened overdoses.
    The prevention of future deaths report was sent to the Association of Ambulance Chief Executives and the emergency call prioritisation advisory group, which is run by NHS England. Neither would comment other than saying they would respond to the coroner.
    Read full story
    Source: HSJ, 15 June 2020
  8. Patient Safety Learning
    A leading doctor has warned that trusts will struggle to get back to anything like pre-covid levels of endoscopy services and will need to prioritise which patients are diagnosed.
    Endoscopy procedures are part of the diagnostic and treatment pathway for many conditions, including bowel cancer and stomach ulcers. Most hospitals have not done any non-emergency procedures since the middle of March because they are aerosol generating — meaning a greater covid infection risk and need for major protective equipment.
    Although some areas are now starting to do more urgent and routine work, capacity is severely limited.
    Kevin Monahan, a consultant gastroenterologist at St Marks’s Hospital, part of London North West Healthcare Trust, and a member of the medical advisory board for Bowel Cancer UK, said the time taken for droplets to settle in rooms after a procedure can be up to an hour and three quarters, depending on how areas are ventilated. Only then can the room be cleaned and another patient seen.
    Dr Monahan said his trust had restarted some endoscopy work and was currently doing around 17 per cent of its pre-covid activity. “We can provide a maximum of about 20 per cent of normal activity — and that is using private facilities for NHS patients,” he said. “I am not at all confident we will be able to double what we are doing now, even in three to four months’ time."
    Read full story
    Source: HSJ, 12 June 2020
  9. Patient Safety Learning
    Young people with learning disabilities are being driven to self-harm after being prevented from seeing their families during the coronavirus lockdown in breach of their human rights, a new report finds.
    The Joint Committee on Human Rights warned that the situation for children and young people in mental health hospitals had reached the point of “severe crisis” during the pandemic due to unlawful blanket bans on visits, the suspension of routine inspections and the increased use of restraint and solitary confinement.
    The report concluded that while young inpatients' human rights were already being breached before the pandemic, the coronavirus lockdown has put them at greater risk – and called on the NHS to instruct mental health hospitals to resume visits.
    It highlighted cases in which young people had been driven to self-harm, including Eddie, a young man with a learning disability whose mother, Adele Green, had not been able to visit him since 14 March.
    “When the lockdown came, it was quite quick in the sense that the hospital placed a blanket ban on anybody going in and anybody going out,” said Ms Green. “Within a week, with the fear and anxiety, he tried to take his own life, which really blew us away. We were mortified.”
    The Committee is urging NHS England to write to all hospitals, including private ones, stating they must allow visits unless there is a specific reason relating to an individual case why it would not be safe, and said the Care Quality Commission (CQC) should be responsible for ensuring national guidance is followed.
    Read full story
    Source: The Independent, 12 June 2020
  10. Patient Safety Learning
    Huge numbers of people with suspected cancer were not referred to hospital for urgent checks or did not have a test during the first month of the lockdown, prompting fears that late diagnosis of the disease will reduce some patients’ chances of survival.
    Unprecedented numbers of cancer patients missed out on vital treatments, diagnostic tests and outpatient appointments as the pandemic unfolded, NHS England data shows.
    Macmillan Cancer Support estimates that 210,000 people should have entered the system this month. That means roughly 130,000 people who would ordinarily be referred to a consultant have not been. About 7% of these patients would usually require cancer treatment, meaning approximately 9,000 people might not have had their cancer diagnosed in April. 
    The organisation said that around 2,500 people who should have been referred for their first treatment after a cancer diagnosis will not have received that treatment.
    Read full story
    Source: The Guardian, 11 June 2020
  11. Patient Safety Learning
    Relatives of 450 people who have died in the coronavirus pandemic are demanding an immediate public inquiry. The families want an urgent review of "life and death" steps needed to minimise the continuing effects of the virus and a guarantee that documents relating to the crisis will be kept.
    A full inquiry would take place later, says lawyer, Elkan Abrahamson, who is representing the families.
    The government has said its current focus is on dealing with the pandemic.
    But the COVID-19 Bereaved Families for Justice UK group say immediate lessons need to be learned to prevent more deaths, and that waiting for ministers to launch an inquiry will cost lives.
    The call for an inquiry comes as a report from the National Audit Office - assessing the readiness of the NHS and social care in England for the pandemic - has shown it is not known how many of the 25,000 people discharged from hospitals into care homes at the peak of the outbreak were infected with coronavirus.
    Health and Social Care Select Committee chairman Jeremy Hunt said it seemed "extraordinary that no one appeared to consider" the risk.
    The Department of Health says it took the "right decisions at the right time".
    Read full story
    Source: BBC News, 12 June 2020
  12. Patient Safety Learning
    Thousands of people lost their lives “prematurely” because care homes in England lacked the protective equipment and financial resources to cope with the coronavirus outbreak, according to council care bosses.
    In a highly critical report, social care directors say decisions to rapidly discharge many vulnerable patients from NHS hospitals to care homes without first testing them for COVID-19 had “tragic consequences” for residents and staff.
    In many places, vulnerable people were discharged into care facilities where there was a shortage of personal protective equipment (PPE) or where it was impossible to isolate them safely, sometimes when they could have returned home, the report says.
    “Ultimately, thousands have lost their lives prematurely in social care and were not sufficiently considered as part of wider health and community systems. And normality has not yet returned,” James Bullion, the president of the Association of Directors of Adult Social Services (Adass), said in a foreword to the report.
    Read full story
    Source: The Guardian, 11 June 2020
  13. Patient Safety Learning
    A poll of members by the Medical Protection Society (MPS) found that 43% of doctors fear investigation if patients come to harm because of delays to referrals and reduced NHS services during the pandemic.
    Treatment has been delayed for millions of patients while the NHS has focused on managing the pandemic - with GPs in many areas still unable to refer as normal and even urgent referrals delayed while the UK has been in lockdown. The NHS Confederation has warned that 10 million people could be on NHS waiting lists by Christmas.
    Reduced NHS services during the pandemic have left even patients who need urgent treatment or scans for cancer waiting longer. GPonline reported in April that patients had been waiting more than a month for urgent cancer checks - and Cancer Research UK warned in May that 2.4 million patients were waiting longer for scans or treatment because of disruption to services during the pandemic.
    Read full story
    Source: GPonline, 11 June 2020
  14. Patient Safety Learning
    Inspectors have placed a women’s mental health service into special measures after patients were said to have been subjected to “inappropriate” and “derogatory” treatment by staff.
    St Andrew’s Healthcare, which runs the women’s inpatient facility in Northampton, has received a series of damning reports among its services over the past two years.
    The inspectors noted during visits between February and March that staff reportedly used language to describe patients on a medium secure ward such as “self-harmers”, “attention seeking”, and “kicking off”.
    Patients said staff used “inappropriate restraint techniques that caused pain” with reports they “bent the patient’s wrist and arm behind their back.”
    They also said staff spoke to them in a “derogatory manner, for example telling them to sort themselves out when engaging in self harm behaviour.”
    Inspectors rated the service “inadequate” overall, noting concerns elsewhere including “forensic failure incidents due to staff shortages”, that staff were not reporting all safeguarding concerns and that “managers did not ensure safe and clean environments in the long stay rehabilitation service and learning disability service.”
    Read full story
    Source: HSJ, 10 June 2020
  15. Patient Safety Learning
    Babylon Health is investigating whether NHS patients were among those affected by a 'software error' that allowed people registered with its private GP service to view recordings of other people's consultations earlier this month.
    Babylon Health has confirmed that a small number of patients were able to view recordings of other patients' consultations earlier this week. The issue came to light after a patient in Leeds who had access to the Babylon app through a private health insurance plan with Bupa reported that he had been able to view around 50 consultations that were not his own.
    The patient told the BBC he was 'shocked' to discover the data breach. "You don't expect to see anything like that when you're using a trusted app," he said. "It's shocking to see such a monumental error has been made."
    Babylon told GPonline that the app used by private and NHS patients is the same, but it had yet to confirm whether the roughly 80,000 patients registered with the company's digital first NHS service GP at Hand were among those affected.
    The problem is understood to have cropped up when a new feature was introduced for patients who switched from audio to video mid-way through a consultation.
    Read full story
    Source: GPOnline, 10 June 2020
  16. Patient Safety Learning
    More than 60% of new covid cases diagnosed at two hospitals in the Midlands in recent days were caught at least two weeks after the patient was admitted — suggesting there may be particular problems with the virus spreading on their wards.
    Northamptonshire is also still grappling with larger numbers of covid cases in hospital, in contrast to most of England. Its NHS organisations have said they do not know the cause of its ongoing problems.
    But the large share of cases diagnosed among patients who have been in hospital for at least 15 days – classed by NHS England as definitely “healthcare associated” – indicate that problems controlling the spread within the hospitals may be playing a significant part, rather than the outbreaks in the community.
    There has been major national concern about in-hospital spread of the virus in recent weeks, with the government introducing new mandatory controls on Friday.
    Read full story
    Source: HSJ, 11 June 2020
  17. Patient Safety Learning
    The aftercare of COVID-19 patients will have significant financial implications for ‘understaffed’ community services, NHS England has been warned.
    This month the national commissioner released guidance for the care of patients once they have recovered from an immediate covid infection and been discharged from hospital.
    It said community health services will need to provide “ongoing health support that rehabilitates [covid patients] both physically and mentally”. The document said this would result in increased demand for home oxygen services, pulmonary rehabilitation, diagnostics and for many therapies such as speech and language, occupational, physio, dieticians and mental health support.
    One GP heavily involved in community rehab told HSJ: “There is a lot detailed information about what people might experience in recovery, but it doesn’t say what should actually happen.
    “We have seen people discharged from hospital that don’t know anything about their follow-up and the community [health sector] hasn’t got any instructions of what they should be doing or what services have even reopened. This guidance needs to go a step further and rapidly say what is expected so local commissioners can put that in place.”
    Read full story
    Source: HSJ, 10 June 2020
  18. Patient Safety Learning
    Northern Ireland faces a massive challenge rebuilding health and social care in the wake of the first COVID-19 wave, Health Minister Robin Swann has said.
    Speaking at the Northern Ireland Assembly on Tuesday, Mr Swann said that the rebuilding process can secure better ways of delivering services but will require innovation, sustained investment and society-wide support.
    He said that services will not be able to resume as before and that rebuilding will be significantly constrained by the continuing threat from COVID-19 and the need to protect the public and staff from the virus.
    “Our health and social care system was in very serious difficulties long before Coronavirus reached these shores. The virus has taken the situation to a whole new level. The Health and Social Care system has had its own lockdown – services were scaled back substantially to keep people safe and to focus resources on caring for those with COVID-19."
    The Health Minister said that despite the pressures, there are opportunities to make improvements.
    “I have seen so many examples of excellence, innovation and commitment as our health and social care staff rose to the challenges created by COVID-19. Decisions were taken at pace, services were re-configured, mountains were moved. Staff have worked across traditional boundaries time and time again. I cannot thank them enough. We must build on that spirit in the months and years ahead. Innovations like telephone triage and video consultations will be embedded in primary and secondary care.”
    Mr Swann added that the health system can't go back to the way it was and that it must be improved.
    Read full story
    Source: Belfast Telegraph, 9 June 2020
  19. Patient Safety Learning
    As the death toll from the virus soars above 40,000, slowly the horrendous toll on non-Covid patients is emerging.
    These are patients who are not afflicted by coronavirus, but who have had their treatment or diagnosis for other potentially deadly conditions postponed or cancelled, as hospitals scrambled to make way for an overwhelming burden of COVID-19 patients.
    Sherwin Hall, a 27-year-old from Leeds, had tried 13 times in one month during the lockdown to get a proper diagnosis for the crippling pain in his groin. He was initially told it might be a sexually transmitted disease. Eventually he was given the all clear of any STD after multiple blood tests and begged for an MRI scan. But he claims he was told no scans would be available because of the COVID-19 emergency.
    Finally he got a scan which confirmed a 14 cm tumour near his pelvis. He clams his consultant confirmed the delay in diagnosis and therefore cancer treatment may have serious consequences on his chances of survival.
    He told ITV news "I am very angry at the way I have been treated due to COVID-19 and the delay on my cancer treatment and now I am fighting for my life."
    His lawyer, Mary Smith, who specialises in medical negligence at Novum Law in Bristol, says she is worried there will be a spike in cases involving delayed diagnosis or treatment coming across her desk.
    She wants an urgent overhaul of the management of this crisis, now its peak appears to have passed. 
    Read full story
    Source: ITV News, 9 June 2020
  20. Patient Safety Learning
    Ministers are facing a high court legal challenge after they refused to order an urgent investigation into the shortages of personal protective equipment faced by NHS staff during the coronavirus pandemic.
    Doctors, lawyers and campaigners for older people’s welfare issued proceedings on Monday which they hope will lead to a judicial review of the government’s efforts to ensure that health professionals and social care staff had enough personal protective equipment (PPE) to keep them safe.
    They want to compel ministers to hold an independent inquiry into PPE and ensure staff in settings looking after Covid-19 patients will be able to obtain the gowns, masks, eye protection and gloves they need if, as many doctors fear, there is a second wave of the disease.
    About 300 UK health workers have so far died of COVID-19, and many NHS staff groups and families claim inadequate PPE played a key role in exposing them.
    Read full story
    Source: The Guardian, 8 June 2020
  21. Patient Safety Learning
    Almost three quarters of GP partners are concerned about how to keep colleagues safe as numbers of patients attending practices return to pre-pandemic levels - with access to PPE a major worry, a GPonline poll has found.
    Half of the 185 GP partners responding to the poll said that they were either 'very worried' or 'slightly worried' about the government's ability to supply the PPE that GPs and practice staff needed to keep them as safe as possible through the rest of the pandemic.
    Only 9% said they were 'very confident' that the government would be able to supply adequate PPE, with a further 20% saying they were 'slightly confident'.
    Some 73% of GP partners said that they were concerned about how to ensure the safety of practice staff as the number of patients attending the surgery begins to rise.
    BMA GP committee chair Dr Richard Vautrey said keeping staff safe was 'a challenge for everyone in the NHS'.
    He told GPonline: 'Even months now into this crisis the government still hasn’t sorted out PPE in a way that means people have absolute confidence that they will have enough to meet their needs, and the growing needs of practices as they will need to be seeing more patients face-to-face for important procedures that can’t be done remotely.
    Read full story
    Source: GPonline, 8 June 2020
  22. Patient Safety Learning
    Senior doctors repeatedly raised concerns over safety and staffing problems at a mental health trust before a cluster of 12 deaths, an HSJ investigation has found.
    The deaths all happened over the course of a year, starting in June 2018, involving patients under the care of the crisis home treatment services at Birmingham and Solihull Mental Health Trust. The causes of the deaths included suicides, drug overdoses, and hanging.
    Coroners found several common failings surrounding the deaths and have previously warned of a lack of resources for mental health services in the city.
    HSJ has now seen internal documents which reveal senior clinicians had raised repeated internal concerns about the trust’s crisis home treatment teams during 2017 and early 2018. The clinicians warned of inadequate staffing levels, long waiting lists, and a lack of inpatient bed capacity.
    In the minutes of one meeting in February 2018, just two months before the first of the 12 deaths, a consultant is recorded as saying he had “grave concerns over safety in [the home treatment teams]”.
    Read full story
    Source: HSJ, 9 June 2020
  24. Patient Safety Learning
    NHS trusts were not consulted before the government announced changes to the use of face coverings and visitor policy in English hospitals, the chief executive of NHS Providers has said.
    Chris Hopson said trust leaders felt "completely in the dark" about the "significant and complex" changes.
    From 15 June, hospital visitors and outpatients must wear face coverings and staff must use surgical masks.
    A spokeswoman said that, while the public were "strongly urged" to wear a face covering while inside hospitals, no-one would be denied care.
    Separately, NHS England has lifted the national suspension on hospital visiting with new guidance for NHS trusts.
    Read full story
    Source: BBC News, 6 June 2020
     
     
  25. Patient Safety Learning
    Care home residents are on course to make up more than half the deaths caused directly or indirectly by the coronavirus crisis in England, according to a new analysis.
    The study warns that the death toll by the end of June from OVID-19 infections and other excess deaths is “likely to approach 59,000 across the entire English population, of which about 34,000 (57%) will have been care home residents”.
    The estimate, produced by the major healthcare business consultancy LaingBuisson, includes people who list a care home as their primary residence, wherever they died – including those who died in hospital.
    It is based on data from the Office for National Statistics, as well as the analyst’s own modelling of the number of care home resident deaths likely to have occurred in the absence of the pandemic.
    The new study coincides with mounting concerns over the failure to protect care homes earlier in the pandemic. Senior care industry figures point to the decision to move some hospital patients back to care homes in mid-March. There have also been complaints that non-Covid-related healthcare became less accessible to homes during the height of the pandemic, leading to extra deaths.
    Read full story
    Source: The Guardian, 7 June 2020
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