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Patient Safety Learning

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  1. Patient Safety Learning
    An 11-year-old boy suffered permanent brain damage after birth because of negligence by hospital midwives who then fabricated notes, a high court judge has ruled.
    Jayden Astley’s challenges in life include deafness, motor impairments, cognitive difficulties and behavioural difficulties, his lawyers said.
    After a five-day trial at the high court in Liverpool, Mr Justice Spencer ruled that staff at the Royal Preston hospital in Lancashire were negligent in their treatment of Jayden in 2012.
    The brain injury was caused by prolonged umbilical cord compression that resulted in acute profound hypoxia – lack of oxygen – sustained during the management of the birth, the court found.
    Midwives failed to accurately monitor Jayden’s heart rate when he was born and failed to identify his bradycardic, or slow, heart rate during delivery. The judge also found that some entries in notes were fabricated.
    In his judgment Spencer said it was agreed that all permanent damage to Jayden’s brain would have been avoided if he had been delivered three minutes earlier.
    Read full story
    Source: The Guardian, 2 August 2023
  2. Patient Safety Learning
    GP practices in England will be able to order a host of checks directly to help speed up the diagnosis of a range of heart and respiratory conditions.
    Traditionally GPs refer to specialists when conditions like heart failure and lung problems are suspected.
    But the ability to direct refer, which was rolled out for cancer last year, is now being extended.
    GPs welcomed the move, but questioned whether there was sufficient testing capacity to cope.
    Royal College of GPs chair Prof Kamila Hawthorne said: "Any initiative to accelerate the process by which patients can be diagnosed and begin to receive any necessary treatment should be seen as positive."
    She said GPs had "long been calling" for better access to diagnostic tests.
    But she added: "For this initiative to be successful, it is vital that diagnostic capacity - both in terms of testing and people to conduct and interpret tests - is sufficient."
    Read full story
    Source: BBC News, 3 August 2023
  3. Patient Safety Learning
    NHS England has announced the first details of its ‘Leadership Competency Framework’, and revealed it will be launched this September.
    The LCF will underpin the annual appraisal of NHS board directors and, in turn, adherence to the revamped Fit and Proper Person Test.
    NHSE also revealed that leaders, including senior clinicians, who hold “significant roles” but are not board members may be subject to the FPPT in the near future.
    The new FPPT framework said the LCF would contain “six competency domains which should be incorporated into all senior leader job descriptions and recruitment processes”.
    Read full story
    Source: HSJ, 3 August 2023
  4. Patient Safety Learning
    Every day Sharon Smith has to take a strong morphine tablet to dull the excruciating pain she has lived with for more than a decade. 
    “I am in chronic pain every day. It’s affected our whole family and I’ve lost all my independence,” said Smith, from Leigh, Greater Manchester.
    Over four years from 2009, she endured three operations on her spine at Salford Royal Hospital, which as an NHS trust was once fêted as England’s safest.
    But the hospital had a dark secret: an incompetent leading surgeon who, an independent review would later find, had already “contributed” to the death of a girl in 2007.
    Now a wider investigation has confirmed that dozens of other patients who went under John Bradley Williamson’s knife were harmed or received poor care.
    Read full story (paywalled)
    Source: The Times, 30 July 2023
  5. Patient Safety Learning
    The NHS has heralded a “new era” of healthcare that will see hundreds of thousands of patients avoid lengthy hospital stays and instead be treated in their own homes.
    From September, 10,000 acutely ill patients will be cared for on “virtual wards”, using remote monitoring technology which automatically transmits data on their condition to teams of doctors and nurses several miles away.
    Health chiefs believe the massive expansion of the scheme, which is already the largest in the world, is essential to free hospital capacity — preventing another winter A&E crisis and helping to bring down record waiting lists.
    Every NHS region has set up virtual wards for frail over-65s, including dementia patients, as well as for respiratory conditions such as asthma or lung disease. From this month the scheme will be rolled out to cover under-18s, allowing terminally ill children to remain at home surrounded by family.
    Read full story (paywalled)
    Source: The Times, 28 July 2023
  6. Patient Safety Learning
    Serious systemic failings contributed to the death of a newborn baby in a cell at Europe’s largest women’s prison, a coroner has concluded.
    Rianna Cleary, who was 18 at the time, gave birth to her daughter Aisha alone in her prison cell at HMP Bronzefield, in Surrey, on the night of 26 September 2019. The care-leaver was on remand awaiting sentence after pleading guilty to a robbery charge.
    The inquest into the baby’s death heard that Cleary’s calls for help when she was in labour were ignored, she was left alone in her cell for 12 hours and bit through the umbilical cord to cut it.
    In a devastating witness statement read to the court, Cleary described going into labour alone as “the worst and most terrifying and degrading experience of my life”.
    She said: “I didn’t know when I was due to give birth. I was in really serious pain. I went to the buzzer and asked for a nurse or an ambulance twice.” Cleary passed out and when she woke up she had given birth.
    The senior coroner for Surrey, Richard Travers, said Aisha “arrived into the world in the most harrowing of circumstances”. He concluded it was “unascertained” whether she was born alive and died shortly after or was stillborn.
    Read full story
    Source: The Guardian, 28 July 2023
  7. Patient Safety Learning
    Soaring numbers of families struggling to care for someone with dementia have hit a “crisis point” with nowhere to turn for help when their loved one puts themselves or others at risk of harm, a charity has said.
    More than 700,000 people in the UK look after a relative with dementia. Many feel they can no longer cope with alarming situations where they or their relative are at immediate risk of being harmed, according to Dementia UK.
    Dementia can affect a person’s ability to manage their reactions to difficult thoughts and feelings. This can lead to them experiencing such intense states of distress that they become verbally or physically aggressive, putting themselves and those around them at risk of harm.
    The charity says carers and their loved ones are being failed because health and social care support services are already stretched to their limit, which has led to a surge in calls to its helpline.
    Sheridan Coker, the deputy clinical lead at Dementia UK, said: “We’re increasingly being contacted by families who are at risk of harm with no one to turn to. We receive calls where the person with dementia has become so distressed that they have physically assaulted the person caring for them, often a family member."
    Read full story
    Source: The Guardian, 31 July 2023
  8. Patient Safety Learning
    Patients in all but one integrated care system found it more difficult to contact their GP practice by phone this year compared to last year. 
    GP patient survey data, published this month, showed the proportion of patients who found it “very” or “fairly easy” to get through by phone had fallen across almost every ICS by as much as seven percentage points. The measure fell nationally from 53 to 50%. 
    The drop in performance comes as NHS England and the government ramp up focus on ease and speed of access to GPs as part of the primary care recovery plan, published in May.
    An NHSE spokesperson said: ”Despite GP teams experiencing record demand for their services, with half a million more appointments delivered every week compared to before the pandemic, the GP survey found that the majority of patients have a good overall experience at their GP practice.
    “However, the NHS recognises more action is needed to improve access for patients, which is why it published a recovery plan in May.”
    Read full story (paywalled)
    Source: HSJ, 31 July 2023
  9. Patient Safety Learning
    A woman treated in a hospital corridor says the lack of privacy was "wholly inappropriate" after other patients saw her without a top.
    Isabel Aston was taken to Princess Royal Hospital in Shropshire with pneumonia and sepsis and said she spent seven hours on a bed in a corridor.
    She said she felt exposed when other patients saw her changing her clothes.
    She explained: "People were walking in both directions [and] there aren't screens around your bed so people wanting the toilet who couldn't get out of bed were faced with the thought of using a bed pan in full view."
    She added that on feeling hot at one point, she wanted to change her t-shirt, but the process proved lengthy due to cannulas in her arms.
    "I did not have anything on underneath," she said. "I'm 64 years of age, I've probably reached an age where I'm not so self-conscious perhaps, but that could have been a much younger patient.
    "That could have been a patient for whom perhaps culturally they couldn't have change their t-shirt... or somebody who had mastectomy scars [and] were very self conscious.
    "It is wholly inappropriate for patients to be so exposed when they are so ill."
    The hospital trust said it aimed to maintain patients' dignity despite being under operational pressures.
    Read full story
    Source: BBC News, 28 July 2023
  10. Patient Safety Learning
    Dangerous allergic reactions are rising in England and now cause some 25,000 NHS hospital stays a year, according to data gathered by the NHS and analysed by the Medicines and Healthcare products Regulatory Agency.
    Health officials say the rate has more than doubled over 20 years, prompting them to issue advice reminding people how to recognise allergies and respond.
    For severe food-related allergic reactions, the rise in admissions is even greater.
    The figures suggest anaphylaxis is on the increase, though some of the rise could be attributed to the growth in population.
    Anaphylaxis can be fatal and develop suddenly at any age.
    People who know they are at risk should always carry two adrenaline pens which they, or someone else, can administer in an emergency.
    In addition, people at risk of an anaphylactic reaction should regularly check the contents of their adrenaline pens have not expired. They should see a pharmacist to get a new one if a pen is close to expiring.
    Read full story
    Source: BBC News, 28 July 2023
  11. Patient Safety Learning
    The UK’s status as a global leader on vaccination is at risk because of falling uptake rates among children and an “alarming” decline in clinical trial activity, MPs have warned.
    The Health and Social Care Committee said in a report that it was concerned that England did not meet the 95% target for any routine childhood immunisations in 2021-22.1
    Committee chair Steve Brine MP said that new spikes in measles cases in London and the West Midlands because of low uptake of MMR vaccines should be a “massive wake-up call” for the government to take action. “Vaccination is the one of the greatest success stories when it comes to preventing infection. Unless the government tackles challenges around declining rates of childhood immunisations and implements reform on clinical trials, however, the UK’s position as a global leader on vaccination risks being lost,” he said.
    The Health and Social Care Committee said, “It is unacceptable that there are people who are unable to take advantage of the important protection that vaccination offers because of practical challenges of time and location that can and must be tackled.”
    Read full story
    Source: BMJ, 27 July 2023
  12. Patient Safety Learning
    Drug companies are systematically funding grassroots patient groups that lobby the NHS medicines watchdog to approve the rollout of their drugs, the Observer has revealed.
    An investigation by the Observer has found that of 173 drug appraisals conducted by the National Institute for Health and Care Excellence (NICE) since April 2021, 138 involved patient groups that had a financial link to the maker of the drug being assessed, or have since received funding.
    Often, the financial interests were not clearly disclosed in NICE transparency documents.
    Many of the groups that received the payments went on to make impassioned pleas to England’s medicines watchdog calling for treatments to be approved for diseases and illnesses including cancer, heart disease, migraine and diabetes. Others made submissions appealing NICE decisions when medicines were refused for being too expensive.
    In one case, a small heart failure charity that gave evidence to a NICE committee arguing for a drug to be approved received £200,000 from the pharmaceutical company, according to the maker’s spending records.
    In another case, a cancer patient group supplied evidence relating to drugs made by 10 companies – from nine of which it had received funding.
    Read full story
    Source: The Guardian, 22 July 2023
  13. Patient Safety Learning
    Bereaved families in Scotland questioned the credibility of the Covid-19 inquiry on its opening day.
    Proceedings started with a presentation in Dundee by the public health physician Dr Ashley Croft, who talked about the scientific and medical understanding of the virus as it existed in late 2019 and how it developed up to the end of last year.
    Members of the Scottish Covid Bereaved group were said to be “bewildered” by the choice of Croft as first speaker of the inquiry, having previously raised concerns about his being used as an expert witness.
    The lawyer Aamer Anwar, who is representing the group, highlighted a High Court judgment that reportedly described Croft as providing “flawed, unreliable” and “unconvincing” evidence and displaying “a cavalier approach to important evidence”.
    Pointing out that no respects were paid to the many people who lost their lives during the pandemic during the presentation either, Anwar described the inquiry’s start as “embarrassing” and “deeply disrespectful”.
    Read full story (paywalled)
    Source: The Times, 27 July 2023
  14. Patient Safety Learning
    A “great” ambulance trust’s “uncompromising” focus on outcomes and its own performance has been a barrier to system working and affected relationships with partners, an external review has advised it.
    The report from the Good Governance Institute on West Midlands Ambulance Service University Foundation Trust found partners felt it was “increasingly out of sync with new ways of working under integrated care” and even “somewhat dismissive of the integrated care agenda”.
    It praised the trust overall, saying: “WMAS is seen by all those we spoke to as being a great organisation: well run, with strong leadership and a clear focus on operational delivery.
    But it said communications, especially through the press, were seen as “bullish and at times damaging to the reputation of partners and harmful to patients”. Its reputation and performance can create a culture of engagement with external partners that “seems defensive at best and arrogant/dismissive at worst”, with the trust being “prickly towards external challenge”, the consultants’ report added.
    Read full story (paywalled)
    Source: HSJ, 27 July
  15. Patient Safety Learning
    Rishi Sunak says the government will wait for the Infected Blood Inquiry's final report before responding to questions around victim compensation.
    Bereaved families heckled the prime minister when he told the inquiry the government would act as "quickly as possible".
    Mr Sunak told the inquiry people infected and affected by the scandal had "suffered for decades" and he wanted a resolution to "this appalling tragedy".
    But although policy work was progressing and the government in a position to move quickly, the work had "not been concluded".
    He indicated there was a range of complicated issues to work through.
    "If it was a simple matter, no-one would have called for an inquiry," Mr Sunak said.
    Campaign group Factor 8 said Mr Sunak had offered "neither new information not commitments" to the victims and bereaved families, which felt "like a betrayal".
    Haemophilia Society chief executive Kate Burt said: "This final delay is demeaning, insulting and immensely damaging.
    "We urge the prime minister to find the will to do the right thing and finally deliver compensation which recognises the suffering that has been caused."
    Read full story
    Source: BBC News, 26 July 2023
  16. Patient Safety Learning
    Health officials waited six months to speak to the surgeon Sam Eljamel after a complaint was made about his conduct that eventually led to his suspension.
    Eljamel, who was head of neurosurgery at NHS Tayside in Dundee between 1995 and 2013, harmed dozens of patients before being suspended in 2013. 
    Even as NHS Tayside commissioned an external review into Eljamel’s conduct, the surgeon was not suspended. Instead, the health board allowed him to continue practising as long as he was monitored. However, a letter sent to Eljamel by NHS Tayside’s clinical director, dated June 21, 2013, reveals that the surgeon was able to negotiate the extent of his own supervision.
    It was during this period of supervision that Jules Rose attended Ninewells Hospital to have a brain tumour removed by the surgeon. He performed two surgeries on her, in August and December, and she later discovered that he had removed her tear gland instead of the tumour.
    Since then she has founded and run the Patient’s Action Group, representing 126 of Eljamel’s patients calling for a public inquiry into how he was able to harm so many patients at NHS Tayside.
    Read full story (paywalled)
    Source: The Times, 25 July 2023
  17. Patient Safety Learning
    Two ambulance trusts have been left without a working electronic patient care record system for a week after a cyber attack affecting its Swedish-based supplier.
    Staff at South Western Ambulance Service Foundation Trust and South Central Ambulance Service FT have been working on paper since the MobiMed system – supplied by the firm Ortivus – went down last Tuesday. More than 1,700 ambulances and clinical workstations use the system, according to the company.
    One employee told HSJ some staff were struggling with a paper-based system which meant they had less information on patients.
    ”We can’t do summary care record searches or see previous call information,” the staff member said. SWASFT sent a message to staff on Friday saying the system was likely to be down “for a prolonged period”.
    Read full story (paywalled)
    Source: HSJ, 25 July 2023
  18. Patient Safety Learning
    Ministers are backing a potentially “dangerous” new model allowing police to reduce their response to mental health incidents after failing to formally assess the risk of harm or death.
    Officials are monitoring any “adverse incomes” from the National Partnership Agreement, which will see police forces stop attending health calls unless there is a safety risk or a crime being committed.
    Policing minister Chris Philp said a pilot by Humberside Police gave him confidence in national roll-out, which aims to “make sure that people suffering mental health crisis get a health response and not a police response”.
    Mental health charities and experts have warned the plans could be “dangerous”, and a coroner raised the alarm following a woman’s suicide after police failed to respond to her disappearance.
    A report published last month said action was needed to prevent future deaths, warning that the new model could “allow each agency to regard such a situation as the other’s responsibility, whilst nobody is on the ground attempting to retrieve a seriously ill patient”.
    Read full story
    Source: The Independent, 26 July 2023
  19. Patient Safety Learning
    The Care Quality Commission has named the trusts which have performed ‘worse than expected’ on patient experience in urgent and emergency care.
    Data from the CQC survey of more than 36,000 people who used urgent and emergency care services in September 2022 shows a total of 10 trusts performed poorly on patients’ overall experience.
    Patients reported longer wait times, while only around half felt staff “definitely” did everything they could to help control their pain in the latest survey.
    Sean O’Kelly, the CQC’s chief inspector of healthcare, said it “remains extremely concerning that for some people care is falling short”.
    “These latest survey responses demonstrate how escalating demand for urgent and emergency care is both impacting on patients’ experience and increasing staff pressures to unsustainable levels."
    Read full story (paywalled)
    Source: HSJ, 26 July 2023
  20. Patient Safety Learning
    More than 250 NHS buildings in Scotland could contain a potentially dangerous type of concrete that can collapse without warning.
    NHS Scotland issued a Safety Action Notice in February and completed a "desktop survey" of its estate in June.
    Reinforced autoclaved aerated concrete (RAAC) was used to build roofs, walls and floors from the 1960s to the 1990s.
    NHS Scotland has warned the material is potentially vulnerable to "catastrophic failure without warning".
    But a Scottish government spokesperson said there was "no evidence to suggest that these buildings are not safe."
    Read full story
    Source: BBC News, 25 July 2023
  21. Patient Safety Learning
    Britain’s health regulator has partly suspended the manufacturing licence of Sciensus, a private company paid millions by the NHS to provide vital medicines, after the death of a cancer patient who was given the wrong dose of chemotherapy.
    The Medicines and Healthcare products Regulatory Agency (MHRA) said it had taken “immediate” action under regulation 28 of the Human Medicines Regulations 2012 law “where it appears to the MHRA that in the interests of safety the licence should be suspended”.
    The MHRA found “significant deficiencies” in standards at Sciensus during an investigation triggered by the death of one patient and the hospitalisation of three others. 
    All four patients were administered “incorrect” doses of an unlicensed version of cabazitaxel, a licensed chemotherapy used to treat prostate cancer, according to people familiar with the matter.
    Read full story
    Source: The Guardian, 25 July 2023
  22. Patient Safety Learning
    Bisexual people experience worse health outcomes than other adults in England, a study has found.
    Data from lesbian, gay or bisexual (LGB) patients indicates these groups have poorer health outcomes compared to those who identify as heterosexual.
    The new findings indicate that bisexual people face additional health disparities within an already marginalised community.
    Experts from the Brighton and Sussex Medical School, and Anglia Ruskin University who led the analysis of more than 835,000 adults in England, suggest the differences could result from unique prejudice and discrimination that can come from both mainstream society and LGBTQ+ communities.
    Read full story
    Source: The Independent, 25 July 2023
  23. Patient Safety Learning
    The deaths of dozens of people who took their own lives while patients of an NHS trust will be reviewed after concerns were raised.
    Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) will review all 63 suicides since 2017.
    It comes after the trust was accused of adding to the records of Charles Ndhlovu, 33, the day after he took his own life to "correct their mistakes".
    Mr Ndhlovu, who was diagnosed with paranoid schizophrenia and substance misuse, had been under CPFT's care for two months when he died in Ely in 2017.
    Last month, his mother Angelina Pattison, from Newmarket, Suffolk, told the BBC his care plan "was done when he died - when they were running around to correct their mistakes, which they have done".
    Read full story
    Source: BBC News, 25 July 2023
  24. Patient Safety Learning
    The Government has rejected several policy proposals to promote “continuity of care” in general practice which were put forward by Jeremy Hunt. 
    The now chancellor championed significant policy changes to strengthen the link between patients and an individual, named GP, when he was Commons health and social care committee chair.
    However, the government’s response to the report rejects several of the key proposals.
    The committee under Jeremy Hunt said “NHS England should champion the personal list model” – under which each patient is linked to a particular GP – “rather than dismiss it as unachievable”.
    The Department of Health and Social Care response said: “The department does not accept this recommendation. We agree that continuity of care is important within general practice but do not agree that requiring a return to the personal list model is the correct approach.
    Government also rejected recommendations from Mr Hunt’s committee to introduce a new national measure to track continuity of care by practice; and to fund primary care networks to appoint a GP “continuity lead” for a session a week.
    Read full story (paywalled)
    Source: HSJ, 24 July 2023
  25. Patient Safety Learning
    An ambulance trust accused of hiding information from a coroner about patients that died is keeping a damning internal report about the deaths secret, the Guardian can reveal. A consultant paramedic implicated in the alleged cover-ups continues to be involved in decisions to keep the report from the public.
    Earlier this month, North East Ambulance Service (NEAS) apologised to relatives after a review into claims it covered up errors by paramedics and withheld evidence from the local coroner about the deceased patients. But a bereaved family left in the dark about mistakes made before their daughter’s death have rejected the apology.
    Now, it has emerged that a 2020 internal interim report on the alleged cover-up continues to be kept secret by the trust. The damning report by consultants AuditOne has been leaked to the Guardian after first being exposed by the Sunday Times. 
    Paul Aitken-Fell, a consultant paramedic blamed in the report for amending information sent to the coroner and removing crucial passages about mistakes by the trust’s paramedics, remains in post. He also holds the gatekeeper role of FoI review officer, and as such has endorsed decisions to refuse to release the report to members of the public who ask for it.
    Read full story
    Source: The Guardian, 24 July 2023
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