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Patient Safety Learning

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  1. Patient Safety Learning
    A coroner has found neglect contributed to a baby's death at the hospital where he was born.
    Jasper Brooks died at the Darent Valley Hospital in Kent on 15 April 2021. The coroner found gross failures by midwives and consultants at the hospital and says Jasper's death was "wholly avoidable".
    Jasper was a second child for Jim and Phoebe Brooks. Due to a complication during pregnancy of her first child, Phoebe was booked in to have an elective Caesarean section to deliver Jasper. But in April 2021 those plans changed overnight.
    A check-up found Phoebe had raised blood pressure. She was told to remain in hospital and that the C-section would happen the following morning - nine days earlier than planned - when there were more staff on duty.
    Jasper's parents say the midwives caring for Phoebe repeatedly failed to listen to her and Jim's concerns - that she was shaking violently, feeling sick, and thought she was bleeding internally.
    "We felt like an inconvenience - no-one wanted to deal with me that night," Phoebe says. "The doctor didn't want to do my C-section, the midwife that's meant to be looking after me, she just doesn't really care.
    "I remember saying clearly to her, 'my whole body is shaking - something's happening, and no-one's taking the time to listen to what I'm saying or listen in on my baby'."
    At the inquest hearing, midwife Jennifer Davis was accused by the family's barrister, Richard Baker KC, of "failing to act on signs of blood loss, failing to determine if Phoebe was in active labour, and failing to call a senior doctor when necessary".
    Jasper was born without a heartbeat, so a resuscitation team was called. But during the inquest, the family learned that further errors were made because the correct people failed to attend the resuscitation.
    There was no consultant neonatologist on site - a doctor with expertise in looking after newborn infants or those born prematurely. Intubation, the process of placing a breathing tube into the windpipe - which should only take a few minutes - did not occur for 18 minutes. There was also a delay in administering adrenaline to try to stimulate Jasper's heart.
    Read full story
    Source BBC News, 24 October 2023
     
  2. Patient Safety Learning
    More than a quarter of ‘critical incidents’ have been declared by just four trusts since the start of the crisis in urgent and emergency care.
    Data obtained by HSJ shows 241 critical incidents have been declared by organisations due to “operational” or “system pressures” between April 2021, when long waits for urgent care began to surge upwards, and last month. Four trusts account for 68 of these (28%).
    Critical incidents are declared when the level of disruption “results in an organisation temporarily or permanently losing its ability to deliver critical services, or where patients and staff may be at risk of harm”. These incidents may require “special measures and support from other agencies, to restore normal operating functions,” according to the NHS England definition. 
    Most critical incidents were only in place for a few days before being stood down by the trust or system, but some were in place for much longer – sometimes for several months at a time, the data suggests.
    Read full story (paywalled)
    Source: HSJ, 25 October 2023
  3. Patient Safety Learning
    The NHS has launched an investigation after it sent “priority” letters to people who died years ago, in some cases decades, urging them to book flu and Covid-19 jabs to reduce their risk of serious illness.
    The health service is asking eligible patients to arrange appointments for both vaccines to avoid a potential “twindemic” of flu and coronavirus this winter, which would pile further pressure on hospitals and GP surgeries.
    “You are a priority for seasonal flu and Covid-19 vaccinations,” the two-page letter tells recipients. “This is because you are aged 65 or over (by 31 March 2024).
    However, some of the letters, which contain personal information such as NHS numbers, have been sent to people who died years ago. Others have been sent to people who are not eligible for the vaccines, with no connection to the addressee.
    In a statement, NHS England told the Guardian it was investigating. It declined to answer questions about when the error was first discovered, what had caused it and how many people had been affected.
    “We have been made aware of some letters sent in error and appreciate this may have been upsetting for those who received it – we are working as quickly as possible to investigate this,” a spokesperson for NHS England said.
    Read full story
    Source: The Guardian, 24 October 2023
  4. Patient Safety Learning
    Several people have been admitted to hospital in Austria after using suspected fake versions of Novo Nordisk’s diabetes drug Ozempic, the country’s health safety body has said, the first report of harm to users as a European hunt for counterfeiters widened.
    The patients were reported to have suffered hypoglycaemia and seizures, serious side-effects that indicate that the product contained insulin instead of Ozempic’s active ingredient semaglutide, the health safety regulator Bundesamt für Sicherheit im Gesundheitswesen (BASG) said on Monday.
    The European Medicines Agency (EMA) warned last week that pens falsely labelled as Ozempic were in circulation, and Austria’s criminal investigation service said on Monday that the fake injection pens could still be in circulation.
    The Danish maker of the drug, Novo Nordisk, has warned of a rise in the online offers of counterfeit Ozempic as well as its weight-loss drug Wegovy, both based on semaglutide.
    “It appears that this shortage is being exploited by criminal organisations to bring counterfeits of Ozempic to market,” said BASG.
    Read full story
    Source: The Guardian, 24 October 2023
  5. Patient Safety Learning
    A major health system’s pathology IT has been hit by a cyber attack, HSJ understands.
    A letter sent by Guy’s and St Thomas’ Foundation Trust chief executive last night said his £2.5bn-turnover trust was unable to connect to the servers of Synnovis.
    The problem is ongoing, and several senior sources told HSJ the system had been the victim of a ransomware attack. One said gaining access to pathology results could take “weeks, not days”. 
    As well as GSTT – the NHS’s largest provider – neighbouring King’s College Hospital FT, which runs several hospitals in the system, and is thought to be affected. Synnovis also provides pathology services for primary care across all six of south east London’s boroughs.
    The news would make it one of the largest critical NHS systems brought down by a cyber attack.
    Read full story (paywalled)
    Source: HSJ, 4 June 2024
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