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Patient Safety Learning

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  1. Patient Safety Learning
    The average wait for an autism diagnosis in England has hit 300 days, according to new NHS data.
    That is up 53% from 12 months prior and exceeds the NICE target of 91 days.
    The National Autistic Society described such wait times as appalling, warning "autistic people shouldn't miss out on vital support because they haven't got a timely assessment."
    A government spokesperson said it had made £4.2m available this year to improve services for autistic children.
    Rose Matthews, 63, from County Durham, said receiving an autism diagnosis had been "lifesaving - and I don't say that flippantly".
    Before receiving their diagnosis at the age of 59, Rose, who uses "they" and "them" as personal pronouns, said: "My life was unravelling.
    "My career was unravelling."
    They said their GP had "deeply misguided ideas about what being autistic meant" and brushed them aside.
    Joey Nettleton-Burrows, policy and public affairs manager for the National Autistic Society (NAS), said: "We do see lot of misunderstanding from people, and it can include health and social care staff, but I wouldn't say it is common with GPs."
    Read full story
    Source: BBC News, 15 December 2023
  2. Patient Safety Learning
    Urgent action is needed to address NHS computer failings which are causing harm to patients, the patient safety watchdog has told BBC News.
    The watchdog has evidence of patient deaths due to IT system errors.
    The government called the reports "concerning" and said it would work with NHS England to take necessary action to protect patients.
    A recent investigation found thousands of hospital letters were unsent due to computer issues.
    The Health Services Safety Investigations Body (HSSIB) says IT failures are among the most serious issues facing hospitals in England.
    "We have seen evidence of patient deaths as a result of IT systems not working," said interim head, Dr Rosie Benneyworth.
    Dr Benneyworth cited the example of a patient who was found unresponsive and then wrongly identified by healthcare staff as not wishing to be resuscitated.
    Staff were unable to access information on the patient quickly through their IT system, which would have shown a mistake had been made, said the watchdog.
    Read full story
    Source: BBC News, 16 December 2023
  3. Patient Safety Learning
    Ambulance handover delays rose last week with close to 13,000 crews waiting more than an hour to offload patients — marginally more than the comparable week last year.
    Week of 27 November 2023 figures were missing data for several days from some trusts, NHSE said.
    The number of hour-plus waits for ambulancs to pass patients to emergency departments was 12,797, according to new NHS England data. 
    That appeared to be steeply up from about 8,000 in the past two weeks, although NHSE said last week’s was not directly comparable due to missing data.
    It was just ahead of the 12,534 recorded for the week ending 11 December last year.
    Last year the numbers rose to over 16,000 in the third week in December then peaked at 18,720 in the week running up to New Year, in what many said was the worst winter crisis for decades, amid a sharp, early wave of flu.
    This year the numbers of long waits have risen earlier than last, and several ambulance trusts have reported coming under severe pressure in the last few days. NHS England has warned junior doctors strikes next week and in the new year may compound hospital flow problems.
    Read full story (paywalled)
    Source: HSJ, 15 December 2023
  4. Patient Safety Learning
    The NHS in England has a record repair bill of almost £12bn, new figures show, with ministers needing to find more than £2bn for urgent maintenance to prevent catastrophic failure.
    The annual report on the condition of the health service’s estate said on Thursday that the cost of improving rundown buildings and decrepit equipment was two and a half times larger than in 2011-2012, when it stood at £4.7bn.
    The cost of the “high-risk” backlog – situations where the need to repair or replace facilities and equipment must be urgently addressed to prevent serious failure, significant injury or major disruption to clinical services – rose by almost a third to a record £2.4bn. This was £0.3bn in 2011-2012.
    However, investment to reduce the backlog fell in the last year from £1.41bn to £1.38bn, a fraction of what is needed to restore the NHS estate back to acceptable levels of risk. The stark figures cover a time prior to the health service becoming embroiled in the crumbling concrete crisis which initially hit school buildings.
    Sir Julian Hartley, the chief executive of NHS Providers, said that “too many NHS buildings are quite simply falling to bits”, and that we need “a step change in the government’s approach to planning and funding essential capital investment in the NHS”.
    He said: “The eye-watering cost of trying to patch up creaking infrastructure and out-of-date facilities is mounting at an alarming rate.
    “Mental health, hospital, community and ambulance services are crying out for much-needed funding for critical projects to overhaul ageing estates and to give patients and staff the safe, reliable conditions they need."
    Read full story
    Source: The Guardian, 14 December 2023
  5. Patient Safety Learning
    An "evil" nurse who drugged patients on a stroke unit for an "easy shift" and a healthcare worker who conspired with her have been jailed.
    Catherine Hudson, 54, was found guilty of giving unprescribed sedatives to two patients at Blackpool Victoria Hospital in 2017 and 2018.
    She was also convicted of conspiring with Charlotte Wilmot, 48, to give a sedative to a third patient.
    Hudson was jailed for seven years and two months. Wilmot was sentenced to three years.
    Evidence during the trial highlighted the "dysfunctional" drugs regime on the stroke ward with free and easy access to controlled drugs and medication which led to "wholesale theft" by staff.
    Prosecutors described it as a "culture of abuse" after police examined WhatsApp phone messages between the co-defendants and other members of staff.
    The pair were investigated after a student nurse witnessed events while on a work placement on the stroke unit and told senior managers in November 2018, who called in police.
    The whistleblowing nurse, who the prosecution had asked not to be named, told officers she had concerns over the use of insomnia medication Zopiclone, which can be life-threatening if given inappropriately.
    She said Hudson had told her the patient had a Do Not Resuscitate Order in place "so she wouldn't be opened up if she died or... came to any harm".
    Read full story
    Source: BBC News, 14 December 2023
  6. Patient Safety Learning
    A trust is reviewing more than 100,000 patients on its outpatient lists, after concerns emerged that some had ‘been lost whilst on hold’ for follow-up appointments.
    A report from Buckinghamshire Healthcare Trust, leaked to HSJ, found 116,575 patient records without a scheduled follow-up after an outpatient consultation, with more than half of those left inappropriately without action, some dating back a decade.
    The review was triggered after staff spotted cases in which patients had been “lost whilst on hold”, the report said.
    The trust this week told HSJ that, since the initial discovery in the summer of last year, it had been validating the lists and reduced the number of outstanding records to 47,778. It aims to complete the reviews in the next two months.
    It told HSJ it had undertaken a harm review and found no “systemic harm”.
    Concerns have been raised over several years about the extent of overdue and unreviewed patients on follow-up lists, and the potential for them to deteriorate and come to harm. There are no national figures monitoring the patients, many of whom have long-term health needs.
    Read full story (paywalled)
    Source: HSJ, 15 December 2023
  7. Patient Safety Learning
    People who have been hospitalised with flu are at an increased risk of longer-term health problems, similar to those with long Covid, data suggests.
    While the symptoms associated with such “long flu” appear to be more focused on the lungs than ongoing Covid symptoms, in both cases the risk of death and disability was greater in the months after infection than in the first 30 days.
    “It is very clear that long flu is worse than the flu, and Long Covid is worse than Covid,” said Dr Ziyad Al-Aly, a clinical epidemiologist at Washington University in St Louis, Missouri, who led the research.
    He was motivated to study the phenomenon after observing the scale of long-term illness experienced by people who have recovered from Covid.
    “Five years ago, it wouldn’t have occurred to me to examine the possibility of a ‘long flu.’ But one of the major lessons we learned from this pandemic is that a virus we all initially thought could only cause acute disease is leaving millions of people with long Covid, he said. “We wondered whether this could be happening with other things. Could this be happening with the flu, for example?”
    The research, published in the Lancet Infectious Diseases, found that while Covid patients faced a greater risk of death or hospital readmission in the following 18 months, both infections carried a significant risk of ongoing disability and disease.
    Read full story
    Source: The Guardian, 14 December 2023
  8. Patient Safety Learning
    Only half of staff across two acute trusts were fully trained in the use of a new electronic patient record before its introduction, which led to disruption and patient harm, HSJ has revealed.
    The implementation of Oracle Cerner’s EPR at Royal Surrey Foundation Trust and Ashford and St Peter’s Hospitals FT was carried out, despite the trusts not having achieved their target of 80% of staff having completed the necessary training, newly disclosed documents show.
    HSJ has also seen an internal report by the Royal Surrey’s informatics team which warned of risks to patient safety and data problems, unless preparations improved in the three months leading up to go-live. 
    The two acute trusts implemented the EPR in May last year under a programme called Surrey Safe Care, but there have been multiple problems ever since – including some of the issues that the internal report warned of.  
    The trusts acknowledged the process had been “challenging” but said they had trained a higher proportion of the staff who were working in the two weeks after go-live, with Royal Surrey describing the findings of the internal informatics report as an “inaccurate representation” of readiness.
    Read full story (paywalled)
    Source: HSJ, 13 December 2023
  9. Patient Safety Learning
    The NHS and a local council have been told to urgently find a home for a 28-year-old autistic man who is facing psychological and physical abuse within a mental health hospital, after an independent review of his care.
    Nicholas Thornton has autism and learning disabilities and is currently being held in the Rochford mental health unit, in Essex, after a decade of being locked away in places not able to care for him adequately.
    Now an independent safeguarding review into his care provided at the Essex hospital has ordered the local authority and NHS to find him a home in the community because his relationship with hospital staff has become so bad he is facing psychological and physical harm.
    He is one of the 2,045 people with learning disabilities and autism trapped within inpatient units across England.
    Mr Thornton has been in the unit, run by the Essex Partnership University NHS Foundation Trust (EPUT), since May this year. He is not under a mental health section, nor does he need mental health treatment, but he is unable to leave because the local authority has not agreed on a place into which he can be discharged.
    EPUT is currently facing a public inquiry probing the deaths of 2,000 patients following multiple reviews since 2016 from coroners, the police and health ombudsman criticising the care within the hospital.
    A safeguarding report into Mr Thornton’s situation, seen by The Independent and Channel Four News, revealed staff working in the Rochford hospital told investigators they cannot adequately care for Mr Thornton themselves as they are not trained in supporting patients with autism.
    Read full story
    Source: The Independent, 13 December 2023
  10. Patient Safety Learning
    The trusts paying the highest premiums for clinical negligence as a proportion of their income have been revealed through HSJ analysis of internal data.
    Several acute trusts in and around London are now spending more than 4% of their income on premium costs to insure themselves against clinical negligence, according to internal NHS data.
    One expert suggested trusts with higher proportions of ethnic minority patients often have high rates of negligence claims against them, partly due to the complexity of medical presentation, but also communication problems.
    Lisa Jordan, head of medical negligence at law firm Irwin Mitchell, said trusts that act as tertiary referral centres tend to admit the most complex cases, which are more likely to lead to claims.
    She added: “Trusts in areas with higher proportions of ethnic minority groups, also often have higher rates. That is in part about the complexity of medical presentation, and also communication problems.”
    Helen Hughes, chief executive of Patient Safety Learning, said: “Scarce funds that could be spent proactively improving the quality of care are being spent on the costs of error and harm.”
    Read full story (paywalled)
    Source: HSJ, 13 December 2023
  11. Patient Safety Learning
    Many people are deeply confused about the growing number of “physician associates” in the NHS and wrongly assume they are doctors, research suggests.
    Around 4,000 physician associates work in the NHS in England. Ministers and health chiefs plan to increase the figure to 10,000 to help plug widespread gaps in the NHS workforce.
    However, there is widespread confusion among the public about their role and relationship with fully trained medics, according to a survey commissioned by the British Medical Association (BMA).
    A quarter of the representative sample of 2,009 people erroneously believed that a physician associate was a doctor, while a fifth made the same mistake about “physician assistants”.
    Many respondents thought that a physician associate was more senior than a junior doctor, even though only the latter have a medical degree.
    The expansion of physician associates has prompted a backlash by grassroots medics. They fear patients will be misled into thinking they have seen a doctor despite physician associates not having the same skills and training.
    The government has moved to try to quell criticism of physician associates by legislating to ensure they are regulated by the General Medical Council (GMC).
    Read full story
    Source: The Guardian, 13 December 2023
  12. Patient Safety Learning
    NHS Highland will no longer receive extra government support in leadership, governance or culture, following improvements after the Sturrock review.
    The board was initially escalated to Stage 3 of NHS performance escalation framework in 2018 following concerns of a culture of workforce bullying and harassment.
    An independent report by John Sturrock QC, commissioned by the Scottish government, confirmed “fear, intimidation and inappropriate behaviour” and called for wide-ranging changes.
    The Healing Process was created in response, with an independent review panel established to speak to victims of bullying and come up with recommendations for the health board to make improvements.
    A total of 272 current and former NHS Highland and local health and social care partnership staff provided testimony between 2019 and March this year, with more than £2.8m paid out to those affected by bullying.
    Concerns were raised by some of the first people to go through the healing process that the system was “broken” and many victims could end up “bitterly disappointed”.
    The board has also established systems and processes to allow colleagues to speak up in the wake of the Sturrock Review, including an independent Guardian Service and staff training in Courageous Conversations.
    NHS Highland was handed oversight of its own escalation and de-escalation, rather than a Scottish government-led oversight group, in November 2021.
    Following a letter of assurance from the board chair earlier this year, the Chief Executive of NHS Scotland, Caroline Lamb, agreed to the de-escalation in September.
    Independent progress tracking shows the board has delivered significantly against many actions laid out by the review but the board concluded in its final June update that ‘culture change is not yet embedded at all levels of our organisation’.
    Read full story
    Source: Health and Care Scotland, 2023
  13. Patient Safety Learning
    Regulators have warned hospital leaders they may have to ‘depart from established procedures’ over winter to minimise ambulance handover delays.
    In a joint letter to nursing and medical leaders, NHS England, the Care Quality Commission and professional regulators said it was “vital that we have a whole system approach to risk across the urgent and emergency care pathway”.
    The push has come amid a huge increase in instances of crews being held outside emergency departments, resulting in extended response times for time-critical 999 calls.
    The letter added: “We… understand there will be concerns about working under pressure, and that you and your teams may need to depart from established procedures on occasion to provide the best care.
    “Please be assured that your professional code and principles of practice are there to guide and support your judgments and decision making in all circumstances. This includes taking into account local realities and the need to adapt practice at times of significantly increased pressure.
    “In the unlikely event of a complaint to your professional regulator they will, as is their usual practice, consider carefully whether they need to investigate. If an investigation is needed, they will consider all relevant factors including the context and circumstances in which you were working.
    “One area that may be an example of this is in handing patients over to emergency departments from ambulance services. There is a strong correlation between ambulance handover delays at emergency departments and ambulance category 2 response delays, meaning longer handovers increase the chances those in need will wait longer for an ambulance.”
    Read full story (paywalled)
    Source: HSJ, 11 December 2023
  14. Patient Safety Learning
    GP practices with the most outdated technology and processes do not have enough staff or funding to take part in NHS England’s performance recovery programme, integrated care boards are warning.
    In new recovery plans which they were required to publish by NHSE, multiple ICBs have said that stretched capacity means hardly any practices have signed up to the “general practice improvement programme”, which is meant to help them implement the national primary care access recovery plan.
    The ICBs pointed out that the programme is time consuming, and practices which take part are not always given funding to pay for staff time.
    HSJ has reviewed the primary care recovery plans which all ICBs were required to bring to their board meetings in October and November, to explain how they were implementing the national plan published by NHSE in the spring.
    NHSE’s plan sought to improve ease and speed of access through spreading “modern” methods and processes; as well as measures to save clinicians’ time, improving same-day access, and delivering more appointments.
    But HSJ’s  review of the ICB plans found several warning that their uptake of the improvement plan was off track, especially for “intermediate” and “intensive” support, which require substantial time for the practices, and are likely to be required by those most in need of help.
    Read full story (paywalled)
    Source: HSJ, 12 December 2023
  15. Patient Safety Learning
    After the $261 million verdict against Johns Hopkins All Children's Hospital, health system public relations departments have a new concern: unwillingly becoming the subject of a streaming service documentary.
    Released on Netflix in June, "Take Care of Maya" tells the story of Maya Kowalski, whose family brought her to the St. Petersburg, Fla., hospital's emergency department in 2016 with chronic pain. After physicians suspected child abuse, the then-10-year-old was kept there apart from her loved ones for nearly three months, during which time her mother killed herself.
    Millions of viewers watched the documentary, which detailed the family's then-unsuccessful attempt to sue the hospital. In November, a Florida jury awarded the Kowalskis the nine-figure sum for damages on counts including medical negligence and false imprisonment.
    "The level of global exposure and awareness of this case helped drive the interest, engagement and discussions in the community," Karen Freberg, PhD, professor of strategic communication at University of Louisville (Ky.), told Becker's. "This is a situation where hospitals across the board must evaluate their crisis communication plans from this experience and see how they would address this situation if it happened to them."
    She said any reputation-fixing lessons for this case, then, will come not from hospitals that have lost big lawsuits, but from companies that have been the subject of unflattering documentaries.
    Read full story
    Source: Becker's Hospital Review, 7 December 2023
  16. Patient Safety Learning
    Women in labour at a London maternity unit deemed “inadequate” were left alone with unsupervised support workers who were not given any guidance, an NHS safety watchdog has found.
    In a scathing report of North Middlesex Hospital’s maternity services, the Care Quality Commission also found examples of delays to induction of birth for women, and one case of a woman with a still-born baby who was left waiting for the unit to call her in for an induction.
    Inspectors have downgraded the maternity unit from “good” to the lowest possible rating “inadequate” following an inspection earlier this year.
    Staff reportedly told inspectors they felt they were “criticised” or “bullied” when reporting safety incidents within the unit.
    “We heard that the criticism or bullying was worse if the incident reported was relative to other staff and their perceived behaviours,” the report said.
    There was also evidence the hospital was not recording the severity of safety incidents correctly for example two “never events”, which are among the highest category incidents, were categorised as “low harm”.
    Other findings included women and babies came to harm as the hospitals did not follow standards to language interpretation despite covering a higher than average minority ethnic population.
    Read full story
    Source: The Independent, 11 December 2023
  17. Patient Safety Learning
    The risk of dying from cancer in England “varies massively” depending on where a person lives, according to a study that experts say exposes “astounding” health inequalities.
    Researchers who analysed data spanning two decades found staggering geographical differences. In the poorest areas, the risk of dying from cancer was more than 70% higher than the wealthiest areas. 
    Overall, the likelihood of dying from cancer has fallen significantly over the last 20 years thanks to greater awareness of signs and symptoms, and better access to treatment and care. The proportion dying from cancer before the age of 80 between 2002 and 2019 fell from one in six women to one in eight, and from one in five men to one in six.
    However, some regions enjoyed a much larger decline in risk than others, and the new analysis has revealed that alarming gaps in outcomes remain.
    “Although our study brings the good news that the overall risk of dying from cancer has decreased across all English districts in the last 20 years, it also highlights the astounding inequality in cancer deaths in different districts around England,” said Prof Majid Ezzati, from Imperial College London, who is a senior author of the study.
    Read full story
    Source: The Guardian, 11 December 2023
  18. Patient Safety Learning
    Campaigners have written to the chief constables of Norfolk and Suffolk to request an investigation into thousands of mental health deaths in those areas.
    They say coroners are raising safety issues but no improvements are being made.
    A report by independent auditors found as many as 8,440 patients had died unexpectedly over three years.
    Norfolk and Suffolk NHS Foundation Trust said it had started a review of patient deaths.
    Coroners worried about the risk of future deaths highlight unsafe practices in prevention of future deaths reports (PFDs). And authorities are required by law to respond with an action plan within 56 days. The Norfolk and Suffolk trust said it had responded to all PFDs and was working to ensure recommendations and actions were implemented.
    But Mark Harrison, from the Campaign to Save Mental Health Services in Norfolk and Suffolk, said: "There's a criminal case to answer. And we want the police to investigate, where the same mistakes have been repeated time and time again."
    He said coroners were repeatedly warning of risks such as delays to treatment, lack of patient follow-ups, chaotic record keeping and disorganised communication between teams.
    Mr Harrison said: "The mental health trust always responds saying they've learned lessons, they are changing policy and practices.
    "But then what we're seeing in analysing the orders from the coroner are repeat circumstances where other people have died in similar circumstances to a previous prevention-of-future-deaths notice."
    Read full story
    Source: BBC News, 12 December 2023
  19. Patient Safety Learning
    An overworked nurse who failed to give medication to a patient told a colleague “I don’t care anymore”, a hearing was told.
    Niall O’loingsigh was lead nurse in the Avon unit within the Charterhouse Care Home in Keynsham, Somerset, which looks after elderly residents and those with dementia. In 2020 a complaint was made by a colleague about him breaching safe medication management protocols and being dishonest in relation to medication administration. A misconduct hearing at the Nursing and Midwifery Council was told later, in May 2021, he was seen behaving in an “unsupportive manner” and told a colleague: “I don’t care anymore”.
    The panel also heard how on 18 May 2021, Mr O’loingsigh failed to record he had administered medication to three residents, BristolLive reported. A colleague wanted to report Mr O’loingsigh’s conduct, in which Mr O’loingsigh patted her on the back and said “well done mate, you did the right thing but I may lose my PIN though”.
    Mr O’loingsigh told his colleague of feelings of distress and anxiety about being reported and its impact on his career, but he wanted to reassure her. The colleague however felt “uncomfortable”. The panel found that he underwent “a course of conduct which put patients at risk of suffering harm at the time of the incidents” and noted “there were repeated failures over a period of time”.
    Read full story
    Source The Mirror, 10 December 2023
  20. Patient Safety Learning
    Physician Associates (PAs) and Anaesthesia Associates (AAs) will soon be regulated by the General Medical Council (GMC), improving patient safety and supporting plans to expand medical associate roles in the NHS to relieve pressure on doctors and GPs. 
    The government will lay legislation this week to allow the GMC to begin the process of regulating medical associates, who are medically trained healthcare professionals who work alongside doctors to care for patients.  
    The GMC will set standards of practice, education and training, and operate fitness to practice procedures, ensuring that PAs and AAs have the same levels of regulatory oversight and accountability as doctors and other regulated healthcare professionals. The regulations will come into force at the end of 2024. 
    Physician Associates and Anaesthesia Associates are already making a great contribution to the NHS, supporting doctors to provide faster high quality care for patients. 
    This new legislation paves the way for these professionals to be held to the same strict standards as doctors, boosting patient safety. 
    Regulation and growth of these roles will support plans to reduce pressure on frontline services and improve access for patients.
    Health and Social Care Secretary, Victoria Atkins, said: 
    "Physician Associates and Anaesthesia Associates are already making a great contribution to the NHS, supporting doctors to provide faster high quality care for patients. 
    This new legislation paves the way for these professionals to be held to the same strict standards as doctors, boosting patient safety. 
    This is part of our Long Term Workforce Plan to reform the NHS to ensure it has a workforce fit for the future."
    Read Press release
    Source: The Department of Health and Social Care and The Rt Hon Victoria Atkins MP, 11 December 2023
  21. Patient Safety Learning
    Patients needing emergency treatment are becoming sicker in A&E as hospitals struggle to free up enough beds, top doctors have warned.
    Dr Adrian Boyle, president of the Royal College of Emergency Medicine (RCEM), told The Independent that elderly patients are waiting so long for treatment in A&E that they’re developing bed sores and delirium.
    Another senior NHS doctor, Dr Vicky Price, who is president-elect of the Society for Acute Medicine, warned that corridor care is now “routine practice” with the situation only set to worsen as A&E departments come under increasing pressure.
    Their comments highlight the ongoing chaos in emergency medicine, as strikes take place during the most difficult time of the year. The chief executive of the NHS, Amanda Pritchard, said on Thursday that last winter was the worst she’d ever seen for the health service, warning that strikes by junior doctors will only make the situation harder for hospitals this year
    The warnings come as the latest NHS data shows that the prime minister, Rishi Sunak, could fail in his promise to deliver 5,000 more acute hospital beds to the NHS this month. Current data shows that the NHS is falling short of the target by just under 1,200 beds, with 97,818 against a target of 99,000.
    Read full story
    Source: The Independent, 10 November 2023
  22. Patient Safety Learning
    Doctors at a Black Country mental health trust have backed a vote of no confidence in their management team.
    Sources say that the Black Country Healthcare NHS Trust is not acting in the best interests of patients and they believe it wants to cut beds.
    They also have no confidence in the way that the trust has removed its chief medical officer, Mark Weaver.
    The NHS Trust said it was aware of concerns and had agreed to work on them going forward.
    The doctors wrote to the trust board following a meeting of the Medical Advisory Committee claiming that over the past two years the relationship with the board had become fractured.
    In the letter they claimed the voice of doctors was not being taken seriously by the board and that clinical priorities were secondary to financial performance.
    They also said they were seriously disturbed with the way in which Mr Weaver had been asked to step down and that the deputy chief medical officer Dr Sharada Abilash had not been asked to take over while due process occurred.
    Read full story
    Source: BBC News, 9 December 2023
  23. Patient Safety Learning
    The Care Quality Commission (CQC) has apologised after admitting it failed to act on whistleblowing concerns “in a timely manner”.
    Allegations had been made to the CQC about staff at Cambridgeshire and Peterborough Foundation Trust tampering with a patient’s record after they had died by suicide.
    As previously reported, the accusations by whistleblower Des McVey have sparked a review of the trust’s conduct in more than 60 suicide cases.
    Mr McVey says the trust only took action following media coverage and that the CQC had ignored his concerns.
    The regulator has now upheld a complaint from him, with operations manager James DeCothi writing to Mr McVey: “I have established that [the relevant CQC inspector] did not share your concerns with the provider in a timely manner and that our contact with you from July 2022 to June 2023 was inconsistent. I apologise on behalf of CQC for this. [The CQC inspector] has reflected on this and has asked me to offer her apologies to you also.
    “I can confirm that CQC have followed up the areas of concern that you have shared, and we will continue to use the information you have shared to inform future regulatory activity. I would like to thank you again for sharing this information with us.”
    Read full story (paywalled)
    Source: HSJ, 11 December 2023
  24. Patient Safety Learning
    The under delivery of intravenous antibiotics in some NHS hospitals due to lack of polices and compliance may be contributing to antimicrobial resistance (AMR), according to a parliamentary report.
    Findings in the report indicated that many health service organisations do not have policies in place to reduce the risk of under delivery and those that do can struggle to comply fully with them.
    The report’s authors warned that the residual volume of antibiotic remaining in the line of the IV administration set can result in under delivery of up to 30% of the prescribed dose.
    They said that, as a result, this could be leading to possible resistance within patients, owing to the accumulative effect. Nurses involved with compiling the document have called for action.
    Based on the findings, the report recommended that all NHS organisations implement line flushing policies by late 2024, with support from the Department for Health and Social Care.
    Read full story (paywalled)
    Source: Nursing Times, 9 December 2023
    Further reading on the hub:
    Short-term intermittent IV antibiotics – Understanding the issue of under delivery Understanding the importance of accurate antibiotic administration through an IV administration set (drip): A patient’s guide Top picks: 10 key resources on antimicrobial resistance
  25. Patient Safety Learning
    Surgeons at one London hospital are performing an entire week’s operations in a single day as part of a ground-breaking initiative that could help tackle the record waiting lists in the NHS.
    Guy’s and St Thomas’ NHS Foundation Trust has already slashed its own elective backlog in certain specialities by running monthly HIT (High Intensity Theatre) lists at weekends.
    Under the innovative model, two operating theatres run side by side and as soon as one procedure is finished the next patient is already under anaesthetic and ready to be wheeled in.
    Nurses are on standby to sterilise the operating theatre and instead of taking 40 minutes between cases it takes less than two, the only delay is the 30 second it takes for the anti-bacterial cleaning fluid to work.
    Kariem El-Boghdadly, the consultant anaesthetist who designed the programme with his colleague Imran Ahmad, compares it to a Formula One pit stop. “They’ve got one person doing the rear right wheel, one person doing the front left wheel. It’s the same thing. The operating theatre is effectively like that.”
    Read full story (paywalled)
    Source: The Times, 10 December 2023
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