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Patient Safety Learning

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  1. Content Article
    Good medical practice sets out the principles, values, and standards of care and professional behaviour expected of all medical professionals registered with the General Medical Council (GMC). Using social media as a medical professional builds on Good medical practice to provide more detail on our expectations of medical professionals in this area. The professional standards describe good practice, and not every departure from them will be considered serious. You must use your professional judgement to apply the standards to your day-to-day practice.
  2. News Article
    Doctors tore down posters offering patients a secondary care review if they were worried about their condition in hospital, the mother of a teenager who died of sepsis claimed. Merope Mills, who has campaigned for a similar policy called “Martha’s Rule” named after her 13-year-old daughter, claimed a small minority of “bad actors” in hospitals risked slowing down the initiative. It comes as NHS England announced 100 hospitals with critical care units will be invited to sign up for the policy, which will be rolled out from April this year. Martha died from sepsis in 2021 after staff at King’s College Hospital failed to move her to intensive care despite her family warning them her condition had deteriorated. “When something similar to Martha’s Rule was introduced to Royal Berkshire Hospital, doctors actually pulled down the posters advertising the service to patients because they hated the idea of giving patients this kind of power,” Mrs Mills told the Today Programme. “A small minority of bad actors whose arrogance, complacency or pride stops them listening and doing the right thing and that is what we are trying to challenge with Martha’s Rule. There are pockets of damaging cultures in hospitals around the country. Sometimes it is not a whole hospital, sometimes it is just a ward in a hospital, sometimes it is just a particular individual on a ward in a hospital.” Read full story Source: The Independent, 21 February 2024
  3. News Article
    In 2009, Emma Murphy took a phone call from her sister that changed her life. “At first, I couldn’t make out what she was saying; she was crying so much,” Murphy says. “All I could hear was ‘Epilim’.” This was a brand name for sodium valproate, the medication Murphy had been taking since she was 12 to manage her epilepsy. Her sister explained that a woman, Janet Williams, on the local news had claimed that taking the drug during her pregnancies had harmed her children. She was appealing for other women who might have experienced this to come forward. Murphy found the news segment that evening and watched it. “I was just stunned,” she says. “Watching that, I knew. I knew there and then that my children had been affected.” At that point, Murphy was a mother to five children, all under six, and married to Joe, a taxi driver in Manchester. “My kids are fabulous, all of them, but I’d known for years that something was wrong,” she says. “They weren’t meeting milestones. There was delayed speech, slowness to crawl, not walking. There was a lot of drooling – that was really apparent. They were poorly, with constant infections. I was always at the doctors with one of them." A call between Murphy and Janet Williams was the start of an incredible partnership. It led to the report published this month by England’s patient safety commissioner, Dr Henrietta Hughes, which recommended a compensation scheme for families of children harmed by valproate taken in pregnancy. Hughes has suggested initial payments of £100,000 and described the damage caused by the drug as “a bigger scandal than thalidomide”. It is estimated that 20,000 British children have been exposed to the drug while in the womb. Williams and Murphy have campaigned relentlessly to reach this point. It is by no means the endpoint – even now, an estimated three babies are born each month having been exposed to the drug. Together, the women formed In-Fact (the Independent Fetal Anti Convulsant Trust) to find and support families like theirs. They were instrumental in the creation of an all-party parliamentary group to raise awareness in government. Read full story Source: The Guardian, 22 February 2024
  4. News Article
    A patient in north Wales suffered "catastrophic" consequences when staff didn't connect their oxygen supply correctly. The Betsi Cadwaladr health board, which was caring for the patient at the time, is investigating and says it was one of a small number of recent similar incidents. But it refused to say whether the patient died, or to explain what the “catastrophic” consequences were. It says it is working to improve staff training to avoid similar incidents happening again. On Tuesday, Wales' health minister Eluned Morgan said the health board still had "a lot to do," before it could be taken out of special measures. A report to the committee said: “Further patient safety incidents have occurred in the health board related to the preparation and administration of oxygen using portable cylinders. “On review, the cylinder had not been prepared correctly, resulting in no flow of oxygen to the patient. “One incident had a catastrophic outcome and is under investigation.” Read full story Source: BBC News, 20 February 2024
  5. News Article
    Medicine shortages have increased and are “around double what they were a year ago”, it has been claimed. Speaking to the Health and Social Care Committee on Monday, Mark Samuels, chief executive of the British Generic Manufacturers Association (BGMA), said they have been highlighting the medicine shortage risk to ministers since July 2021 and the BGMA is “very concerned about it”. He said: “We’ve been monitoring it for several years now, and as you saw in the written evidence, shortages have increased. “They’re around double what they were a year ago. We have them at 101 shortages in February this year.” We've just been hearing devastating stories from people about the emotional toll it's sort of taking on them not being able to access vital medications. The shortage of certain medications “continues to be challenging”, Dr Rick Greville, director of distribution and supply at the Association of the British Pharmaceutical Industry (ABPI), told the committee. But when asked if the shortage is getting better or worse, he said it is “difficult to know as to whether it is increasing significantly, but certainly it’s a long-standing issue”. Meanwhile, there is “serious concern” about the potential harm to people with diabetes due to a shortage of medication, the committee was told. Read full story Source: Evening Standard, 20 February 2024 Have you (or a loved one) ever been prescribed medication that you were then unable to get hold of at the pharmacy? To help us understand how these issues impact the lives of patients and families, please share your experience and insights in our community thread on the topic: Medication supply issues: have you been affected? You'll need to register with the hub first, its free and easy to do. We would also like to hear from pharmacists working in community or hospital settings, and others who have insights to share on this issue. What barriers and challenges have you seen around medication availability? Is there anything that can be done to improve wider systems or processes?
  6. News Article
    Codeine linctus, an oral solution or syrup licensed to treat dry cough in adults, is to be reclassified to a prescription-only medicine due to the risk of abuse, dependency and overdose, the Medicines and Healthcare products Regulatory Agency (MHRA) has announced. Codeine linctus is an opioid medicine which has previously been available to buy in pharmacies under the supervision of a pharmacist but will now only be available on prescription following an assessment by a healthcare professional. Since 2019, there have been increasing reports in the media of codeine linctus being misused as an ingredient in a recreational drink, commonly referred to as ‘Purple Drank’. The decision to reclassify the medicine has been made following a consultation with independent experts, healthcare professionals and patients. 992 responses were received. The consultation was launched by the MHRA after Yellow Card reports indicated instances of the medicine being abused, rather than for its intended use as a cough suppressant. Dr Alison Cave, MHRA Chief Safety Officer, said: "Patient safety is our top priority. Codeine linctus is an effective medicine for long term dry cough, but as it is an opioid, its misuse and abuse can have major health consequences." Alternative non-prescription cough medicines are available for short-term coughs to sooth an irritated throat, including honey and lemon mixtures and cough suppressants. Patients are urged to speak to a pharmacist for advice and not to buy codeine linctus from an unregistered website as it could be dangerous. Read full story Source: MHRA, 20 February 2024
  7. Event
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    In this presentation, Dr Laura Sheard, Associate Professor, University of York, Honorary Principal Research Fellow, Bradford Institute for Health Research, will talk about the importance of prison healthcare, how it can be improved and why she is passionate about this topic. Laura will draw on her own experience of the four years she worked in HMP Leeds alongside findings from several mixed methods studies that Laura led in particular “Qual-P” which focused on understanding and improving the quality of and access to everyday primary care in prisons in the North of England. A large part of the presentation will discuss the major factors which influence the quality of primary care. These are: chronic understaffing; high variability of quality between sites, little to no quality measurement; excessive Did Not Attend rate; community-prison interface incompatibility including IT systems and opioid prescribing; facilitative relationships between healthcare staff and patients. Register
  8. Content Article
    As the Cumberlege Review and Paterson Inquiry made clear, having accurate and timely data on treatments and outcomes is critical to patient safety. NHS England is working to strengthen this data by implementing a central database to collect key details of implantable devices at the time of operation. The new Outcomes and Registry Platform will bring existing registries together for the first time and introduce new registries. In a blog for the Patient Safety Commissioner website, Scott Pryde, Programme Director for NHS England’s Outcomes and Registries Programme, and Katherine Wilson, Clinical Steering Group Chair of the programme, discuss the new National Registry of Hearing Implants, a registry specifically for cochlear implants. They highlight the importance of collaboration between patients, clinicians, regulators and medical device manufacturers.
  9. Content Article
    In this open letter to Steve Brine, Chair of the Health and Social Committee, The Association of Ambulance Chief Executives say they believe the “spirit” of national agreement on how to implement the Right Care, Right Person model is not being followed by police, raising “significant safety concerns”. It outlines key concerns, including the timescales for implementation, the consistency of application and failure by the police to attend when required.
  10. News Article
    Ambulance chiefs have warned that patients are coming to harm, paramedics are being assaulted and control room staff reporting a “high stakes game of chicken” with police during the implementation of a controversial new national care model. The Association of Ambulance Chief Executives say in a newly published letter they believe the “spirit” of national agreement on how to implement the Right Care, Right Person model is not being followed by police, raising “significant safety concerns”. The membership body set out multiple concerns about the rollout of the model, under which the police refuse to attend mental health calls unless there is a risk to life or of serious harm. In the letter to Commons health and social care committee chair Steve Brine, AACE chair Daren Mochrie says timescales for introducing it were often “set by the police rather than “agreed” following meaningful engagement with partners”, meaning demand was shifting before health systems had built capacity. They also flag a lack of NHS funding to meet the new asks. Mr Mochrie, also CEO of North West Ambulance Service Trust, described a “grey area” relating to what he called “concern for welfare” calls, which meet neither the police nor attendance services’ threshold for attendance. “To date this is the single biggest feedback theme we have heard from ambulance services, with some control room staff describing feeling like they’re in a ‘high-stakes game of chicken’ where the police have refused to attend and told the caller to hang up, redial 999 and ask for an ambulance,” he wrote. Read full story (paywalled) Source: HSJ, 20 February 2024
  11. Content Article
    On the 7 February 2024, the Patient Safety Commissioner for England published a report considering options for redress for those who have been harmed by two of the interventions covered by the Independent Medicines and Medical Devices Safety Review: sodium valproate and pelvic mesh. In this blog, Patient Safety Learning sets out the background to this report, outlines responses from patient groups and campaigners, and reflects on how this work will be taken forward.
  12. Content Article
    Extracts of a letter from David Osborn to the UK Covid-19 Public Inquiry Legal Team regarding misleading evidence by Professor Yvonne Doyle, which: Highlights errors in Prof Yvonne Doyle’s evidence to the Inquiry relating to the declassification of Covid‑19 as a high consequence infectious disease. Calls into question Professor Sir Jonathan Van Tam’s evidence to the Inquiry in which he sought to attribute responsibility for the downgrade from FFP3 to FRSM to Public Health England. The letter sets out his involvement in the issue of the 4-Nations IPC guidance version 1.0 which implemented that downgrade. Further reading on the hub: Healthcare workers with Long Covid: Group litigation – a blog from David Osborn
  13. News Article
    A suicidal man died hours after being discharged from a scandal-hit hospital which is at the centre of a probe into the care of Nottingham triple killer Valdo Calocane. Daniel Tucker was released from a mental health ward at Highbury Hospital in Nottingham last year and died shortly afterwards, having taken a toxic substance he had purchased online. An inquest into his death last week found there were multiple failings by Nottinghamshire Healthcare Foundation Trust in the lead-up to Tucker’s death, with no appropriate care plan or risk assessment in place for him before or after his discharge. The 10-day hearing heard he had been discharged from the hospital on 22 April, despite having shared suicidal intentions with staff just days before. The jury concluded that failures by staff to ensure an appropriate plan for him contributed to his death. It comes after health secretary Victoria Atkins ordered the Care Quality Commission to carry out an inquiry into Nottinghamshire Healthcare. The probe will look at the handling of Calocane, who had been discharged from Highbury Hospital and was a patient under the trust’s community crisis services when he stabbed three people to death in a brutal knife rampage. Read full story Source: The Independent, 18 February 2024
  14. Content Article
    Decisions to admit older, frail patients to critical care must pay particular attention to quality of life and the potential burden of care on patients. This burden may extend beyond surviving a critical illness. These decisions are not easy and require careful thought, clinical judgment, and communication write Daniele Bryden and colleagues in this BMJ opinion piece. 
  15. News Article
    Michelle Nolan takes morphine daily for the pain she has lived with for 14 years after botched surgery at the hands of a once renowned surgeon. She suffered irreversible nerve damage in July 2010 when John Bradley Williamson, a former president of the British Scoliosis Society, inserted a screw that was too long into her spine at Spire Manchester Hospital. The 49-year-old from Chadderton, near Oldham, needs crutches and lost her job as a legal secretary and later her house and marriage. “I lost everything because of him,” she said. “I thought I was the only one he had harmed.” She was not. Families and patients operated on by Williamson over two decades at the Salford Royal Hospital, Spire Manchester Hospital and the Royal Manchester Children’s Hospital, have formed a support group and want a full recall of all of his patients. They fear some could be suffering without realising they are victims of poor care. Williamson told the coroner investigating Catherine’s death that her surgery “progressed uneventfully” and “the blood loss was perhaps a little higher than one would usually anticipate but was certainly not extreme”. Yet days after her death, Williamson sent an internal letter to the hospital’s haematology department head Simon Jowitt describing the surgery as “difficult” and involving “a catastrophic haemorrhage”. Read full story (paywalled) Source: The Times, 18 February 2024
  16. News Article
    The government is considering plans to allow dentists from abroad to work without taking an exam to check their education and skills. The proposal, which is subject to a three-month consultation, aims to address the severe shortage of NHS dentists. It is hoped a quicker process would attract more dentists. The British Dental Association has accused the government of avoiding the issues "forcing" dentists to quit. The proposal forms part of the government's £200 million NHS Dental Recovery Plan for England, announced earlier this month. Under the plan, dentists could also be paid more for NHS work, while so-called "dental vans" would be rolled out to areas with low coverage, alongside an advice programme for new parents. There is also a proposal of £20,000 bonuses for dentists working in under-served communities, as part of an effort to increase appointment capacity by 2.5 million next year. At present, overseas dentists are required to pass an exam before they can start work in the UK - the new idea would see the General Dental Council (GDC) granted powers to provisionally register them without a test. Stefan Czerniawski, executive director of strategy at the GDC said: "We need to move at pace, but we need to take the time to get this right - and we will work with stakeholders across the dental sector and four nations to do so." Read full story Source: BBC News, 17 February 2024
  17. News Article
    A woman said she has been unable to get her ADHD medication for months. Hannah Huxford, 49, from Grimsby is one of thousands of patients unable to get hold of medicine to manage their symptoms due to a national shortage. Mrs Huxford, who was diagnosed with the condition two years ago, described the situation as a "huge worry". The Department of Health and Social Care (DHSC) said it had taken action to improve the supply of medicines but added that "some challenges remain". Mrs Huxford said the medicine made a "huge difference" and got her life back on track. "It enables me to function and concentrate so I can be more proactive, I can be more productive," she explained. She said she had been unable to get her usual supply since October 2023 and has to ration what she can get hold of. "Christmas time it was just getting beyond a joke. I was going back to the pharmacy, probably two or three times in a month, just to collect the little IOUs and it was getting to the point where that, in itself, was becoming a stress," she said. "All of a sudden, if this medication is taken away from me, I'm frightened that I will go back to not being able to cope." James Davies, from the Royal Pharmaceutical Society, said the supply shortage has been caused by manufacturing problems and an increase in demand. "There are more people who are being diagnosed with ADHD, more people seeking to access ADHD treatments. That's not just related to the UK, this is a global problem," he said. Mr Davies said some ADHD medication has come back into stock but added "it's quite a fluid situation at the moment". Read full story Source: BBC News, 19 February 2024 Have you (or a loved one) ever been prescribed medication that you were then unable to get hold of at the pharmacy? To help us understand how these issues impact the lives of patients and families, please share your experience and insights in our community thread on the topic: You'll need to register with the hub first, its free and easy to do. We would also like to hear from pharmacists working in community or hospital settings, and others who have insights to share on this issue. What barriers and challenges have you seen around medication availability? Is there anything that can be done to improve wider systems or processes?
  18. News Article
    Patients are facing delays stuck on hidden waiting lists that do not show up in the official figures in England, a BBC News investigation reveals. The published waiting list stands at 7.6 million - but the true scale of the backlog is thought to be much higher. This is because patients needing ongoing care are not automatically included in those figures - even if they face major delays. NHS England said hospitals should be monitoring and counting such cases. But BBC News found evidence suggesting this is not always the case. The problem affects patients receiving ongoing care, as well as those removed from waiting lists even before starting treatment. BBC News has spoken to patients waiting months and even years for vital treatment, such as cancer care, spinal treatment and others at risk of going blind because of deteriorating eyesight. Hospitals are meant to return patients facing unnecessary delays to the waiting list to ensure they are counted in the backlog figures. But of 30 NHS trusts asked by BBC News how regularly this was happening, only three could provide figures. Karen Hyde, from Insource, a company that helps hospitals manage waiting lists, said the guidance was "commonly ignored". "This is a huge issue. The NHS does not incentivise hospitals to keep a close eye on these patients. "We know there are long waits for those on the waiting list. For those not on the official waiting list, it is likely to be even worse - but the figures are not published." Read full story Source: BBC News, 19 February 2024
  19. Content Article
    On 29 December 2022, Shahzadi Khan was detained under section 2 of the Mental Health Act due to her mental state and the risks she presented. She was found to have had a manic episode with psychotic symptoms. Due to a lack of beds, she was placed in a privately-run mental health hospital in Norfolk. She remained there until her discharge to the family home on 26 January 2023. She was commenced on Olanzapine and Zopiclone for her mental health whilst an inpatient.   Her diagnosis on discharge was mania with psychotic symptoms. She was to remain on olanzapine in the community. Her placement out of area contributed to disjointed and inadequate discharge planning to support her in the community and was exacerbated by poor communication between the team managing out of area placements and the local team. As a consequence, the aftercare planning did not take place in accordance with S117 Mental Health Act.   This was exacerbated by a failure by all health professionals involved in her care within the mental health trust to recognise that she needed to be referred on to the Trafford Shared Care pathway. A referral would have ensured she received support and care for at least 12 weeks when she returned to the community. There is no clear reason for this failure. She was seen by the Home-Based Treatment Team (HBTT) on 28 January and 2 February, then discharged back to her GP. Within a week of that discharge from HBTT, which meant she had been left with no mental health support, she had deteriorated significantly. On 9 February her GP sent her to hospital for emergency assessment due to her presentation. She was discharged home to be seen by the Home- Based Treatment Team on 11th February. She was seen by that team on 11, 12, and 13 February. There was still no recognition of the fact that the Trafford policy was not being followed. She had indicated her lack of compliance with olanzapine, suicidal thoughts and her behaviour on 13th February was erratic. On 14 February 2023 she took a fatal overdose of prescribed zopiclone at her home address.
  20. News Article
    Italy will carry out an inquiry into its handling of the coronavirus pandemic in a move hailed as “a great victory” by the relatives of people killed by the virus but criticised by those who were in power at the time. Italy was the first western country to report an outbreak and has the second highest Covid-related death toll to date in Europe, at more than 196,000. Only the UK’s death toll is higher. The creation of a commission to examine “the government’s actions and the measures adopted by it to prevent and address the Covid-19 epidemiological emergency” was approved by the lower house of parliament after passing in the senate. Consuelo Locati, a lawyer representing hundreds of families who brought legal proceedings against former leaders, said: “The families were the first to ask for a commission and so for us this is a great victory. The commission is important because it has the task, at least on paper, to analyse what went wrong and the errors committed so as not to repeat the massacre we all suffered.” Read full story Source: The Guardian, 15 February 2024
  21. News Article
    Areas across England where the highest proportion of ethnic minorities live have the poorest access to GPs, with experts attributing this disparity to an outdated model being used to determine funding. As of October 2023, there were 34 fully qualified full-time-equivalent GPs per 100,000 patients in the areas with the highest proportion of people from ethnic minority backgrounds, according to a Guardian analysis of NHS Digital and census data. This is 29% lower than the 48 general practitioners per 100,000 people serving neighbourhoods with the highest proportion of white British people. Although ethnic minorities tend to be younger than the white British population, minority ethnic areas still have the lowest number of GPs per person even when factors such as age, sex and health necessities are considered. Prof Miqdad Asaria at the London School of Economics department of health policy said it was “very concerning” that ethnic minorities “have systematically poorer access to primary care which is likely to be a key driver of current and future health inequalities”. “Primary care plays a crucial role in preventing disease, diagnosing and treating illness, and facilitating access to specialist or hospital treatment for people who need it,” he added. Read full story Source: The Guardian,15 February 2024
  22. News Article
    A trust’s main maternity unit has been rated “inadequate” and given a warning notice amid concerns delayed Caesarean sections are causing harm to babies. The Care Quality Commission (CQC) told Maidstone and Tunbridge Wells Trust to make significant improvements in how quickly it carries out emergency C-sections, the regulator said in a report today. The trust was also told to improve risk management, governance and oversight of services at its Tunbridge Wells Hospital. Inspectors found between April and July last year, 42% of “category 1” emergency Caesareans – defined as those posing an immediate threat to the life of the woman or foetus — at the Tunbridge Wells Hospital were delayed. The National Institute for Health and Care Excellence says these should be carried out “as soon as possible and in most situations within 30 minutes of making the decision”. The report identified “ongoing recurrent delays” to emergency Caesareans overnight, as the trusts did not have a second theatre available. This “meant an increased risk of harm, including cases reported by the service such as babies with ‘acute foetal hypoxia’ had emerged due to delayed births”, the inspection report said. It also criticised the trust for not responding to a high level of post-partum haemorrhages, some of which had caused “moderate” harm. Read full story (paywalled) Source: HSJ, 16 February 2024
  23. Content Article
    Risks and statistics are an essential part of patient information. What is a person’s risk of developing a particular condition in their lifetime, or of having a certain symptom if they have that condition? What are the risk factors for a disease, and can people change these? What is the chance of a treatment or procedure working? And what is the risk of getting the different side-effects and complications that can come with it? Many patients are unable to comprehend basic statistics, never mind navigate their way through the reams of data that may come with health information to compare treatment options. As information producers, our job is to make sure we can guide patients through the minefield of data and figures to help them feel confident in making their own decisions. This guide from the Patient Information Forum highlights a range of approaches and tools for unbiased communication.  This resource covers the following topics: illustrating risk, perceptions of risk, know your numbers, explaining uncertainty, useful resources and references.
  24. News Article
    Ambulance trusts have often prioritised capacity and response times over dealing with cases of misconduct, a review of culture in the sector for NHS England has found. The review says ambulance trusts need to “establish clear standards and procedures to address misconduct”. The work was carried out by Siobhan Melia, who is Sussex Community Healthcare Trust CEO, and was seconded to be South East Coast Ambulance Service Foundation Trust interim chief from summer 2022 to spring last year. Her report says bullying and harassment – including sexual harassment – are “deeply rooted” in ambulance trusts, and made worse by organisational and psychological barriers, with inconsistencies in holding offenders to account and a failure to tackle repeat offenders. She says “cultural assessments” of three trusts by NHSE had found “competing pressures often lead to poor behaviours, with capacity prioritisation overshadowing misconduct management”, adding: “Staff shortages and limited opportunities for development mean that any work beyond direct clinical care is seen as a luxury or is rushed. “Despite this, there is a clear link between positive organisational culture and improved patient outcomes. However, trusts often focus on meeting response time standards for urgent calls, whilst sidelining training, professional development, and research.” Read full story (paywalled) Source: HSJ, 15 February 2024
  25. Content Article
    This is an independent review commissioned by NHS England, chaired by Siobhan Melia, Chief Executive, Sussex Community NHS Foundation Trust, to support the improvement of the culture within the ambulance service. The review considers the prevailing culture within ambulance trusts in England. It considers the core factors impacting cultural norms and offers actionable recommendations for improvement. Based on insights from key stakeholders, this review has identified six key recommendations to improve the culture in ambulance trusts.
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