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Patient Safety Learning

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  1. Patient Safety Learning
    Parkinson’s patients are suffering from “devastating effects” as GPs have started to switch to cheaper drugs which have different release rates into the body.
    Parkinson’s UK put out a warning when a 65-year-old man who had been successfully managing the condition for 17 years suddenly needed help eating and getting dressed.
    This happened after his branded medication Sinemet was changed to a cheaper form of the drug.
    Barrie Smith - who comes from Birmingham - was left in pain, developed slow speech and experienced an uncontrolled tremor when his normal Sinemet medication was switched to a more generic form of medication last year without consultation. He called the effects “devastating”.
    Dr Rowan Wathes, Associate Director of the Parkinson’s Excellence Network at Parkinson’s UK, said: “Changes to brands or manufacturers can trigger a significant deterioration of symptoms. It is vitally important for prescribers to specify the Parkinson’s medication brand or generic manufacturer on prescriptions for people with Parkinson’s. ”
    Read full story
    Source: The Independent, 30 January 2023
    You may also be interested in the following blogs written by Parkinson's UK for the hub:
    Medication delays: A huge risk for inpatients with Parkinson’s Keeping patients with Parkinson’s safe in hospital: 4 key actions for staff Preparing to go into hospital – tips for people with Parkinson's and their carers
  2. Patient Safety Learning
    Black people have the highest rate of sexually transmitted infections in Britain and officials are not doing enough to address the issue, sexual health experts have warned.
    Black Britons have “disproportionally high rates” of various STI diagnoses compared to white Britons, with those of Black Caribbean heritage specifically having the highest rates for chlamydia, gonorrhoea, herpes and trichomoniasis.
    Experts have told The Independent that healthcare providers are failing to address these disparities in STIs. They have called for more research to fully understand the complicated reasons why STIs are higher among people of Black ethnicity.
    Research conducted through the Health Protection Research Unit (HPRU) found that there were no clinical or behavioural factors explaining the disproportionately high rates of STI diagnoses among Black people.
    But higher rates of poverty and poor health literacy among marginalised communities are all linked with higher STI rates, according to a 2016 study, which found that behavioural and contextual factors are likely to be contributing.
    Moreover, experiences of racism among Black people can fuel a reluctance to engage with sexual health services and test frequently, according to HIV activist Susan Cole-Haley.
    She told The Independent: “I very much believe that it is linked to socioeconomic disadvantage and racism, often in healthcare settings, which can be a significant barrier for people accessing testing, for instance, and feeling comfortable engaging with care.”
    Read full story
    Source: The Independent, 19 February 2023
  3. Patient Safety Learning
    A surgeon who may have infected two new mothers with herpes has been granted anonymity during the inquests into their deaths in an "unprecedented" ruling.
    Coroner Catherine Wood said she made the decision because the surgeon's "apprehension" about being named when he stands as a witness would "likely impede his evidence in court" and affect his health.
    Mid Kent and Medway Coroners is investigating the cases of Kimberly Sampson, 29, and Samantha Mulcahy, 32, who both died in 2018 after the same obstetrician conducted their caesareans. They were treated 6 weeks apart in hospitals run by East Kent Hospitals University NHS Trust (EKHUT).
    On February 26 – the day before the inquest was due to begin and 16 months after it was first announced – EKHUT made a last-minute bid for anonymity covering the surgeon and a midwife also involved in both cases. The trust said they should not be named unless the inquest concluded they had passed on the infection, because of the "reputational damage" they would suffer, and because the surgeon's health was already being impacted by reports.
    Read full story
    Source: Medscape, 9 March 2023
  4. Patient Safety Learning
    In an enormous leap forward in the understanding of Parkinson’s disease (PD), researchers have discovered a new tool that can reveal a key pathology of the disease: abnormal alpha-synuclein — known as the “Parkinson’s protein” — in brain and body cells.
    The breakthrough published in the scientific journal The Lancet Neurology, opens a new chapter for research, with the promise of a future where every person living with Parkinson’s can expect improved care and treatments — and newly diagnosed individuals may never advance to full-blown symptoms.   
    The tool, called the α-synuclein seeding amplification assay (αSyn-SAA), can detect pathology in spinal fluid not only of people diagnosed with Parkinson’s, but also in individuals who have not yet been diagnosed or shown clinical symptoms of the disease, but are at a high risk of developing it. 
    By helping to identify people at the earliest stages of PD, “We could then study what happens at different biological stages of the disease,” says Dr. Sherer. Says Ken Marek, MD, PPMI principal investigator, “αSyn-SAA enables us to move to another level in effecting new strategies for prevention of disease.” 
    Read full story
    Source: The Michael J Fox Foundation for Parkinson' research, 13 April 2023
  5. Patient Safety Learning
    MPs will investigate the sexual harassment and sexual assault of female surgeons taking place within the NHS.
    BBC News reported women being sexually assaulted even in the operating theatre, while surgery took place.
    And the first major report into the problem found female trainees being abused by senior male surgeons.
    The Health and Social Care Committee said it would look into the issue and its chair, Steve Brine, said the revelations were "shocking".
    "The NHS has a duty to ensure that hospitals are safe spaces for all staff to work in and to hold managers to account to ensure that action is taken against those responsible," Mr Brine said.
    "We expect to look into this when we consider leadership in the NHS in our future work."
    Read full story
    Source: BBC News, 13 September 2023
  6. Patient Safety Learning
    A trust facing a police investigation into one of the NHS’s largest ever maternity scandals is no longer rated ‘inadequate’ by the Care Quality Commission in its well-led and maternity domains.
    Nottingham University Hospitals Trust was rated “inadequate” for its leadership and maternity services during inspections in 2021 and 2022, following serious care failings exposed by staff and patients during this period. The Nottinghamshire police confirmed last week they were opening an investigation.
    But the regulator noted improvements after its well-led and maternity inspections which took place in April and June.
    The well-led rating has gone up from “inadequate” to “requires improvement” and maternity services at both hospitals have also gone up to “requirements improvement”.
    Greg Rielly, CQC deputy director of operations in the Midlands, said: “During this inspection, we saw a team that consistently led with integrity who were open and honest in their approach.”
    However, he stressed that while the culture across the trust was improving, some staff still didn’t feel able to raise concerns without fear of retribution.
    “Leaders were aware of this and were working to create a workplace that is free from bullying, harassment, racism, and discrimination so we hope to see an improved picture soon,” he said.
    Read full story (paywalled)
    Source: HSJ, 13 September 2023
  7. Patient Safety Learning
    A high-profile government climbdown which legalised a type of cannabis medicine on the NHS five years ago misled patients, campaigners say.
    It was thought the law change would mean the unlicensed drug, which treats a range of conditions, could be freely prescribed by specialist doctors.
    But fewer than five NHS patients have been given the medicine, leaving others to either pay privately or miss out.
    The government says safety needs to be proven before a wider rollout.
    Legalisation of whole-cannabis medicine was hailed as a breakthrough for patients - giving either NHS or private specialist doctors the option to prescribe it if they believed their patients would benefit.
    But patients are being turned away, say campaigners, because doctors often do not know about the medicine, which is not on NHS trusts' approved lists. Some specialists who do know about it say there is insufficient evidence of the drug's safety and benefits to support prescribing.
    Senior paediatric consultant Dr David McCormick, from King's College Hospital in London, says it was "disingenuous" of the government to suggest in 2018 that NHS prescribing was ready to take place.
    "Parents were clamouring at our door, or phoning all the time, as they believed we were able to prescribe and that was not the case.
    "The message went out, 'doctors can now prescribe cannabis products' and that put us in a difficult position, because in truth we need to apply for that to be approved by NHS England."
    Read full story
    Source: BBC News, 13 September 2023
  8. Patient Safety Learning
    A woman who died during an operation for a buttock enlargement in Turkey was not given enough information to make a safe decision about the procedure, a coroner has concluded.
    Melissa Kerr, 31, from Gorleston, Norfolk, died at the private Medicana Haznedar Hospital in Istanbul, in 2019.
    Ms Kerr had gone abroad to have what is commonly referred to as a Brazilian butt-lift or BBL, the Norwich inquest heard.
    The inquest was told Brazilian butt-lift operations carried the highest risk of all cosmetic surgery procedures.
    The UK has an agreed moratorium on carrying out such operations due to the dangers involved, expert witness and plastic surgeon Simon Withey said in a report for the inquest.
    Mr Withey said if the risk of the procedure had been explained to Ms Kerr before she had financially committed to the procedure she would not "in all probability" have gone through with it.
    Coroner Jaqueline Lake said she would be writing a report for the health secretary to try and prevent further deaths from this "risky" procedure. She said she was "concerned patients are not being made aware of the risks or the mortality rate associated with such surgery".
    She added, while the UK government had no control over what happens in other countries, "the danger to citizens who continue to travel abroad for such procedures continues... and I'm of the view future deaths can be prevented by way of better information".
    Read full story
    Source: BBC News, 12 September 2023
  9. Patient Safety Learning
    ChatGPT could be used to diagnose patients in a bid to reduce waiting times in emergency departments, researchers have suggested.
    It comes after a study found the language model, powered by artificial intelligence (AI), “performed well” in generating a list of diagnoses for patients and suggesting the most likely option.
    Researchers in the Netherlands entered the records of 30 patients who visited an emergency department in 2022, as well as anonymous doctors’ notes, into ChatGPT versions 3.5 and 4.0.
    The AI analysis was compared to two clinicians who made a diagnosis based on the same information, both with and without laboratory data.
    When lab data was included, doctors had the correct answer in their top five differential diagnoses in 87% of cases, compared with 97% for ChatGPT 3.5 and 87% for ChatGPT 4.0.
    There was a 60% overlap between the differential diagnoses by clinicians and ChatGPT.
    The team said that while ChatGPT was “able to suggest medical diagnoses much like a human doctor would”, more work is needed before it is applied in the real world.
    Read full story
    Source: The Independent, 13 September 2023
  10. Patient Safety Learning
    Children have suffered severe harm at two further hospital trusts as a result of failures in paediatric audiology, HSJ has revealed.
    HSJ reported in July that three children at Croydon Health Service Trust may have come to “severe harm” – meaning they may have suffered permanent damage – following failures in the trust’s processes in audiology.
    Now East and North Hertfordshire Trust and North West Anglia Foundation Trust have also confirmed a small number of cases of severe or serious harm; while some trusts have yet to confirm findings from case reviews they have carried out.
    Major problems emerged earlier this year, initially in Scotland, of poor quality checks missing children with hearing problems who should have received support, and of a failure to inspect the services.
    NHS England ordered a review of data from the national newborn screening programme which, alongside other review work, identified six English trusts as having likely failures in their service: Croydon, East and North Herts, North West Anglia, Warrington and Halton Hospitals, North Lincolnshire and Goole, and Worcestershire Acute Hospitals.
    Read full story (paywalled)
    Source: HSJ, 14 September 2023
  11. Patient Safety Learning
    A new regional centre which promotes the reporting of suspected safety concerns associated with healthcare products has been launched in Northern Ireland.
    The Yellow Card centre for Northern Ireland will bring together a dedicated team to increase awareness, educate, and promote reporting of suspected adverse events to the Medicines and Healthcare products Regulatory Agency (MHRA) Yellow Card scheme.
    The Yellow Card scheme provides a mechanism for patients, care givers and healthcare staff to report suspected safety concerns associated with healthcare products.
    Speaking at the launch of the new service, Northern Ireland Chief Pharmaceutical Officer Professor Cathy Harrison said: “Collecting and monitoring information on possible adverse effects of medications and healthcare products is vital to ensuring patient safety.
    "It is fitting that the launch of the Yellow Card centre for Northern Ireland coincides with World Patient Safety Day on 17 September, with this year’s theme of "Engaging patients for patient safety".
    "The Yellow Card scheme puts the patient voice at its heart. By voluntarily reporting issues, patients, families and care givers can play a crucial role in their own care, and the safety of healthcare as a whole. I welcome the launch of the new regional centre and would encourage anyone who has suspected safety concerns to report them.”
    Read full story
    Source: Department of Health (Northern Ireland), 13 September 2023
  12. Patient Safety Learning
    The government has backed Martha’s rule, a campaign to give families and patients the right to a second assessment if they feel their concerns are not being taken seriously.
    Health secretary Steve Barclay said ministers are “committed” to implementing the rule, insisting the case for it is “compelling”.
    Martha Mills died after developing sepsis while under the care of King’s College Hospital NHS Foundation Trust in south London.
    Mr Barclay said the case set out by Ms Mills, was “compelling”.
    “For everyone that has heard it, it is an absolutely heartbreaking case,” he told the BBC.
    Mr Barclay said: “I’m determined that we ensure we learn the lessons from it and very keen to learn from best international practice.”
    Mr Barclay said there are “international lessons”, particularly from Ryan’s Rule in Australia, giving patients a direct line to a second opinion.
    “And I particularly want to give much more credence to the voice of patients,” Mr Barclay said.
    He added: “I think a key part of this measure is ensuring that patients feel heard and can get a second opinion.”
    Read full story
    Source: The Independent, 14 September 2023
  13. Patient Safety Learning
    Ambulance chiefs say handover delays have got worse at some trusts in recent months, despite the picture improving nationally since last winter.
    A report from the Association of Ambulance Chief Executives says there are continuing concerns about handover delays at emergency departments.
    Jason Killens, the body’s lead chief executive for operations, told HSJ: “There’s been some improvement [at some sites] since February, but what we’ve also seen is a commensurate or bigger decay in other sites across that same period.”
    Mr Killens said “it’s difficult to be precise” about why some trusts have struggled more than others but that challenged hospitals are often affected by “pathway issues” including delayed discharges.
    “And then maybe there are challenges around stable leadership or the visibility of the leadership, the culture there about managing that risk dynamically, and so on,” he added.
    Read full story (paywalled)
    Source: HSJ, 14 September 2023
  14. Patient Safety Learning
    A record 7.68 million people are on a hospital waiting list in England, figures show.
    The total at the end of July represents nearly one in seven people and is a jump of more than 100,000 in a month.
    The rising number means the prime minister's pledge to bring down waiting lists is under threat. The government has blamed strikes for adding to the pressures facing the NHS.
    It comes as ministers have announced an extra £200m for the NHS this winter.
    Health Secretary Steve Barclay said he wanted to see "high impact" interventions to help the NHS get through winter.
    Read full story
    Source: BBC News, 14 September 2023
  15. Patient Safety Learning
    Millions of women and girls experience debilitating periods, yet nearly one-third never seek medical help, and more than half say their symptoms are not taken seriously, according to research.
    A survey of 3,000 women and girls for the Wellbeing of Women charity found that they are often dismissed as “just having a period”, despite experiencing severe pain, heavy bleeding and irregular cycles that can lead to mental health problems.
    Almost all of those surveyed, who were between 16 and 40 years old and based in the UK, had experienced period pain (96%), with 59% saying their pain was severe. 91% had experienced heavy periods, with 49% saying their bleeding was severe. 
    Prof Dame Lesley Regan, the chair of Wellbeing of Women, said: “It’s simply unacceptable that anyone is expected to suffer with period symptoms that disrupt their lives, including taking time off school, work, or their caring responsibilities, all of which may result in avoidable mental health problems.

    “Periods should not affect women’s lives in this way. If they do, it can be a sign of a gynaecological condition that requires attention and ongoing support – not dismissal.”
    Wellbeing of Women has launched its “Just a Period” campaign, which Regan said aims to address “the many years of medical bias, neglect and stigma in women’s health”. This includes tips on how to get the most out of seeing your GP and what women should do if they feel they have been dismissed.
    Read full story
    Source: The Guardian, 14 September 2023
  16. Patient Safety Learning
    The NHS still relies heavily on paper notes, with experts warning they are not as safe or efficient as electronic records.
    It comes after a survey by the British Medical Journal (BMJ) found the majority of NHS trusts are still using paper, despite 88% of all trusts in England being equipped with electronic patient record (EPR) systems.
    Of 182 trusts, 4% said they only use paper notes, while 25% are fully electronic. Some 71% use both paper and an EPR system.
    Of the 172 trusts that responded to questions on prescriptions, 9% said they only use paper drug charts, 27% are fully electronic, and 64% use a mixture.
    Writing for the BMJ, freelance journalist and doctor Jo Best argued that the continued reliance on paper is less safe and efficient, while difficulties around sharing electronic records could be preventing even the most advanced trusts from realising their full potential.
    Read full story
    Source: The Independent, 14 September 2023
  17. Patient Safety Learning
    Women are being "failed at every stage" when it comes to maternity care, say campaigners, as they call for more support for those experiencing traumatic births.
    Mumsnet found 79% of the 1,000 women who answered their questionnaire had experienced some form of birth trauma, with 53% saying it had put them off from having more children.
    And according to the snapshot of UK mothers, 44% also said healthcare professionals had used language implying they were "a failure or to blame" for what happened.
    Conservative MP Theo Clarke is leading calls for more action after her own experience, where she thought she was "going to die" after suffering a third degree tear and needing emergency surgery.
    Now, she has set up an all party parliamentary group on birth trauma.
    She said: "[It is] clear that more compassion, education and better after-care for mothers who suffer birth trauma are desperately needed if we are to see an improvement in mums' physical wellbeing and mental health.
    "It is vitally important women receive the help and support they deserve."
    Chief executive of Mumsnet, Justine Roberts, said the trauma had "long-lasting effects", adding: "It's clear that women are being failed at every stage of the maternity care process - with too little information provided beforehand, a lack of compassion from staff during birth, and substandard postnatal care for mothers' physical and mental health."
    Read full story
    Source: Sky News, 15 September 2023
  18. Patient Safety Learning
    The WHO-hosted global conference on patient safety and patient engagement concluded yesterday with agreement across a broad range of stakeholders on a first-ever Patient safety rights charter. It outlines the core rights of all patients in the context of safety of healthcare and seeks to assist governments and other stakeholders to ensure that the voices of patients are heard and their right to safe health care is protected. 
    “Patient safety is a collective responsibility. Health systems must work hand-in-hand with patients, families, and communities, so that patients can be informed advocates in their own care, and every person can receive the safe, dignified, and compassionate care they deserve,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “Because if it’s not safe, it’s not care.”
    "Our health systems are stronger, our work is empowered, and our care is safer when patients and families are alongside us,” said Sir Liam Donaldson, WHO Patient Safety Envoy. “The journey to eliminate avoidable harm in health care has been a long one, and the stories of courage and compassion from patients and families who have suffered harm are pivotal to driving change and learning to be even safer." 
    The global conference on patient engagement for patient safety was the key event to mark World Patient Safety Day (WPSD) which will be observed on 17 September under the theme “Engaging patients for patient safety”. Meaningful involvement of patients, families and caregivers in the provision of health care, and their experiences and perspectives, can contribute to enhancing health care safety and quality, saving lives and reducing costs, and the WPSD aims to promote and accelerate better patient and family engagement in the design and delivery of safe health services. 
    At the conference, held on 12 and 13 September, WHO unveiled two new resources to support key stakeholders in implementing involvement of patients, families and caregivers in the provision of health care. Drawing on the power of patient stories, which is one of the most effective mechanisms for driving improvements in patient safety, a storytelling toolkit will guide patients and families through the process of sharing their experiences, especially those related to harmful events within health care. The Global Knowledge Sharing Platform, created as part of a strategic partnership with SingHealth Institute for Patient Safety and Quality Singapore, supports the exchange of global resources, best practices, tools and resources related to patient safety, acknowledging the pivotal role of knowledge sharing in advancing safety.
    “Patient engagement and empowerment is at the core of the Global Patient Safety Action Plan 2021–2030. It is one of the most powerful tools to improve patient safety and the quality of care, but it remains an untapped resource in many countries, and the weakest link in the implementation of patient safety measures and strategies. With this World Patient Safety Day and the focus on patient engagement, we want to change that”, said Dr Neelam Dhingra, head of the WHO Patient Safety Flagship.
    Read full story
    Source: WHO, 14 September 2023
  19. Patient Safety Learning
    Leaders of two maternity services have been told to take urgent action, after inspectors found understaffing and declining levels of care, despite safety warnings from midwives. 
    Maternity services at University Hospital North Durham and Darlington Memorial Hospital have been downgraded from “good” to “inadequate” in Care Quality Commission reports, published today. 
    The CQC noted a “concerning deterioration” in the care the two services provided, despite midwives telling managers they felt the service was unsafe.
    Sue Jacques, chief executive of County Durham and Darlington Foundation Trust, which runs the hospitals, said the CQC’s findings would be taken “extremely seriously”.
    The reports also said staff reported “feeling ‘frozen out’ or that their concerns were ignored by leaders” and that staff felt “‘continuity of carer’ was the trust’s main focus, despite depleted safe staffing levels, skill mix, and staff being pulled in to cover acute areas on a frequent basis”. Last year, trusts were told not to pursue continuity of carer models – which were previously championed by NHS England – unless they had adequate staffing levels to do so safely. 
    Read full story (paywalled)
    Source: HSJ, 15 September 2023
  20. Patient Safety Learning
    Women are being unnecessarily alarmed about their risk of breast cancer by consumer genetic test results that do not take family history into account, researchers have said.
    Women who discover outside a clinical setting that they carry a disease-causing variant of the BRCA1 or BRCA2 genes may be told that their risk of breast cancer is 60-80%. But analysis of UK Biobank data suggests the risk could be less than 20% for those who do not have a close relative with the condition.
    Dr Leigh Jackson, of the University of Exeter’s medical school, who is the lead author of the analysis published in the journal eClinical Medicine, said that in extreme cases this could result in women unnecessarily undergoing surgery.
    “Being told you are at high genetic risk of disease can really influence levels of fear of a particular condition and the resulting action you may take,” he said. “Up to 80% risk of developing breast cancer is very different from 20%.”
    Until recently, women who received BRCA results did so because they had attended clinic due to symptoms or a family history of disease. However, an increasing number are now learning of their genetic risk after paying for home DNA testing kits or taking part in genetic research, without ever having any personal link with breast cancer. 
    Read full story
    Source: The Guardian, 15 September 2023
  21. Patient Safety Learning
    A London coroner has warned the health secretary that preventable child suicides are likely to increase unless the government provides more funding for mental health services.
    Nadia Persaud, the east London area coroner, told Steve Barclay that the suicide of Allison Aules, 12, in July 2022 highlighted the risk of similar deaths “unless action is taken”.
    In a damning prevention of future deaths report addressed to Barclay, NHS England and two royal colleges, Persaud said the “under-resourcing of CAMHS [child and adolescent mental health services] contributed to delays in Allison being assessed by the mental health team”.
    An inquest into Allison’s death last month found that a series of failures by North East London NHS foundation trust (NELFT) contributed to her death.
    In her report, Persaud said delays and errors that emerged in the inquest exposed wider concerns about funding and recruitment problems in mental health services.
    “The failings occurred with a children and adolescent mental health service which was significantly under-resourced. Under-resourcing of CAMHS services is not confined to this local trust but is a matter of national concern,” she said.
    Read full story
    Source: The Guardian, 14 September 2023
  22. Patient Safety Learning
    Children who have not been vaccinated against measles may have to enter isolation for 21 days if a classmate becomes infected.
    The UK Health Security Agency (UKHSA) predict the capital alone could see 160,000 cases occur as measles, mumps and rubella (MMR) vaccination rates are at the lowest in a decade.
    Both Haringey and Barnet Council wrote to parents to tell them any unvaccinated child who comes into close contact with a measles case could be asked to self-isolate for up to 21 days.
    This week statistics from NHS England show that across the country more than 102,000 children aged four and five starting in reception are not protected against catching measles, mumps and rubella.
    32,000 children in London alone aren’t vaccinated, reveal NHS England, and just three-quarters of children in the capital have received the two required doses of the MMR jab, which protects against measles. This is 10% lower than the national average.
    Measles is highly infectious and if left unvaccinated nine out of ten children in a classroom will catch the disease if just one child is infectious.
    Read full story
    Source: The Independent, 15 September 2023
  23. Patient Safety Learning
    Sick children’s health problems are getting worse as record numbers wait up to 18 months for NHS care, doctors treating them have warned.
    The number of under-18s on the waiting list for paediatric care in England has soared to 423,500, the highest on record. Of those, 23,396 have been forced to wait over a year for their appointment.
    Delays facing children and young people are now so common that Dr Jeanette Dickson, the chair of the Academy of Medical Royal Colleges, the body representing all UK doctors professionally, warned that children are “the forgotten casualties of the NHS’s waiting list crisis”.
    “As a paediatrician, I’ve seen first hand the damaging impact that long waiting times have on children, on their education and overall wellbeing, and of course on their families,” said Dr Camilla Kingdon, the president of the Royal College of Paediatrics and Child Health (RCPCH).
    The figures came from the RCPCH’s analysis of official performance data recently published by NHS England.
    The health of some children was deteriorating while they languished on the waiting list because their illness and age meant they needed to have their treatment fast, Kingdon added. “Many treatments and interventions must be administered within specific age or developmental stages. No one wants to wait for treatment, but children’s care is frequently time-critical.”
    Read full story
    Source: The Guardian, 17 September 2023
  24. Patient Safety Learning
    The deputy leader of a trust rated ‘inadequate’ by a health watchdog four times in the past decade has admitted the necessary changes to its culture may take a further four years.
    Norfolk and Suffolk Foundation Trust staved off calls to break it up earlier this year after the Care Quality Commission raised its rating from “inadequate” to “requires improvement”.
    However, it has come under increased scrutiny in recent months after a review found it lost track of patient deaths, and a subsequent BBC Newsnight investigation discovered the report was edited to remove criticism of its leadership.
    The BBC found earlier drafts removed references to a “culture of fear” highlighted by some staff.
    Now deputy CEO Cath Byford has addressed growing concerns about the morale of staff working at the organisation, and their ability to speak up, at a meeting of Norfolk County Council’s health overview and scrutiny committee.
    During the meeting, she revealed the results of an anonymous survey which received 18,000 staff interactions. Most feedback was “not positive” admitted Ms Byford.
    She said many staff reported bullying and harassment, unfairness, inequality, and nepotism. This was particularly the case in recruitment, with staff feeling jobs were being lined up for certain individuals.
    Read full story (paywalled)
    Source: HSJ, 15 September 2023
  25. Patient Safety Learning
    NHS England has warned the decision by police forces to respond to far fewer incidents involving people in mental distress could pose ‘risks’ to both patients and a service “already under enormous pressure”. 
    National mental health director Claire Murdoch has written to integrated care board leaders and mental health trust CEOs about the possible impact of the “right care, right person” policing model which is being rolled out across England.
    In July, policing minister Chris Philp gave all forces the green light to implement the RCRP model. The approach was first trialled in Humberside and involves officers only attending mental health calls where there is a risk to life or serious harm.
    Now, in a letter seen by HSJ, Ms Murdoch has admitted the new model is a “major change for services already under enormous pressure” and warns that implementing all of the actions set out in the national partnership agreement may take time between the police and the NHS. This took three years in Humberside, she notes.
    Ms Murdoch wrote: “I know you will all be doing your best to make this work, but I am so mindful of the risks to services and people with mental health problems, as I am sure you are too.”
    Read full story (paywalled)
    Source: HSJ, 15 September 2023
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