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Patient Safety Learning

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  1. Patient Safety Learning
    America is facing an intensified push to pass stalled federal legislation to address the US’s alarming maternal mortality rates and glaring racial disparities which have led to especially soaring death rates among Black women giving birth.
    Maternal mortality rates in the US far outpace rates in other industrialised nations, with rates more than double those of countries such as France, Canada, the UK, Australia, Germany. Moms in the US are dying at the highest rates in the developed world.
    Overall maternal mortality rates in the US spiked during the pandemic. Maternal deaths in the US rose 40% from 861 in 2020 to 1,205 in 2021, a rate of 32.9 deaths per 100,000 live births. For Black women, these maternal mortality rates were significantly higher, at 69.9 deaths per 100,000 live births in 2021.
    These racial disparities in maternal health outcomes have persisted and worsened for years as the number of women who die giving birth in the US has more than doubled in the last two decades.
    The CDC noted in a review of maternal mortalities in the US from 2017 to 2019, that 84% of the recorded maternal deaths were preventable.
    Read full story
    Source: The Guardian, 23 July 2023
  2. Patient Safety Learning
    NHS England’s target for all trusts to have a working electronic patient record (EPR) system by March 2025 is now ‘unachievable’’ and a new date has been set a year later, government has admitted.
    A new report of the Infrastructure and Projects Authority – the government body which scrutinises and supports major projects – states: “Delivery confidence is [rated] red as a number of NHS trusts are reporting they are unlikely to be able to fully implement an electronic patient record by March 2025.”
    The document, published quietly last week, downgrades the rating from “amber” to “red” – and also reveals £700m was cut from the programme’s budget last year. 
    The “frontline digitisation” programme was launched by government and NHSE in 2021 with the aim of getting all trusts to a minimum level of capability, including 90% to have an EPR of an acceptable standard by the end of 2023, and 100 per cent by March 2025. 
    But the IPA report states that a revised business case is now being prepared to reflect a new “end date” of March 2026.
    Read full story (paywalled)
    Source: HSJ, 24 July 2023
  3. Patient Safety Learning
    Women who lose babies during pregnancy will be able to get a certificate as an official recognition of their loss as well as better collection and storage of remains under new government plans.
    The government will make sure the certificate is available to anyone who requests one after experiencing any loss pre-24 weeks’ gestation.
    The NHS will develop and deliver a sensitive receptacle to collect baby loss remains when a person miscarries. A&Es will also have to ensure that cold storage facilities are available to receive and store remains or pregnancy tissue 24/7 so that women don’t have to resort to storing them in their home refrigerators.
    The new recommendations are part of the government’s response to the independent Pregnancy Loss Review.
    Read full story
    Source: The Independent, 23 July 2023
  4. Patient Safety Learning
    Most NHS staff think they have too little time to help patients and the quality of care the service provides is falling, a survey reveals.
    Medical and nursing groups said the “very worrying” findings showed that hard-pressed staff cannot give patients as much attention as they would like because they are so busy.
    In polling YouGov carried out for the Guardian, 71% of NHS staff who have direct contact with patients said they did not have the amount of time they would like to have to help them. A third (34%) felt they had “somewhat less than enough time” and 37% “far less than enough time” than they wanted. Almost a quarter (23%) felt they had the right amount of time while just 3% said they had “more time” than they wanted.
    The survey presents a worrying picture of the intense pressures being felt at the NHS frontline. Those same personnel were asked if they thought the quality of care the service is able to offer has got better or worse over the last five years. Three-quarters (75%) said “worse”, including a third (34%) who answered “much worse”, while 17% said “about the same” and only 6% replied “better”.
    Read full story
    Source: The Guardian, 24 July 2023
  5. Patient Safety Learning
    A trust breached its own internal illness policy when managers sacked a doctor who had PTSD and had been drunk at work, an employment tribunal has ruled.
    Judges criticised the move as a “complete failure” by East and North Hertfordshire Trust when Vladimir Filipovich was dismissed in July 2019.
    Dr Filipovich was summoned to a hearing following allegations he had been drunk at work, did not disclose a diagnosis of post-traumatic stress disorder to his employer, and failed to take a recommended prescription of Citalopram.
    In a decision published this month, the tribunal sharply criticised how the trust’s investigator handled the Citalopram claim, concluding he “did nothing to investigate the matter whatsoever”, and found ENHT had “appeared to simply take legal advice” on how to dismiss Dr Filipovich.
    The tribunal also concluded ENHT “stopped following” its own illness policy, which aimed to get practitioners to return to work, and “abandoned” its requirement to obtain the latest occupational advice.
    Read full story (paywalled)
    Source: HSJ, 21 July 2023
  6. Patient Safety Learning
    Just one-fifth of staff at a trust engulfed in an abuse scandal expressed confidence in the executive team, according to the Care Quality Commission (CQC), which has downgraded the trust and its leadership team to ‘inadequate’.
    The CQC inspected Greater Manchester Mental Health Trust following NHS England launching a review into the trust in November 2022 after BBC Panorama exposed abuse and care failings at the medium-secure Edenfield Centre.
    The two inspections, made between January and March 2023, which assessed inpatient services and whether the organisation was well-led, also saw the trust served with a warning notice due to continued concerns over safety and quality of care, including failure to manage ligature risks on inpatient wards.
    Inspectors identified more than 1,000 ligature incidents on adult acute and psychiatric intensive care wards in a six-month period. In the year to January, four deaths had occurred by use of ligature on wards which the CQC said “demonstrated that actions to mitigate ligature risks and incidents by clinical and operational management had not been effective”.
    Read full story (paywalled)
    Source: HSJ, 21 July 2023
  7. Patient Safety Learning
    The Royal College of Nursing (RCN) has said patients are waiting for days in corridors at Belfast's Royal Victoria Hospital's Emergency Department.
    Rita Devlin, NI director of the RCN, visited the unit on Thursday after getting calls from nursing staff.
    She described the situation as "scandalous".
    Speaking to Radio Ulster's Evening Extra programme, Ms Devlin said while it was the Royal Hospital on Thursday, the situation is "bad right across the EDs".
    She said talking to nurses at the Royal, she was struck by "the absolute despair" some are feeling.
    "I spoke to some young, newly qualified nurses who are leaving because they just can't take the stress and the pressure any more," she said.
    Read full story
    Source: BBC News, 20 July 2023
  8. Patient Safety Learning
    The director of the Modernisation Agency in the early 2000s is returning to lead a new national service improvement drive, NHS England has announced, while asking systems and providers to “baseline” their improvement needs and capability.
    NHSE is establishing a “national improvement board” to oversee a new improvement programme called NHS Impact, as recommended by a review last year of the current infrastructure.
    NHSE announced the board will be chaired by David Fillingham, who was director of the NHS Modernisation Agency from 2001-2004 where, NHSE said, “he focused on developing new practices and fostering leadership development”. 
    The national improvement board will choose a small number of improvement priorities to be followed across national bodies and the wider health service. It will “set the direction of system wide improvement” through “collaboration and co-design,” NHSE said.
    Read full story (paywalled)
    Source: HSJ, 19 July 2023
  9. Patient Safety Learning
    Campaigners are planning to launch legal action after NHS chiefs in North Yorkshire placed limits on which adults can get referrals for autism and attention deficit hyperactivity disorder (ADHD) assessments.
    North Yorkshire and York Health and Care Partnerships introduced a pilot programme in March in which adults seeking an NHS assessment for autism or ADHD are triaged via an online screening tool.
    NHS chiefs say this screening process prioritises those with the most severe needs, rather than processing referrals in chronological order.
    These priority needs reportedly include the patient being at risk of immediate self-harm or harming others, at risk of being unable to have lifesaving hospital treatment or care placement, or an imminent risk of family court decisions being determined on diagnosis.
    Those who do not meet the criteria are given guidance and signposted to other support networks.
    But campaigners say that in practise that means that most people cannot get a referral for an assessment – GPs can no longer make referrals themselves.
    Read full story
    Source: The Big Issue, 19 July 2023
    Related reading on the hub:
    Long waits for ADHD diagnosis and treatment are a patient safety issue  
  10. Patient Safety Learning
    Adults across an integrated care system area are facing ‘unacceptable’ 10-year waits for an NHS assessment for attention deficit hyperactivity disorder, the longest known wait for such services in England.
    Herefordshire and Worcestershire integrated care board has warned in board papers of “exceptionally high waiting times for ADHD assessment and treatment for Worcestershire patients (10 years+), with workforce challenges and service fragility compromising service delivery”.
    HSJ understands the long waits for ADHD diagnosis, which is a national problem, is predominately affecting adults with approximately 2,000 people on Herefordshire and Worcestershire’s ADHD list alone.
    Local provider Herefordshire and Worcestershire Health and Care Trust also warned on its website that its paediatric services were also “experiencing unprecedented demand”.
    Read full story (paywalled)
    Source: HSJ, 19 July 2023
  11. Patient Safety Learning
    The bodies of people who died with Covid were treated like "toxic waste" and families were left in shock, a bereaved woman has told the inquiry.
    Anna-Louise Marsh-Rees said her father Ian died "gasping for breath" after catching the virus while in hospital.
    Ms Marsh-Rees, who leads Covid-19 Bereaved Families for Justice Cymru, said he was "zipped away", and his belongings put in a Tesco carrier bag.
    Ian Marsh-Rees died after catching the virus while in hospital, aged 85. His daughter said finding information regarding his care in hospital and how he became infected was "almost like an Agatha Christie mystery".
    She said no GP ever suggested he might have Covid, although she now knows his discharge notes said he had been exposed to Covid.
    "It wasn't until we saw his notes some months later that we saw the DNA CPR (do not attempt CPR) placed on him, and this was without consultation with us," she said.
    "It kind of haunts us all that… people used to say 'well they're in the right place' when they go to hospital. I'm not sure they would say that any more," Ms Marsh-Rees said.
    She now wants to change the way deaths are handled by health boards. She said it was important to prepare families before and support them after the death of a loved one, from palliative care to dignity in death.
    Read full story
    Source: BBC News, 18 July 2023
  12. Patient Safety Learning
    Just one in five staff who were approached in a trust’s internal inquiry – prompted by an undercover broadcast raising serious care concerns – engaged with the process, a report has revealed. 
    Essex Partnership University Foundation Trust said it took “immediate action” to investigate issues highlighted in a Channel 4 Dispatches programme into two acute mental health wards last year. This included speaking to staff identified as a high priority in the investigation. 
    However, a new Care Quality Commission report has revealed, of the 61 staff members the trust approached, only 12 engaged with the process. 
    Read full story (paywalled)
    Source: HSJ, 19 July 2023
  13. Patient Safety Learning
    A cut to the NHS tech budget, revealed by HSJ, has been described as “pretty outrageous” by a former government adviser and eminent medical leader.
    Sir John Bell, an immunologist and geneticist and regius chair of medicine at Oxford University, made the comments in a talk at the Tony Blair Institute’s Future of Britain conference.
    NHSE’s cut to its tech budget was attributed to having to divert the money to fund spending growth, and some other inflationary costs, without receiving extra from government. At the time, NHSE said the service “remains firmly committed to our digital strategy from supporting hospitals to adopt electronic patient record systems to transforming how patients access NHS services through the NHS App”.
    But Sir John said: “The NHS is a technology averse healthcare system.”
    He said NHS spending on medicines was “much lower than peers and if you look at our access to technology – like MRI and CR scanners – we’re right at the back. We just don’t do it.”
    He added that rapid tech development and adoption was needed particularly to enable mass early diagnosis of diseases, and new treatment therapies.
    Read full story (paywalled)
    Source: HSJ, 18 July 2023
  14. Patient Safety Learning
    Children in some areas of England are waiting up to 18 months on average for dental general-anaesthetic treatment and teeth extractions, an investigation reveals.
    Some have been left with prolonged dental pain, according to information shared with BBC News.
    The parents of one girl who has waited three years for extractions say the pain keeps her up at night.
    At the start of this year, more than 12,000 under-18s were on waiting lists for assessment or treatment at community dental service (CDS) providers, data obtained by the Liberal Democrats from the NHS Business Services Authority and shared with BBC News earlier this year reveals.
    Children are referred to a CDS provider when they have tooth decay too severe to be treated in general practice.
    They also treat those with physical or learning disabilities when general practice is not a practical option.
    The longest average wait faced by children for general-anaesthetic treatment at a CDS provider is 80 weeks, at Harrogate and District NHS Foundation Trust.
    Read full story
    Source: BBC News, 19 July 2023
  15. Patient Safety Learning
    Senior sources have described a ‘culture battle’ in NHS England’s approach to urgent care recovery after systems were told to carry out “maturity” self-assessments, and appoint “champions” to drive improvements.
    Systems were last week told by NHSE to ”self assess” their compliance against key asks in the UEC recovery plan, and asked to nominate urgent care “recovery champions” to “create a community, close to the front line, who can help drive improvement” in emergency care.
    The “champions” and self-assessments are part of a new “universal offer” of support being drawn up by NHSE under its scheme for urgent care recovery, in which Integrated Care Boards are also being placed in “tiers” of intervention.
    It is the first project carried out under NHSE’s new service improvement banner, called “NHS Impact” or “improving patient care together”, which was established after an internal review recommended it should focus on a “small number of shared national priorities”.
    Read full story (paywalled)
    Source: HSJ, 18 July 2023
  16. Patient Safety Learning
    Concerns codeine-based cough syrup could be addictive and have serious health consequences have led the UK medicines safety regulator to consider stopping its sale over the counter.
    The Medicines and Healthcare products Regulatory Agency (MHRA) is asking the public for their views on changing codeine linctus - which is a syrup with the active ingredient codeine phosphate and is used to treat a dry cough - to a prescription-only medicine.
    This comes in the wake of multiple reports to the regulator that the medicine is instead being used recreationally for its opioid effects. Since 2018, the MHRA has received 116 reports of recreational drug abuse of, dependence on, and/or withdrawal from codeine medicines, including codeine linctus.
    Dr Alison Cave, MHRA Chief Safety Officer, said this can have a severe impact on people’s health. She said: “Codeine linctus is an effective medicine, but as it is an opioid, its misuse and abuse can have major health consequences.”
    Pharmacists are also “significantly” concerned, especially about the overdose risk.
    Read full story
    Source: The Independent, 18 July 2023
  17. Patient Safety Learning
    Physical health and “hips, knees and eyes” still command the lion’s share of government money, despite persistent calls for fairer mental health funding, the Royal College of Psychiatrists’ departing president has told HSJ.
    Adrian James also said future leaders must tackle bed and workforce shortages, while upcoming inquiries into poor care must allow people to speak openly without fear. 
    NHS England CEO Amanda Pritchard has called the minimum investment standard for mental health “non-negotiable”. However, in an interview with HSJ, Dr James said mental health services are often missing out while “big chunks” of government money are allocated to reduce waiting lists. 
    He said: “The [covid] recovery plan that was negotiated with the government really was about your hips, knees and eyes, in spite of big voices – one of them mine – saying, ‘what about the mental health backlog’. At that point, we didn’t get any extra money.”
    Read full story (paywalled)
    Source: HSJ, 18 July 2023
  18. Patient Safety Learning
    A coroner has criticised an NHS trust over the deaths of two new mothers with herpes.
    Kimberley Sampson, 29, and Samantha Mulcahy, 32, died in 2018 after having caesarean sections six weeks apart by the same surgeon at hospitals in Kent.
    Their families have been waiting five years for answers on how they came to be infected with the virus, which can cause sores around the mouth or genitals.
    Catherine Wood, Mid Kent and Medway coroner, said Sampson could have been given an anti-viral treatment sooner.
    Wood added that in Mulcahy’s case “suspicion should have been raised” given the knowledge among staff from Sampson’s earlier death.
    The coroner ruled out human culpability of any of the medical staff involved in the case and said it was “unlikely” for the surgeon to be the cause of the herpes infection found in both women.
    Read full story
    Source: The Guardian, 14 July 2023
  19. Patient Safety Learning
    A14-year-old girl could lose the ability to walk after her brain surgery was cancelled three times as NHS children’s services are stretched to breaking point.
    Piper Miller, who has severe autism, needs urgent surgery to remove fluid on her brain that if unaddressed could also leave her unable to control her bladder.
    But her operation has been pushed back three times in the past month due to emergency operations taking priority and severe short staffing made worse by junior doctors’ strikes.
    Her mum, Toni Milner said the delays had had a “heartbreaking and gut-wrenching” effect on her daughter whose anxiety is “sent through the roof” each time she is told she is not having her surgery.
    Piper’s story comes as NHS data uncovered by The Independent reveals at least 340 life-saving children’s operations, such as transplant and lung surgery, were shelved from April to December 2022, while 763 emergency operations were refused due to a lack of intensive care beds.
    Read full story
    Source: The Independent, 16 July 2023
  20. Patient Safety Learning
    Soon after her son Jaxson was born, Lauren Clarke spotted that his eyes were yellow and bloodshot. “We kept asking if he had jaundice, but each time we were told to keep feeding him and just put Jaxson in front of a window,” she says.
    It was only when Clarke was readmitted six days later with an infection that Jaxson’s jaundice was detected by a midwife. By this time, his levels were becoming dangerously high.
    “We spent a further five days in hospital for Jaxson to be treated with light therapy and antibiotics. If I hadn’t had to go back to hospital, he could have died or had serious long-term health conditions,” she says.
    This week, the NHS race and health observatory will announce new funding for research into the efficacy of jaundice screening in black, Asian and minority ethnic newborns on the back of a recent report showing that tests to assess newborn babies’ health are not effective for non-white children.
    The research cannot come too soon. Jaxson’s aunt, Gemma Poole, a midwife from Nottingham, created her company, the Essential Baby Company, to develop resources and training about the specific needs of women and babies with black and brown skins, after Jaxson’s jaundice was initially missed by clinicians.
    Poole believes the trauma her nephew, brother and sister-in-law had to go through could have been avoided if health professionals had known better ways to spot jaundice in non-white babies.
    “The colour of gums, the soles of the feet and hands, the whites of eyes, how many wet and dirty nappies and if the baby is waking for feeds and alert could be more reliable indicators if a black or brown baby has jaundice,” she says.
    Read full story
    Source: The Guardian, 16 July 2023
  21. Patient Safety Learning
    Doctors have warned the decision to remove face mask guidance in healthcare settings is "playing Russian roulette" with staff and patients' welfare.
    It was withdrawn in May in hospitals, dentists and GP surgeries having been in place since June 2020.
    Doctors from the British Medical Association (BMA) Scotland condemned the decision at the time.
    Now, the Scottish Healthcare Workers Coalition has written to ministers to highlight the "very serious flaws" in changing the guidance.
    The group is made up of Scottish healthcare workers who worked throughout the pandemic and are now living with long Covid or another chronic post-viral illness or disability.
    In the letter, the coalition states the updated guidance is not based on the science of coronavirus transmission and "represents a flawed and dangerous decision which will result in more infection in health and social care settings".
    Dr Shaun Peter Qureshi, of the Scottish Healthcare Workers Coalition, said: "At-risk patients have entirely legitimate concerns that they may endanger their health by visiting their GP or hospital.
    "With at least 4% of NHS staff now living with chronic post-Covid complications, the Scottish government must follow the evidence and improve protections from the airborne spread (of the virus) in healthcare settings, not reduce them."
    Read full story
    Source: BBC News, 17 July 2023
  22. Patient Safety Learning
    Children with suspected ADHD and autism are waiting as long as seven years for treatment on the NHS, as the health service struggles to manage a surge in demand during a crisis in child mental health.
    Experts said “inhumane” waits are putting a generation of neurodiverse children at risk of mental illness as they are “pushed to the back of a very long queue” for children and adolescent mental health services (Camhs).
    UK children with suspected neurodevelopmental conditions faced an average waiting time of one year and four months for an initial screening in 2022, more than three times longer than the average wait for all Camhs services, according to research carried out by the House magazine and shared with the Guardian.
    Half of all trusts responding to a freedom of information request had an average wait of at least a year, and at one-sixth of trusts it was more than two years. The NICE guidance for autism and mental health services stipulates that no one should wait longer than 13 weeks between being referred and first being seen.
    Read full story
    Source: The Guardian, 17 July 2023
    Related reading on the hub:
    Long waits for ADHD diagnosis and treatment are a patient safety issue
  23. Patient Safety Learning
    The government is on track to break a key election promise from Boris Johnson to build 40 new hospitals in England by the end of the decade, a damning report by the public spending watchdog has found.
    Delays to projects mean the target is unlikely to be met, with work on buildings in the second cohort of the scheme yet to have started as of May, according to the National Audit Office.
    The approach to achieving objectives at the lowest possible cost could also result in hospitals that are too small, the watchdog warned, as modelling assumptions may be unrealistic about the extent to which care in future will be provided outside hospitals.
    The government failed to achieve good value for money, with the scheme having cost £1.1bn by March this year, and progress has been slower than expected, the report concluded.
    The claim will ignite concerns that the new hospitals would struggle to cope in the event of another pandemic, given England already has one of the highest rates of hospital bed occupancy among countries in the Organisation for Economic Co-operation and Development.
    Read full story
    Source: The Guardian, 17 July 2023
  24. Patient Safety Learning
    A trust at the centre of a maternity scandal has been failing to meet Royal College standards in one of its maternity units, HSJ can reveal.
    The duty anaesthetist for the maternity unit at the William Harvey Hospital in Ashford has also had to cover the hospital’s primary percutaneous coronary intervention suite. This could mean no anaesthetist is available to carry out an emergency Caesarean if they are needed to treat a heart attack patient. 
    This goes against Royal College of Anaesthetists’ guidelines, which say a duty anaesthetist must be “immediately available for the obstetric unit 24/7”. The guidelines add that where the duty anaesthetist has other responsibilities – because, for example, they work at a smaller maternity unit where the workload does not justify them being there exclusively – then “these should be of a nature that would allow the activity to be immediately delayed or interrupted should obstetric work arise”. 
    The William Harvey unit is East Kent Hospitals University Foundation Trust’s major birth centre. The trust has around 6,500 births a year – the majority at the WHH – and was heavily criticised for poor maternity care in a report by Bill Kirkup last year.
    Read full story
    Source: HSJ. 17 July 2023
  25. Patient Safety Learning
    The US Food and Drug Administration (FDA) has approved the first over-the-counter contraceptive pill, allowing millions of women and girls in the country to buy contraception without a prescription at a time when some states have sought to restrict access to birth control and abortion.
    FDA officials said on Thursday it cleared Perrigo’s Opill – an every day, prescription-only hormonal contraception first approved in 1973 – to be sold over-the-counter. The pill will be available in stores and online in the first quarter of next year, and there will be no age restrictions on sales. The regulatory approval paves the way for people to purchase the pill without a prescription for the first time since oral contraceptives became widely available in the 1960s.
    “Today’s approval marks the first time a nonprescription daily oral contraceptive will be an available option for millions of people in the United States,” Patrizia Cavazzoni, the director of the FDA’s center for drug evaluation and research, said in a statement.
    “When used as directed, daily oral contraception is safe and is expected to be more effective than currently available nonprescription contraceptive methods in preventing unintended pregnancy.”
    Read full story
    Source: The Guardian, 13 July 2023
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