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Patient Safety Learning

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News posted by Patient Safety Learning

  1. Patient Safety Learning
    The health inequalities between different ethnicities, neighbourhoods and social classes are already stark, with millions of women in the most deprived areas in England dying almost eight years earlier than those from wealthier areas.
    But according to the UK Health Security Agency’s (UKHSA) report, these disparities will worsen as the impact the climate crisis has on health is disproportionately negative to the most disadvantaged groups.
    These particular groups include people with disabilities, homeless people and people living in local authorities with high levels of deprivation.
    Sir Michael Marmot, the director of the Institute of Health Equity and the author of the landmark Marmot review into health inequalities in 2010, said that climate breakdown can make health inequalities worse.
    Prof Lea Berrang Ford, the head of the Centre for Climate and Health Security at the UKHSA, made it clear that the negative health effects of climate breakdown will not be distributed equally across the UK, social determinants or generations.
    The report said that children and young people will experience increasingly severe weather into their retirement, with effects persisting or increasing for their children.
    Ford said: “The distribution of the impacts of climate change do not just differ across geographic regions, but also across different socio-demographic groups.
    “Climate change is well recognised as likely to exacerbate existing health inequalities, and across a range of health impacts the most vulnerable groups are adults over 65 years old, children and those with pre-existing medical conditions.”
    Read full story
    Source: The Guardian, 11 December 2023
  2. Patient Safety Learning
    NHS England has issued a national alert to all trusts providing maternity services after faults were discovered in IT software that could pose “potential serious risks to patient safety”.
    According to the alert, the Euroking electronic patient record provided by Magentus Software could be displaying incorrect patient information to clinicians.
    The Euroking EPR is used in the maternity departments of at least 15 trusts according to information held by HSJ.
    These organisations have been asked to “consider if Euroking meets their maternity service’s needs” and to “ensure their local configuration is safe”. Trusts with different maternity EPR providers have also been asked to reassess the clinical safety of their solutions.
    The potential “serious risks” relate to a fault in the Euroking EPR which allows new patient information to overwrite previously recorded information, which could lead to “incorrect management of the pregnancy and subsequent harm”.
    Read full story (paywalled)
    Source: HSJ,  8 December 2023
  3. Patient Safety Learning
    GPs have warned that the extent of verbal abuse directed at them and their practice staff ‘is increasing’, with the majority reporting that things are worse now than during the height of the Covid pandemic.
    A UK-wide survey of more than 2,000 doctors – of which 617 were GPs – found that 85% of GPs have reported receiving verbal abuse from patients within the last 12 months.
    The research conducted by Medical and Dental Defence Union of Scotland (MDDUS) also found that 15% of GPs reporting verbal abuse said they ‘had to resort to involving the police’ to deal with abusive patient situations over the past year.
    In the survey, GPs identified key triggers such as ‘lack of access to a face-to-face consultation’ and ‘complaints about their quality of care’ as the factors that could escalate to verbal abuse.
    One GP who responded to the survey said: "During a consultation with a young adult, they got very irate and demanded I just give them what they came for.
    "I explained they had to calm down and we would only proceed then at which they called me an ugly, fat, c**t and threatened to smash my face in. That consultation stayed with me for quite a while after that."
    Another said: ‘A patient smashed the surgery front door (it needed replacing) because he didn’t get what he wanted when he wanted it.
    "This was very scary for staff and other patients and the police didn’t even come until the next day. I felt alone, defensive and wondered why we bother to try to provide a service when some patients have already decided it isn’t good enough for them."
    Read full story
    Source: Pulse, 7 December 2023
  4. Patient Safety Learning
    A hospital has introduced a new artificial intelligence system to help doctors treat stroke patients.
    The RapidAI software was recently used for the first time at Hereford County Hospital.
    It analyses patients' brain images to help decide whether they need an operation or drugs to remove a blood clot.
    Wye Valley NHS Trust, which runs the hospital, is the first in the West Midlands to roll out the software.
    Jenny Vernel, senior radiographer at the trust, said: “AI will never replace the clinical expertise that our doctors and consultants have.
    "But harnessing this latest technology is allowing us to make very quick decisions based on the experiences of thousands of other stroke patients.”
    Radiographer Thomas Blackman told BBC Hereford and Worcester that it usually takes half an hour for the information to be communicated.
    He said the new AI-powered system now means it is "pinged" to the relevant teams' phones via an app in a matter of minutes.
    "It's improved the patient pathway a lot," he added.
    Read full story
    Source: BBC News, 7 December 2023
  5. Patient Safety Learning
    NHS leaders have issued a warning over surging flu cases as the number of patients in hospital with the bug soared by more than 50% in a week.
    An average of 234 people were in hospital with flu each day last week – up 53% on the previous seven days. Figures from NHS England also showed a rise in norovirus cases in hospitals last week with an average of 406 cases per day, up from 351 the previous week and a 28% rise from last year.
    The latest data comes after public health officials sent a warning over whooping cough levels, with 719 suspected cases reported between July and November, up from 217 last year.
    This week several NHS hospitals have sent out alerts to the public warning of “extremely busy” A&Es.
    Dr Tim Cooksley, former president of the Society for Acute Medicine, warned: “Pressures are being exacerbated by increasing rates of sickness among colleagues, as well as pressures on precious resources such as isolation areas and side rooms, adding to the strain on already overstretched services...
    “Undoubtedly we will see more older patients enduring prolonged degrading periods of corridor care and many people experiencing difficult symptoms whilst they sit on elective waiting lists.
    “Most hospitals are already experiencing chaotic and dangerous scenarios.”
    He added that there was “a lack of understanding of the gravity of the situation” from new health secretary Victoria Atkins.
    Read full story
    Source: The Independent, 7 December 2023
  6. Patient Safety Learning
    Pregnant women have been urged to get vaccinated following a spike in suspected whooping cough cases in England and Wales.
    Official figures show doctors reported some 716 suspected cases between July and November - up from 217 in the previous period last year.
    Whooping cough, or pertussis, is a bacterial infection of the lungs and breathing tubes that spreads easily and infected tens of thousands of people before vaccines were introduced.
    It is easily preventable, experts say, but can sometimes cause serious problems for babies and children.
    Dr Gayatri Amirthalingam, consultant epidemiologist at the UKHSA, said the rise in suspected cases of whooping cough was “expected” due to low immunity as a result of the Covid pandemic.
    Despite vaccinations being available in the UK the infection hasn’t gone away “completely” but immunisation can provide “life-long protection”.
    “Social distancing and lockdown measures imposed across the UK during the COVID-19 pandemic had a significant impact on the spread of infections, including whooping cough,” Dr Amirthalingam added.
    “As expected, we are now seeing cases of whooping cough increase again so it’s vital pregnant women ensure they get vaccinated to protect their baby.”
    Read full story
    Source: The Independent, 7 December 2023
  7. Patient Safety Learning
    More than 40 million women a year experience lasting health issues after childbirth, a global review has found, prompting calls for greater recognition of common postnatal problems.
    The sweeping analysis of maternal health worldwide shows a very high burden of long-term conditions that last for months and even years after giving birth. One in three new mothers worldwide are affected.
    The findings emerged from a series published in the Lancet Global Health and eClinicalMedicine, backed by the UN’s Special Programme on Human Reproduction, the World Health Organization and the US Agency for International Development.
    Prof Pascale Allotey, the director of sexual and reproductive health and research at the WHO, said: “Many postpartum conditions cause considerable suffering in women’s daily life long after birth, both emotionally and physically, and yet they are largely underappreciated, underrecognised, and underreported.
    “Throughout their lives, and beyond motherhood, women need access to a range of services from healthcare providers who listen to their concerns and meet their needs – so they not only survive childbirth but can enjoy good health and quality of life.”
    Read full story
    Source: The Guardian, 6 December 2023
  8. Patient Safety Learning
    Patient Safety Learning sets out its response to the announcement by the Department of Health and Social Care that it will be reviewing the statutory duty of candour for health and social care providers in England.
    "We welcome today's announcement by the Government that they will hold a review into the statutory duty of candour for health and social care providers.
    The statutory duty of candour is intended to ensure that healthcare providers are open and transparent with the public. It sets specific requirements for organisations to follow when things go wrong with care and treatment.

    Earlier this year the Parliamentary and Health Service Ombudsman highlighted concerns around the implementation of duty of candour and called for a review to assess its effectiveness in their report Broken trust: making patient safety more than just a promise. In our response to this report, we supported this recommendation.

    As part of reviewing problems with compliance, we believe that there are also broader questions that also need to be addressed concerning how the implementation of this is monitored and what remediation and redress is available to patients and the families when these obligations are not met.

    We also believe that this review should look at how the duty of candour is being implemented in light of the introduction of the new Patient Safety Incident Response Framework (PSIRF), given that this represents a significant change to the NHS’s approach to incident investigation."
    Source: Patient Safety Learning, 6 December 2023
  9. Patient Safety Learning
    Private hospitals saw record admissions this year after hundreds of thousands of people sought care through their insurance amid rocketing NHS waiting lists, new figures show.
    Between January and June 443,000 private treatments took place – a 7% rise from 2022, the vast majority of which were claimed through medical insurance policies.
    According to the Private Hospital Information Network (PHIN), which collects data from hospitals in the sector, there was a 12% increase in the number of people paying for care via insurance with 157,000 people using this route from January to March and 148,000 from April to June this year.
    The news comes as the NHS’s waiting list continues to grow with almost 7.8 million appointments recorded. Recently published data shows that there is a total of 6.5 million individual people on the waiting list.
    Read full story
    Source: The Independent, 7 December 2023
  10. Patient Safety Learning
    A coroner has warned a trust in the West Midlands for the third time about bed shortages, after three patient deaths which he believes are linked.
    In his report on the death in July of Philip Malone, area coroner for Birmingham and Solihull James Bennett told Birmingham and Solihull Mental Health Foundation Trust that its psychiatric bed capacity “remains inadequate”.
    Mr Malone – who was diagnosed with treatment-resistant schizophrenia in the 1980s and adult autism in May this year – died by suicide while awaiting an inpatient psychiatric bed at BSMHFT after a deterioration in his symptoms of anxiety, thought disorder, and hallucinations.
    Clinicians decided on 28 June that Mr Malone should be detained under the Mental Health Act, but as no inpatient psychiatric bed was available, he remained in the supported accommodation. Mr Malone died on 3 July.
    In a public report warning of the risks which may cause future deaths, issued last week, Mr Bennett said he had issued two previous “prevention of future death” reports which focused on a “chronic lack” of mental health resources in Birmingham and Solihull.
    Mr Bennett said: “The issue of adequately funding psychiatric beds is local and national. Locally, BSMHFT requires its commissioners to provide the necessary funding.
    “Whilst some action may have been taken it is insufficient to resolve the problem. It follows there is a genuine risk of future deaths directly connected to a shortage of psychiatric bed spaces in Birmingham and Solihull unless further action is taken.”
    Read full story (paywalled)
    Source: HSJ, 5 November 2023
  11. Patient Safety Learning
    A consultant gynaecologist who admitted sterilising a woman without her permission has been suspended from practising for 12 months.
    The woman - known as Patient A - was sterilised by Dr David Sim following an emergency caesarean section.
    Dr Sim previously admitted that the sterilisation was not necessary to save the woman's life or prevent harm to her health.
    The procedure took place at Daisy Hill Hospital in Newry in September 2021.
    On 1 December, the Medical Practitioners Tribunal Service (MPTS) found his fitness to practice was impaired.
    The tribunal previously heard Dr Sim and the patient had discussed sterilisation twice over a period of years, but the patient had never consented or expressed any wish to undergo sterilisation.
    When she required the emergency caesarean section, Dr Sim delivered the baby and blocked the patient's fallopian tubes to permanently impair their normal function.
    Dr Sim previously admitted to the tribunal that this was in violation of the woman's reproductive rights.
    Read full story
    Source: BBC News, 5 December 2023
  12. Patient Safety Learning
    Living with seizures and crippling pain, Zara Corbett says she's "begging for help" as she copes with endometriosis.
    The 21-year-old told BBC News NI that if she had any other condition she would be receiving help.
    "With gynae problems, particularly endometriosis, you are left waiting for years."
    "Women should not be left suffering this pain, it's not good enough," the beautician said.
    Zara has been put into early menopause - which is one potential treatment for endometriosis.
    The County Down woman said Northern Ireland needed a dedicated centre to provide specialist support.
    "I am begging for help from medical professionals including support from a multi-agency network because we are at our wits end - life cannot go on like this," she said.
    Endometriosis UK, an organisation that helps women with the condition, said it was shocked and saddened that it does not see "good, prompt care" in Northern Ireland.
    Its chief executive, Emma Cox, who visited Belfast in May, said services in Northern Ireland were "lagging behind" the rest of the UK.
    "We hear of the very long waiting lists to access gynaecologists to get a diagnosis but also waiting lists to access surgeons, it's about the disease being taken seriously," Ms Cox said.
    Read full story
    Source: BBC News, 6 December 2023
  13. Patient Safety Learning
    There will be no national mandate for GPs to use advice and guidance in a certain number of cases, NHS England has told Pulse. 
    National medical directors for primary and secondary care said that formalised pathways should be developed ‘locally’, and decisions should be based on an area’s population.
    In September, it was reported that NHS England’s upcoming outpatients strategy would further increase the use of advice and guidance (A&G) before GP referrals are accepted, with the RCGP then "voicing concerns" about this proposal. 
    However, when asked about the reports that this would be mandated, Dr Stella Vig, national medical director for secondary care and clinical director for elective care, said she ‘doesn’t know’ where that came from, and ‘doesn’t recognise’ those comments.
    NHS England also released guidance clarifying the medico-legal risks and clinical responsibility for clinicians using A&G or referral assessment services (RAS), which is now available on the NHS Futures website.
    The guidance said that these forms of specialist advice are "expanding rapidly" as a result of improvements to digital services.
    On legal issues, it said liability ‘will be determined on a case by case basis’ but that GPs could be liable if "all relevant clinical information is not provided" when sending an A&G request. 
    But specialists at hospitals would be accountable if they send back advice to the GP which is ‘not clinically appropriate’ or if they ‘refuse to accept a patient’. 
    On turnaround times, NHS England has said that ‘local variables will ultimately dictate the agreed response times’ for hospital teams dealing with A&G – but the guidance recommends that the response time "should not exceed 10 working days for routine requests". 
    Read full story
    Source: Pulse, 30 November 2023
  14. Patient Safety Learning
    The boss of a hospital trust being investigated by police for alleged negligence over 40 patient deaths has been accused of sending a hypocritical email urging staff to have the courage to raise concerns despite the dismissal of whistleblowing doctors.
    The investigation, Operation Bramber, was sparked by two consultants who lost their jobs after raising concerns about deaths and patient harm in the general surgery and neurosurgery departments of the Royal Sussex County hospital in Brighton.
    In an email to staff on Friday, the chief executive, George Findlay, said the trust was committed to learning from its mistakes. He said: “When things do go wrong, we must be open, learn and improve together. That openness is how we give people courage to raise concerns and make a positive difference to patient care.”
    James Akinwunmi, a consultant neurosurgeon who was unfairly dismissed by the trust in 2014 after he raised the alarm about patient safety, said Findlay’s email was “laughable”.
    He told the Guardian: “Whistleblowers, including myself, have done exactly what he is encouraging in the email and they were sacked for it, so you can draw your own conclusions. I suspect what they are doing is damage limitation. Instead, they should be dealing with surgeons who have been a problem for years.”
    Another more recent whistleblower, who did not want to be named, expressed incredulity at Findlay’s claim that he wanted to encourage staff to raise concerns.
    They said: “The email is hypocritical. How can staff have the ‘courage to raise concerns’ after what has happened to those who have? Those brave enough to blow the whistle about patient safety have been sanctioned, lost their job and had their lives destroyed.”
    Read full story
    Source: The Guardian, 3 December 2023
  15. Patient Safety Learning
    A health and social care minister privately said there was ‘systemic’ racism within the NHS and called for an investigation into it.
    Helen Whately told Matt Hancock of her belief in a private message which was today shown to the covid public inquiry.
    An inquiry hearing with Mr Hancock – who said he agreed with the point – was shown an exchange between Ms Whately, then care minister, and Mr Hancock in June 2020.
    The Guardian had reported the previous day that an internal report had found systemic racism at NHS Blood and Transplant.
    Ms Whately, who is now minister of state covering social care and urgent and emergency services, said: “I think the Bame next steps proposed are important but don’t go far enough. There’s systemic racism in some parts of the NHS, as seen in NHSBT.”
    She added: “Now could be a good moment to kick off a proper piece of work to investigate and tackle it.”
    Read full story (paywalled)
    Source: HSJ, 1 December 2023
  16. Patient Safety Learning
    A teaching trust has reported six ‘never events’ in less than two months, including incidents in a specialty already under review for errors.
    The incidents occurred at University Hospitals Birmingham between 26 July and 10 September, including two wrong-side lesion biopsies in dermatology, two incorrect blood transfusions, one injection to the incorrect eye, and one misplaced nasogastric tube.
    The two incorrect blood transfusions involved the same patient at Heartlands Hospital and were reported after a biomedical scientist carried out a retrospective investigation into the case. On both occasions, the patient was transfused with incorrect red blood cells.
    It brings the total number of blood transfusion events reported at UHB to seven since 2020-21. The issue is already subject to a review by the Royal College of Physicians after Mike Bewick identified concerns in his review of patient safety at the trust.
    It comes after clinicians working within the haematology specialty raised multiple concerns over patient safety in 2021 and intervention from the General Medical Council over concerns around junior doctors.
    John Atherton, chair of UHB’s clinical quality and safety committee, told the board a preliminary review into never events had identified that “maybe we weren’t addressing these [incidents] seriously enough”.
    Read full story (paywalled)
    Source: HSJ, 1 December 2023
  17. Patient Safety Learning
    Ministers must intervene over systemic failures which are “too big for hospital or ambulance trusts to fix on their own” and have led to multiple preventable deaths, a senior coroner has warned.
    In a move usually considered rare for such an official, Cornwall and Isles of Scilly coroner Andrew Cox has written to the Department of Health and Social Care a second time over ongoing delays to ambulance responses and long ambulance handovers in the area.
    Last year he warned the NHS was “broken” after he ruled ambulance and emergency care delays contributed to the deaths of four people. Now, he has sent a similar report on the same types of failings in the deaths of John Seagrove, Pauline Humphris, and Patricia Steggles at Royal Cornwall Hospital to new health secretary Victoria Atkins.
    Mr Cox wrote: “I set out in my [prevention of future death report] last year my understanding of the reasons for the difficulties that are continuing in the Cornwall & Isles of Scilly coroner area. I do not believe those reasons will have changed significantly.
    ”The challenges are systemic in nature. They are too big for a single doctor, nurse or paramedic to fix. They are too big for either the hospital trust or the ambulance trust to fix on their own.”
    Read full story
    Source: HSJ, 1 December 2023
  18. Patient Safety Learning
    The government faces a rebellion with at least 30 Tories backing an amendment to extend interim payouts to more victims of the infected blood scandal.
    Up to 30,000 people were given contaminated blood products in the 1970s and 80s. Thousands have died.
    A Labour amendment will be brought on Monday calling for a new body to be set up to administer compensation. More than 100 MPs, including Tories Sir Robert Buckland, Sir Edward Leigh and David Davis, are backing the move.
    In a letter sent to Chancellor Jeremy Hunt, shadow chancellor Rachel Reeves called the scandal "one of the most appalling tragedies in our country's recent history."
    She added: "Blood infected with hepatitis C and HIV has stolen life, denied opportunities and harmed livelihoods."
    She praised Theresa May, who set up the Infected Blood Inquiry when she was prime minister in 2017. But she warned: "For the victims, time matters. It is estimated that every four days someone affected by infected blood dies."
    The chancellor, himself a former health secretary, told the inquiry in July that the government accepted the moral case for compensation. But he said no final decisions could be made before the inquiry publishes its findings - now expected in March next year.
    In August 2022, the government agreed to make the first interim compensation payments of £100,000 each to about 4,000 surviving victims and bereaved widows.
    But inquiry chairman Sir Brian Langstaff, said in April this year that the parents and children of victims should also receive compensation and also called for a full compensation scheme to be set up immediately.
    The Commons Speaker will decide on Monday which amendments to the bill MPs will vote on. But the government has said it will not be supporting the amendment.
    A Department of Health spokesperson said: "We are deeply sympathetic to the strength of feeling on this and understand the need for action. However, it would not be right to pre-empt the findings of the final report into infected blood."
    Read full story
    Source: BBC News, 3 December 2023
  19. Patient Safety Learning
    NHS “inaction” for more than a decade is causing unnecessary deaths of black, Asian and minority ethnic transplant patients, a report by MPs has concluded.
    An inquiry into organ donation in the UK found that minority ethnic and mixed heritage people faced a “double whammy of inequity”: they are more likely to need donors, because they are disproportionately affected by conditions such as sickle cell and kidney disease, and they are less likely to find the right blood, stem cell or organ match on donor registers.
    Matching tissue type is vital to the chances of successful treatment, and compatible donors who are not relations are more likely to be found among donors from a similar ethnic background.
    While there are more donors than in previous years, theall-party parliamentary group (APPG) for ethnicity transplantation and transfusion’s inquiry report says just 0.1% of blood donors, 0.5% of stem cell donors and less than 5% of organ donors are of minority ethnic or mixed background. As a result, white people are nearly twice as likely to find a stem cell donor and 20% more likely to find a kidney donor.
    The inquiry found a “staggering lack of consistent and detailed ethnicity data” within healthcare systems, which “undermines accountability and jeopardises the lives of those awaiting life-saving treatments”.
    Responding to the findings, Habib Naqvi, the chief executive of the NHS Race and Health Observatory, said such stark ethnic disparities in organ donor participation were of “grave concern” and required “more investment from health providers and targeted campaigns to raise awareness” to build trust in the healthcare system.
    Jabeer Butt, the chief executive of the Race Equality Foundation, said the inequalities were unacceptable. “Every person, regardless of ethnic background, deserves an equal chance at receiving life-saving transplants and donations when needed. This is a solvable problem, but it requires a shared commitment to action across government, health organisations and communities. Lives depend on it,” he said.
    Read full story
    Source: The Guardian, 4 December 2023
  20. Patient Safety Learning
    A hospital that unnecessarily delayed a man’s surgery at the last minute because he had HIV failed in their care, according to England’s Health Ombudsman.
    The 48-year-old from Walsall, who does not want to be named, had been due to have prostate surgery at Walsall Manor Hospital on 10 March 2020.
    His surgery was scheduled to be the first of the morning. As he was about to enter the operating room, he was told that due to his HIV status his surgery would now be moved to last on the operating list that afternoon.
    The hospital claimed that this was due to the level of cleaning and infection control that would need to take place following his surgery to reduce the risk to others.
    However, the Parliamentary and Health Service Ombudsman (PHSO), found that Walsall Healthcare NHS Trust acted inappropriately and failed the man.
    This is because the universal precautions that apply to all patients having surgery are enough to protect and prevent infections from spreading among patients and staff. Therefore, no additional cleaning should have been necessary.  
    The policy of placing a patient at the end of an operating list usually relates to patients with a high-risk bacterial infection. It should not be applied to a person who has HIV and is receiving treatment.
    The Ombudsman also found that although the Trust had made some changes since this happened, they had not done enough to make sure the same mistake did not reoccur.
    PHSO recommended the Trust apologise to the man and create an action plan to stop this happening again. The Trust has complied with these recommendations.
    Read full story
    Source: Parliamentary and Health Service Ombudsman, 1 December 2023
  21. Patient Safety Learning
    Opt-out blood tests for HIV, Hepatitis B and Hepatitis C will be rolled out to a further 46 hospitals across England, the government has announced.
    Health Secretary Victoria Atkins said the new £20m programme would lead to earlier diagnoses and treatment.
    Under the scheme, anyone having a blood test in selected hospital A&E units has also been tested for HIV, Hepatitis B and Hepatitis C, unless they opted out.
    The trials have been taking place for the last 18 months in 33 hospitals in London, Greater Manchester, Sussex and Blackpool, where prevalence is classed by the NHS as "very high".
    Figures released by the NHS earlier show those pilots have identified more than 3,500 cases of the three bloodborne infections since April 2022, including more than 580 HIV cases.
    Ms Atkins said: "The more people we can diagnose, the more chance we have of ending new transmissions of the virus and the stigma wrongly attached to it."
    She added that rolling out the tests to more hospitals would help ensure early diagnoses so people "can be given the support and the medical treatment they need to live not just longer lives but also higher quality lives".
    Read full story
    Source: BBC News, 29 November 2023
  22. Patient Safety Learning
    Moving less complex procedures out of operating theatres and into other care settings to free up capacity to support elective recovery has ‘inadvertently’ increased the risk of ‘never events’ at an acute trust, a report has warned. 
    The warning was made in a report into four never events at North Bristol Trust’s Southmead Hospital between November 2022 and January 2023 – two of which involved the same patient. 
    The review was commissioned by Bristol, North Somerset and South Gloucestershire integrated care board to examine common issues in never events involving invasive procedures. It found an increase in never events when procedures were moved away from operating theatres to other care settings. 
    The review found moving procedures from theatres to outpatient or day case facilities to “support the reduction in the [elective] backlog and improve the waiting times for patients… may also inadvertently increase the risk of never events”. 
    It added: “It is likely that a theatre environment has more established and embedded safety control mechanisms. Governance processes in moving such procedures should consider the impact on quality, for example, the gaps between safety processes and consideration of the minimum requirements for the new procedure location.”
    Read full story (paywalled)
    Source: HSJ, 29 November 2023
  23. Patient Safety Learning
    The NHS has been accused of “breaking the law” by creating a massive data platform that will share information about patients.
    Four organisations are bringing a lawsuit against NHS England claiming that there is no legal basis for its setting up of the Federated Data Platform (FDP). They plan to seek a judicial review of its decision.
    NHS England sparked controversy last week when it handed the £330m contract to establish and operate the FDP for seven years from next spring to Palantir, the US spytech company.
    The platform involves software that will allow health service trusts and also integrated care systems, or regional groupings of trusts, to share information much more easily in order to improve care.
    Rosa Curling, director of Foxglove, a campaign group that monitors big tech and which is co-ordinating the lawsuit, said: “The government has gambled £330m on overhauling how NHS data is handled but bizarrely seems to have left off the bit where they make sure their system is lawful.
    NHS England says the platform will help hospitals tackle the 7.8m-strong backlog of care they are facing and enable them to discharge sooner patients who are medically fit to leave.
    But this may be the first in a series of legal actions prompted by fears that the FDP could lead to breaches of sensitive patient health information, and to data ultimately being sold.
    “You can’t just massively expand access to confidential patient data without making sure you also follow the law.”
    Read full story
    Source: The Guardian, 30 November 2023
  24. Patient Safety Learning
    People with Covid-19 were discharged to care homes over fears about the NHS getting “clogged up”, the pandemic inquiry has heard.
    Professor Dame Jenny Harries, England’s deputy chief medical officer during the pandemic and now head of the UK Health Security Agency, told the inquiry of how an email she sent in mid-March 2020 described the “bleak picture” and “top line awful prospect” of what needed to happen if hospitals overflowed.
    Discharging people to care homes – where thousands of people died of Covid – has been one of the central controversies when it comes to how the Government handled the pandemic.
    On Wednesday, the Covid inquiry was read an email exchange between Rosamond Roughton, an official at the Department of Health, and Dame Jenny on March 16 2020.
    Ms Roughton asked what the approach should be around discharging symptomatic people to care homes, adding: “My working assumption was that we would have to allow discharge to happen, and have very strict infection control? Otherwise the NHS presumably gets clogged up with people who aren’t acutely ill.”
    Ms Roughton added that this was a “big ethical issue” for care home providers who were “understandably very concerned” and who were “already getting questions from family members”.
    In response, Dame Jenny emailed: “Whilst the prospect is perhaps what none of us would wish to plan for, I believe the reality will be that we will need to discharge Covid-19 positive patients into residential care settings for the reason you have noted.
    “This will be entirely clinically appropriate because the NHS will triage those to retain in acute settings who can benefit from that sector’s care.
    “The numbers of people with disease will rise sharply within a fairly short timeframe and I suspect make this fairly normal practice and more acceptable, but I do recognise that families and care homes will not welcome this in the initial phase.”
    Read full story
    Source: The Independent, 29 November 2023
  25. Patient Safety Learning
    The management of fragile maternity services is being hamstrung by a lack of clear standards and direction from government and regulators, trust chairs and chief executives have told HSJ.
    Kathy Thomson, the retiring chief executive of Liverpool Women’s Foundation Trust, told HSJ that a major overhaul of regulation and oversight of maternity care was needed.
    She warned that trust leaders were confused about what was expected of their stewardship of maternity services. Much of the increased scrutiny of the sector was coming from people with little knowledge and experience of maternity care, and maternity was beset by too many initiatives which “somebody thinks are a nice thing to do”.
    Ms Thomson’s comments were echoed by a wide range of other NHS leaders (see ’damaging confidence’ below). 
    Ms Thomson told HSJ: “How clear are we nationally about the real ask of maternity services? Are we going to say it’s the ten NHS Resolution (NHSR) safety standards, which are really tough to achieve and which we agonise over? Or is it the CQC standards, because they will often take a different view around very similar issues?
    “We’ve had that this year after we’ve been assessed as compliant by NHSR, but then had to re-provide evidence after we’ve been criticised by the CQC for something… and then NHSR have written back to say we’re still fully compliant.
    “So, should you put your time and energy into the NHSR standards, or do you spend the time on the more subjective drivers? Because we can’t keep doing all of it and having different parts of the NHS saying this is what you need to do or expecting something different.”
    Read full story (paywalled)
    Source: HSJ, 30 November 2023
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