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Patient Safety Learning

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News posted by Patient Safety Learning

  1. Patient Safety Learning
    The Urological Society of Australia and New Zealand (USANZ) supports recommendations in the Hearing and Responding to Stories of Survivors of Surgical Mesh report released by the New Zealand Ministry of Health in response to complications resulting from the use of surgical mesh in a range of operations, including for stress incontinence and pelvic organ prolapse.

    The Ministry of Health commissioned the review, in which New Zealand urologists participated alongside a wide range of consumer and other health groups, to provide a plan “to minimize future risk to consumers and support those harmed by it”.

    “The Urological Society acknowledges that complications from the use of mesh for treating stress urinary incontinence and pelvic organ prolapse has caused considerable physical and psychological harm in some patients, which we feel is unacceptable, said USANZ President, Dr Stephen Mark. "We also acknowledge and accept findings that there were deficiencies in technical and communication skills of some surgeons. We recognise the distress caused to these patients and want to be part of the solution in helping these people, as well as ensuring no patients are harmed in future."
    “Further research is necessary to achieve best practice outcomes and help us understand why, when, and in which patient complications may occur. For this reason, USANZ supports participation with Australia in a mesh registry. By collaborating with Australian researchers, we can be part of a substantial database that would underpin ongoing research in the interests of patient safety."
    Read full story
    Source: New Zealand Doctor, 13 January 2020
  2. Patient Safety Learning
    The NHS 111 helpline for urgent medical care is facing calls for an investigation after poor decision-making was linked to more than 20 deaths.
    Experts say that inexperienced call handlers and the software used to highlight life-threatening emergencies may not always be safe for young children. At least five have died in potentially avoidable incidents.
    Professor Carrie MacEwen, Chairwoman of the Academy of Medical Royal Colleges, said: “These distressing reports suggest that existing processes did not safeguard the needs of the children in these instances.”
    Since 2014 coroners have written 15 reports involving NHS 111 to try to prevent further deaths. There have been five other cases where inquests heard of missed chances to save lives by NHS 111 staff; two other cases are continuing and one was subject to an NHS England investigation.
    Read full story (paywalled)
    Source: The Times, 5 January 2020
  3. Patient Safety Learning
    A coroner has criticised an ambulance trust after it took nearly four hours to reach a woman who had taken an overdose. 
    Taking the unusual step of publishing a prevention of future deaths report before an inquest had concluded, coroner for Gateshead and South Tyneside Terence Carney said “the real and imminent danger of [the deceased Maureen Wharton’s] admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way”.
    Ms Wharton called North East Ambulance Service Trust to say she was dying of cancer and had taken prescribed drugs, including an opioid-based medication and sleeping pills. She threatened to take more and later called back, appearing drowsier.
    North East Ambulance Service graded the 61-year-old’s call as “category three”, which meant she should have received a response within two hours. It took three hours and 45 minutes for the ambulance service to access her flat, by which time she was already dead. 
    Mr Carney pointed out no attempts had been made to identify family or other support for her, or to contact other agencies which could have responded. The inquest into her death is expected to conclude later this year. 
    In a statement, NEAS said it has already made changes to safeguard patients in mental health cases, including implementing greater oversight in its control rooms, improving call transfers to crisis teams, mapping available local mental health services, introducing more staff training, and telling patients in a crisis but not at risk of physical harm about other, more appropriate, services. 
    Read full story (paywalled)
    Source: HSJ, 14 January 2020
  4. Patient Safety Learning
    The Care Quality Commission (CQC) has raised concerns about the treatment of patients at mental health units run by Cygnet. It follows inspections in the wake of a BBC Panorama investigation about alleged abuse at Wharlton Hall in County Durham.
    The CQC found that patients under the firm's care were more likely to be restrained. Higher rates of self-harm were also noted by inspectors who quizzed managers and analysed records at the company's headquarters.
    The regulator also found a lack of clear lines of accountability between the executive team and its services. It said directors' identity and disclosure and barring service checks had been carried out, butd that required checks had not been made to ensure that directors and board members met the "fit and proper" person test for their roles.
    Systems used to manage risk were also criticised, while training for intermediate life support was not provided to all relevant staff across services where physical intervention or rapid tranquilisation was used.
    Cygnet runs more than 100 services for vulnerable adults and children, caring for people with mental health problems, learning disabilities and eating disorders.
    The CQC says Cygnet must now take immediate action to address the concerns raised.
    Cygnet said a number of the services highlighted have since been improved, but "we are not complacent and take on board recommendations where we must improve".
    Read full story
    Source: BBC News, 14 January 2020
  5. Patient Safety Learning
    The NHS is spending millions of pounds encouraging patients to give feedback but the information gained is not being used effectively to improve services, experts have warned.  
    Widespread collection of patient comments is often “disjointed and standalone” from efforts to improve the quality of care, according to a study by the National Institute for Health Research (NIHR).
    Nine separate studies of how hospitals collect and use feedback were analysed. They showed that while thousands of patients give hospitals their comments, their reports are often reduced to simple numbers – and in many cases, the NHS lacks the ability to analyse and act on the results.
    The research found the NHS had a “managerial focus on bad experiences” meaning positive comments on what went well were “overlooked”.
    The NIHR report said: “A lot of resource and energy goes into collecting feedback data but less into analysing it in ways that can lead to change, or into sharing the feedback with staff who see patients on a day-to-day basis.
    NHS England's chief nurse, Ruth May, said: "Listening to patient experience is key to understanding our NHS and there is more that that we can hear to improve it. This research gives insight into how data can be analysed and used by frontline staff to make changes that patients tell us are needed."
    Read full story
    Source: 13 January 2020
  6. Patient Safety Learning
    The US Food and Drug Administration (FDA) needs to do more to quickly and substantially reform its system for reporting adverse events caused by medical devices, two researchers wrote in an Editorial published in JAMA Internal Medicine.
    The editorial notes several instances where information on a medical device was withheld from the public or not reported fully. 
    The current adverse events reporting system relies on device makers to voluntarily report adverse events, which the authors say does not place patient safety as a priority. 
    The editorial specifically highlights a study involving Medtronic's Insync III model 8042 heart failure pacemaker, which the authors said caused a "high burden of serious adverse events (including death)." The authors said it took the FDA 19 months to recall the device after the first instance of the device failing was reported. The FDA also decided to classify the recall as Class II, which signifies a low probability of serious adverse events. 
    "This long unexplained delay before the recall and the inappropriate recall classification raise concerns about patient harms that could have been prevented by speedier and stronger regulatory actions," the authors wrote. 
    Read full story
    Source: Becker's Hospital Review, 10 January 2020
  7. Patient Safety Learning
    Leadership behaviour from the “very top of the NHS” has led to an increase in bullying, according to an official strategy document produced by an acute trust.
    East and North Hertfordshire Trust published its new people and organisation strategy in its January board papers. Within it, the report said: “Leadership behaviour from the very top of the NHS, during this time of pressure has led to an increase in accusations of bullying, harassment and discrimination.”
    In a separate section, the paper noted the difficulties of being a healthcare professional, saying “many staff leave before they need to and many more cite bullying, over work and stress, as reasons for absence and mistakes”.
    Read full story (paywalled)
    Source: HSJ, 13 January 2020
  8. Patient Safety Learning
    Hospitals are having to redeploy nurses from wards to look after queues of patients in corridors, in a growing trend that has raised concerns about patient safety.
    Many hospitals have become so overcrowded that they are being forced to tell nurses to spend part of their shift working as “corridor nurses” to look after patients who are waiting for a bed.
    The disclosure of the rise in corridor nurses comes days after the NHS in England posted its worst-ever performance figures against the four-hour target for A&E care. They showed that last month almost 100,000 patients waited at least four hours and sometimes up to 12 or more on a trolley while hospital staff found them a bed on the ward appropriate for their condition.
    “Corridor nursing is happening across the NHS in England and certainly in scores of hospitals. It’s very worrying to see this,” said Dave Smith, the Chair of the Royal College of Nursing’s Emergency Care Association, which represents nurses in A&E units across the UK. "Having to provide care to patients in corridors and on trolleys in overcrowded emergency departments is not just undignified for patients, it’s also often unsafe.”
    A nurse in south-west England told the Guardian newspaper how nurses feared the redeployments were leaving specialist wards too short of staff, and patients without pain relief and other medication. Some wards were “dangerously understaffed” as a result, she claimed.
    She said: “Many nurses, including myself, dread going into work in case we’re pulled from our own patients to then care for a number of people in the queue, which is clearly unsafe. We’re being asked to choose between the safety of our patients on the wards and those in the queue."
    Read full story
    Source: The Guardian, 12 January 2020
  9. Patient Safety Learning
    A teenager with a severe nut allergy died in part because of human error, a coroner has ruled.
    Shante Turay-Thomas, 18, had a severe reaction to eating a hazelnut. The inquest heard a series of failures meant that an ambulance took more than 40 minutes to arrive at her home in Wood Green, north London.
    Her mother Emma Turay, who said she felt "badly let down" by the NHS, wants an "allergy tsar" to be appointed to help prevent similar deaths.
    The inquest heard call staff for the NHS's 111 non-emergency number failed to appreciate the teenager's worsening condition was typical of a severe allergic reaction to nuts.
    A telephone recording of the 111 call, made by her mother, at 23:01 BST on Friday 14 September 2018, revealed how the 18-year-old could be heard in the background struggling to breathe.
    "My chest hurts, my throat is closing and I feel like I'm going to pass out," she said before asking her mother to check how long the ambulance would be, then adding: "I'm going to die."
    The inquest heard Ms Turay-Thomas had tried to use her auto-injector adrenaline pen, however it later emerged she had only injected a 300 microgram dose, rather than the 1,000 micrograms needed to stabilise her condition.
    It also emerged she was unaware of the need to use two shots for the most serious allergic reactions and had not received medical training after changing her medication delivery system from the EpiPen to a new Emerade device.
    The inquest at St Pancras Coroner's Court was told an ambulance that was on its way to the patient had been rerouted because the call was incorrectly categorised as requiring only a category two response, rather than the more serious category one.
    Read full story
    Source: BBC News, 13 January 2020
  10. Patient Safety Learning
    Multiple failings have been found in the Parliamentary Health Service Ombudsman's (PHSO)  investigation into the death of a young woman with anorexia.
    PHSO has admitted to multiple failings in how it handled a three-and-a-half year investigation into the systemic failings by NHS providers in Cambridgeshire and Norfolk which led to the death of Averil Hart in 2012.
    The findings come as a senior coroner in Cambridgeshire investigates whether there are links between the failures in Averil’s care and that of four other women with an eating disorder who were under the care of the same services.
    The PHSO’s failings have been revealed in an internal review, published today, which ruled the regulator’s investigation took too long and should’ve been completed in half the time.
    It also found “insufficient” resource was allocated to the Averil’s investigation, despite staff requesting it, which led to significant delays.
    Read full story
    Source: HSJ, 10 January 2020
  11. Patient Safety Learning
    A quarter of children referred for specialist mental health care because of self-harm, eating disorders and other conditions are being rejected for treatment, a new report has found. 
    The study by the Education Policy Institute warns that young patients are waiting an average of two months for help, and frequently turned away. It follows research showing that one in three mental health trusts are only accepting cases classed as the most severe. 
    GPs have warned that children were being forced to wait until their condition deteriorated - in some cases resulting in a suicide attempt - in order to get to see a specialist.
    Read full story
    Source: The Telegraph, 10 January 2020
  12. Patient Safety Learning
    Women in some parts of the country are half as likely to be diagnosed with ovarian cancer as elsewhere, new analysis of NHS data has revealed.
    The proportion of women diagnosed at an early stage of the disease, when it is most susceptible to treatment, varied in some areas from 22% to 63%.
    UK survival rates for cancer have lagged behind other countries and NHS England has set a target to improve early diagnosis with an ambition to have 75% of all cancers diagnosed early by 2028.
    The ovarian cancer audit data shows the UK is far from achieving this with only 33% of cancers diagnosed at stage one or two while 50% of cancers were detected at stage three and four.
    Chief Executive of Ovarian Cancer Action, Cary Wakefield, said: “Diagnosing ovarian cancer at the earliest stages is crucial, but sadly as we gather data it is clear that a postcode lottery exists around the country, with some areas diagnosing significantly more patients early than others. We want to see all patients diagnosed early enough to get treatment and survive this disease, no matter where they live.”
    Read full story
    Source: The Independent, 9 January 2020
  13. Patient Safety Learning
    Legal action is being launched against the NHS over the prescribing of drugs to delay puberty. 
    Papers have been lodged at the High Court by a mother and a nurse against the Tavistock and Portman NHS Trust, which runs the UK's only gender-identity development service (Gids). Lawyers will argue it is illegal to prescribe the drugs, as children cannot give informed consent to the treatment.
    The Tavistock said it had a "cautious and considered" approach to treatment.
    The nurse, Sue Evans, left the Gids more than a decade ago after becoming increasingly concerned teenagers who wanted to transition to a different gender were being given the puberty blockers without adequate assessments and psychological work.
    Ms Evans said: "I used to feel concerned it was being given to 16-year-olds. But now, the age limit has been lowered and children as young as perhaps 9 or 10 are being asked to give informed consent to a completely experimental treatment for which the long-term consequences are not known."
    Read full story
    Source: BBC News, 8 January 2020
  14. Patient Safety Learning
    Family doctors are under intense pressure and general practice is running on empty, warns the Royal College of GPs (RCGP). It says severe staff shortages are causing "unacceptable" delays for patients in England.
    In a letter to Health Secretary Matt Hancock, its chairman says ministers must take urgent action to deal with the lack of GPs.
    The government said it had recruited a "record number" of GP trainees. Ministers are committed to recruiting 6,000 more GPs in England by 2025.
    Prof Martin Marshall, who took over as RCGP chairman in November, says GPs are struggling with an escalating workload, which is causing many to burn out and leave the profession.
    Dr Andrew Dharman, who works at the The Avenue surgery in Ealing, said the stress has got worse because of the enormous workload placed on GPs. He said: "Sometimes it feels like you're drowning. You know you're trying to stay afloat and on top of all the workload. And you're trying to make sure you're providing the kind of care that you envisage when you go to medical school."
    "You feel frustrated sometimes that you can't necessarily do that because of the amount of work and patients."
    Read full story
    Source: BBC News, 9 January 2020
  15. Patient Safety Learning
    Delays to follow-up appointments for glaucoma patients leaves them at risk of sight loss, the Healthcare Investigation Safety Branch (HSIB) warns in their new report.
    The report highlights the case of a 34-year old woman who lost her sight as a result of 13 months of delays to follow-up appointments.
    Lack of timely follow-up for glaucoma patients is a recognised national issue across the NHS. Research suggests that around 22 patients a month will suffer severe or permanent sight loss as a result of the delays. In HSIB’s reference case, the patient saw seven different ophthalmologists and the time between her initial referral to hospital eye services (HES) and laser eye surgery was 11 months. By this time her sight had deteriorated so badly, she was registered as severely sight impaired.
    The investigation identified that there is inadequate HES capacity to meet demand for glaucoma services, and that better, smarter ways of working should be implemented to maximise the current capacity. The report makes several safety recommendations focused on the management and prioritisation of appointments. 
    Helen Lee, RNIB Policy and Campaigns Manager, said: “This report has brought vital attention to a serious and dangerous lack of specialist staff and space in NHS ophthalmology services across the country. We know that thousands of patients in England are experiencing delays in time-critical eye care appointments, which is leading to irreversible sight loss for some."
    “Without immediate action, the situation will only continue to deteriorate as the demand for appointments increases. RNIB urges full and immediate implementation of the recommendations set out in this report to improve the capacity, efficiency and effectiveness of ophthalmology services.”
    Read full story
    Source: HSIB, 9 January 2020
  16. Patient Safety Learning
    A backlog of thousands of deaths of people with learning disabilities awaiting official review has grown further, despite NHS England committing in spring last year to “address” the buildup. 
    Information obtained by HSJ shows the number of incomplete reviews increased slightly between May and November last year – from 3,699 to 3,802.
    The “national learning disabilities mortality review” programme – known as LeDeR – was launched in 2016 and is meant to review all deaths of people aged four and over.
    Mencap head of policy and public affairs, Dan Scorer, said: “It is unacceptable that thousands of deaths have still not been reviewed despite NHS England announcing further funding to make sure all reviews were carried out quickly and thoroughly. These latest figures show that little progress has been made; the programme is still failing to address outstanding reviews as well as keep pace with incoming referrals."
    “Behind these figures are families whose loved ones’ deaths may have been potentially avoidable and they have a right to know that health and care services are learning and acting on LeDeR reviews’ recommendations.”
    Read full story (paywalled)
    Source: HSJ, 8 January 2020
  17. Patient Safety Learning
    The partner of a dying man was denied the chance to be at his bedside during his final moments after a hospital wrongly banned her from daily visits, an ombudsman report has found.
    Brian Boulton, 70, was admitted to Royal Gwent Hospital in Newport, South Wales, after suffering from a chest infection, which was later diagnosed as aspiration pneumonia caused by oesophageal cancer.
    Celia Jones, his “long term life partner” of twenty years, was accused by hospital staff of giving the retired tailor a larger dose of the prescribed furosemide medication than was allowed. Ms Jones, 65, was restricted to one-hour visits twice a week, meaning she was unable to be with him when he died a day after her last authorised visit on Wednesday 27 September 2017.
    The Public Services Ombudsman for Wales has upheld her complaints about her “appalling” treatment, ruling that the visiting restrictions were imposed “without warning” and resulted in a “significant injustice”.
    It found no record of Ms Jones, a retired nurse, admitting to a senior ward manager that she gave the large dose of medicine to her partner.
    Read full story
    Source: The Telegraph, 6 January 2020
  18. Patient Safety Learning
    At least 61 women in the UK have been diagnosed with a potentially fatal cancer linked to breast implants, but the type they received continues to be used, with no plans by the regulator to follow France and Australia in banning them.
    Lawyers for more than 40 of the women, who are bringing legal action against the manufacturers as well as the clinics and doctors who carried out the surgery, say the textured implants linked to anaplastic large cell lymphoma (ALCL) should be withdrawn from the market. Smooth implants are available instead, which have no proven connection to the cancer of the white blood cells.
    The Medicines and Healthcare Products Regulatory Agency (MHRA) says the disease is very rare, but Sarah Moore, a solicitor at Leigh Day law firm, believes there are more cases than the regulator is aware of. “I think there has been misdiagnosis and under-diagnosis, and I think we have to bear in mind that in the last 18 months there have been 17 more reported cases of ALCL,” she said.
    The leading manufacturer of textured implants, Allergan, has withdrawn them from worldwide sale. In December 2018 its European kitemark for the implants expired – the French agency that had granted certification had asked for extra safety data that the company said it could not provide in time. They have not been on sale in Europe since then. The US authorities asked the company to recall its textured implants in July 2019 and Allergan took them off the market.
    France and Australia have since banned the sales of all textured implants, although neither has suggested that women should actively seek to have them removed.
    In the UK, other brands of textured implants are still in use. Neither NHS England, the NHS Business Services Authority nor the MHRA could say how many had been given to women in the NHS after a mastectomy for breast cancer.
    Read full story
    Source: The Guardian, 7 January 2020
  19. Patient Safety Learning
    About 9,000 nurses across Northern Ireland have begun a 12-hour strike today in a second wave of protests over pay and staffing levels.
    More than 2,000 appointments and procedures have been cancelled, including a number of elective caesarean operations.
    The Health and Social Care Board said it expects "significant disruption"
    Royal College of Nursing (RCN) Director Pat Cullen told BBC Radio Ulster's Good Morning Ulster programme that nurses felt "bullied" by health officials. Her comments followed a warning by the heads of Northern Ireland's health trusts on Tuesday that this week's strikes could push the system "beyond tipping point".
    Valerie Thompson, a deputy ward sister at Londonderry's Altnagelvin Hospital, said concerns over safe staffing levels and pay parity had brought her to the picket line.
    "We need to have the proper amount of staff to care for our patients, give them the respects, dignity, care they deserve," she said. "We are a loyal workforce; we get on with it, and rally around. But it is difficult. We miss breaks, go home late, staff are just exhausted."
    Read full story
    Source: BBC new, 8 January 2020
  20. Patient Safety Learning
    The Healthcare Safety Investigation Branch (HSIB) has launched an investigation looking at nasogastric tubes and how previously identified safety improvements for the placement of these tubes are put into practice.
    Nasogastric (NG) tubes are used to deliver fluid, food and medication to patients via a tube that passes through the nose and down into the stomach. There is a risk of serious harm and risk to life if NG tubes are incorrectly placed into the lungs, rather than the stomach, and feed is passed through them.
    HSIB has started this investigation after they were notified of a patient who inadvertently had a nasogastric tube inserted into his lung.
    Further information
    Source: HSIB, 7 January 2020
  21. Patient Safety Learning
    New research from the UK’s Drug Safety Research Unit (DSRU) has found that hospital pharmacists, doctors and nurses only recorded batch numbers for biologic medicines between 38% and 58% of the time during routine hospital practice.
    Further, an analysis of spontaneous adverse drug reaction (ADR) reports showed that brand names were only included 38% of the time, while batch number traceability was only 15%.
    Because of the study results, the DSRU is encouraging health professionals to improve the recording in order to aid patient safety, suggesting that it has “some way to go to encourage health professionals to record this information.”
    Read full story
    Source: PharmaTimes Online, 7 January 2020
  22. Patient Safety Learning
    Hundreds of sexual assaults are reported each year on mixed-sex mental health wards in England, HSJ can reveal, highlighting the urgent need for investment to improve facilities.
    New figures obtained by HSJ show there have been at least 1,019 reports of sexual assaults between men and woman on mixed wards since April 2017 to October 2019. This compares to just 286 reports of incidents on single-sex mental health wards over the same period.
    Of those reports made on mixed-sex wards, 491 were considered serious enough to refer to safeguarding, and 104 were reported to the police.
    The level of incidents still being reported suggests patients are not being protected from sexual assault on mixed wards, despite the issue being highlighted by several national reports in recent years.
    Read full story  (paywalled)
    Source: HSJ, 7 January 2020
  23. Patient Safety Learning
    Artificial intelligence can diagnose brain tumours more accurately than a pathologist in a tenth of the time, a study has shown.
    The machine-learning technology was marginally more accurate than a traditional diagnosis made by a pathologist, by just 1%, but the results were available in less than 2 minutes and 30 seconds, compared with 20 to 30 minutes by a pathologist.
    The study, published in Nature Medicine, demonstrates the speed and accuracy of AI diagnosis for brain surgery, allowing surgeons to detect and remove otherwise undetectable tumour tissue.
    Daniel Orringer, an Associate Professor of Neurosurgery at New York University's Grossman School of Medicine and a senior author, said: “As surgeons, we’re limited to acting on what we can see; this technology allows us to see what would otherwise be invisible to improve speed and accuracy in the [operating theatre] and reduce the risk of misdiagnosis."
    “With this imaging technology, cancer operations are safer and more effective than ever before.”
    Read full story
    Source: The Independent, 6 January 2020
  24. Patient Safety Learning
    A health board has cancelled planned operations at four of its hospitals "in the interest of patient safety".
    Hywel Dda University Health Board made the decision after "an extraordinary weekend" of "critical pressures". On Monday, inpatient operations were cancelled at Bronglais, Glangwili, Prince Philip and Withybush hospitals in mid and west Wales.
    The health board said it had contacted the patients affected and outpatient appointments continued as normal. No decisions have been taken yet to cancel more non-emergency operations on Tuesday, it added.
    Dr Philip Kloer, the health board's medical director, said the weekend saw hospitals "at a level of escalation not seen before".
    "It is in the interest of patient safety that we have postponed planned operations today," he added.
    Plaid Cymru's shadow minister for health, Helen Mary Jones, said the decision to cancel operations was "deeply concerning". She said that patients in Wales "deserve so much better".
    Read full story
    Source: BBC News, 6 January 2020
  25. Patient Safety Learning
    Mother Natalie Deviren was concerned when her two-year-old daughter Myla  awoke in the night crying with a restlessness and sickness familiar to all parents. Natalie was slightly alarmed, however, because at times her child seemed breathless.
    She consulted an online NHS symptom checker. Myla had been vomiting. Her lips were not their normal colour. And her breathing was rapid. The symptom checker recommended a hospital visit, but suggested she check first with NHS 111, the helpline for urgent medical help. To her bitter regret, Natalie followed the advice.
    She spoke for 40 minutes to two advisers, but they and their software failed to recognise a life-threatening situation with “red flag” symptoms, including rapid breathing and possible bile in the vomit.
    Myla died from an intestinal blockage the next day and could have survived with treatment.
    The two calls to NHS 111 before the referral to the out-of-hours service were audited. Both failed the required standards, but Natalie was told that the first adviser and the out-of-hours nurse had since been promoted. She discovered at Myla’s inquest that “action plans” to prevent future deaths had not been fully implemented. The coroner recommended that NHS 111 have a paediatric clinician available at all times.
    In her witness statement at her daughter’s inquest in July, Natalie said: “You’re just left with soul-destroying sadness. It is existing with a never-ending ache in your heart. The pure joy she brought to our family is indescribable.”
    Read full story
    Source: The Times, 5 January 2020
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