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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    The NHS and a local council have been told to urgently find a home for a 28-year-old autistic man who is facing psychological and physical abuse within a mental health hospital, after an independent review of his care. Nicholas Thornton has autism and learning disabilities and is currently being held in the Rochford mental health unit, in Essex, after a decade of being locked away in places not able to care for him adequately. Now an independent safeguarding review into his care provided at the Essex hospital has ordered the local authority and NHS to find him a home in the community because his relationship with hospital staff has become so bad he is facing psychological and physical harm. He is one of the 2,045 people with learning disabilities and autism trapped within inpatient units across England. Mr Thornton has been in the unit, run by the Essex Partnership University NHS Foundation Trust (EPUT), since May this year. He is not under a mental health section, nor does he need mental health treatment, but he is unable to leave because the local authority has not agreed on a place into which he can be discharged. EPUT is currently facing a public inquiry probing the deaths of 2,000 patients following multiple reviews since 2016 from coroners, the police and health ombudsman criticising the care within the hospital. A safeguarding report into Mr Thornton’s situation, seen by The Independent and Channel Four News, revealed staff working in the Rochford hospital told investigators they cannot adequately care for Mr Thornton themselves as they are not trained in supporting patients with autism. Read full story Source: The Independent, 13 December 2023
  2. News Article
    The trusts paying the highest premiums for clinical negligence as a proportion of their income have been revealed through HSJ analysis of internal data. Several acute trusts in and around London are now spending more than 4% of their income on premium costs to insure themselves against clinical negligence, according to internal NHS data. One expert suggested trusts with higher proportions of ethnic minority patients often have high rates of negligence claims against them, partly due to the complexity of medical presentation, but also communication problems. Lisa Jordan, head of medical negligence at law firm Irwin Mitchell, said trusts that act as tertiary referral centres tend to admit the most complex cases, which are more likely to lead to claims. She added: “Trusts in areas with higher proportions of ethnic minority groups, also often have higher rates. That is in part about the complexity of medical presentation, and also communication problems.” Helen Hughes, chief executive of Patient Safety Learning, said: “Scarce funds that could be spent proactively improving the quality of care are being spent on the costs of error and harm.” Read full story (paywalled) Source: HSJ, 13 December 2023
  3. News Article
    Many people are deeply confused about the growing number of “physician associates” in the NHS and wrongly assume they are doctors, research suggests. Around 4,000 physician associates work in the NHS in England. Ministers and health chiefs plan to increase the figure to 10,000 to help plug widespread gaps in the NHS workforce. However, there is widespread confusion among the public about their role and relationship with fully trained medics, according to a survey commissioned by the British Medical Association (BMA). A quarter of the representative sample of 2,009 people erroneously believed that a physician associate was a doctor, while a fifth made the same mistake about “physician assistants”. Many respondents thought that a physician associate was more senior than a junior doctor, even though only the latter have a medical degree. The expansion of physician associates has prompted a backlash by grassroots medics. They fear patients will be misled into thinking they have seen a doctor despite physician associates not having the same skills and training. The government has moved to try to quell criticism of physician associates by legislating to ensure they are regulated by the General Medical Council (GMC). Read full story Source: The Guardian, 13 December 2023
  4. Content Article
    Healthcare Inspectorate Wales (HIW) is the independent inspectorate of the NHS and regulator of independent healthcare in Wales. The findings of their Annual report outline the sustained pressure on healthcare services across Wales, highlighting risks relating to emergency care, staffing concerns, poor patient flow and the accessibility of appointments. It sets out how the HIW carried out their functions across Wales, seeking assurance on the quality and safety of healthcare through a range of activities. This includes inspections and review work in the NHS, and regulatory assurance work in the independent healthcare sector. The report provides a summary of what HW's work has found, the main challenges within healthcare across Wales, and HIW's view on areas of national and local concern.
  5. News Article
    NHS Highland will no longer receive extra government support in leadership, governance or culture, following improvements after the Sturrock review. The board was initially escalated to Stage 3 of NHS performance escalation framework in 2018 following concerns of a culture of workforce bullying and harassment. An independent report by John Sturrock QC, commissioned by the Scottish government, confirmed “fear, intimidation and inappropriate behaviour” and called for wide-ranging changes. The Healing Process was created in response, with an independent review panel established to speak to victims of bullying and come up with recommendations for the health board to make improvements. A total of 272 current and former NHS Highland and local health and social care partnership staff provided testimony between 2019 and March this year, with more than £2.8m paid out to those affected by bullying. Concerns were raised by some of the first people to go through the healing process that the system was “broken” and many victims could end up “bitterly disappointed”. The board has also established systems and processes to allow colleagues to speak up in the wake of the Sturrock Review, including an independent Guardian Service and staff training in Courageous Conversations. NHS Highland was handed oversight of its own escalation and de-escalation, rather than a Scottish government-led oversight group, in November 2021. Following a letter of assurance from the board chair earlier this year, the Chief Executive of NHS Scotland, Caroline Lamb, agreed to the de-escalation in September. Independent progress tracking shows the board has delivered significantly against many actions laid out by the review but the board concluded in its final June update that ‘culture change is not yet embedded at all levels of our organisation’. Read full story Source: Health and Care Scotland, 2023
  6. News Article
    GP practices with the most outdated technology and processes do not have enough staff or funding to take part in NHS England’s performance recovery programme, integrated care boards are warning. In new recovery plans which they were required to publish by NHSE, multiple ICBs have said that stretched capacity means hardly any practices have signed up to the “general practice improvement programme”, which is meant to help them implement the national primary care access recovery plan. The ICBs pointed out that the programme is time consuming, and practices which take part are not always given funding to pay for staff time. HSJ has reviewed the primary care recovery plans which all ICBs were required to bring to their board meetings in October and November, to explain how they were implementing the national plan published by NHSE in the spring. NHSE’s plan sought to improve ease and speed of access through spreading “modern” methods and processes; as well as measures to save clinicians’ time, improving same-day access, and delivering more appointments. But HSJ’s review of the ICB plans found several warning that their uptake of the improvement plan was off track, especially for “intermediate” and “intensive” support, which require substantial time for the practices, and are likely to be required by those most in need of help. Read full story (paywalled) Source: HSJ, 12 December 2023
  7. News Article
    Regulators have warned hospital leaders they may have to ‘depart from established procedures’ over winter to minimise ambulance handover delays. In a joint letter to nursing and medical leaders, NHS England, the Care Quality Commission and professional regulators said it was “vital that we have a whole system approach to risk across the urgent and emergency care pathway”. The push has come amid a huge increase in instances of crews being held outside emergency departments, resulting in extended response times for time-critical 999 calls. The letter added: “We… understand there will be concerns about working under pressure, and that you and your teams may need to depart from established procedures on occasion to provide the best care. “Please be assured that your professional code and principles of practice are there to guide and support your judgments and decision making in all circumstances. This includes taking into account local realities and the need to adapt practice at times of significantly increased pressure. “In the unlikely event of a complaint to your professional regulator they will, as is their usual practice, consider carefully whether they need to investigate. If an investigation is needed, they will consider all relevant factors including the context and circumstances in which you were working. “One area that may be an example of this is in handing patients over to emergency departments from ambulance services. There is a strong correlation between ambulance handover delays at emergency departments and ambulance category 2 response delays, meaning longer handovers increase the chances those in need will wait longer for an ambulance.” Read full story (paywalled) Source: HSJ, 11 December 2023
  8. Content Article
    James Titcombe, Melanie Leis, and Peter Howitt delineate the major themes of a roundtable to address challenges in improving patient safety, emphasising the need for data sharing nuances, cultural shifts, optimising limited resources, prioritising workforce plans, and staff well-being.
  9. News Article
    After the $261 million verdict against Johns Hopkins All Children's Hospital, health system public relations departments have a new concern: unwillingly becoming the subject of a streaming service documentary. Released on Netflix in June, "Take Care of Maya" tells the story of Maya Kowalski, whose family brought her to the St. Petersburg, Fla., hospital's emergency department in 2016 with chronic pain. After physicians suspected child abuse, the then-10-year-old was kept there apart from her loved ones for nearly three months, during which time her mother killed herself. Millions of viewers watched the documentary, which detailed the family's then-unsuccessful attempt to sue the hospital. In November, a Florida jury awarded the Kowalskis the nine-figure sum for damages on counts including medical negligence and false imprisonment. "The level of global exposure and awareness of this case helped drive the interest, engagement and discussions in the community," Karen Freberg, PhD, professor of strategic communication at University of Louisville (Ky.), told Becker's. "This is a situation where hospitals across the board must evaluate their crisis communication plans from this experience and see how they would address this situation if it happened to them." She said any reputation-fixing lessons for this case, then, will come not from hospitals that have lost big lawsuits, but from companies that have been the subject of unflattering documentaries. Read full story Source: Becker's Hospital Review, 7 December 2023
  10. News Article
    Women in labour at a London maternity unit deemed “inadequate” were left alone with unsupervised support workers who were not given any guidance, an NHS safety watchdog has found. In a scathing report of North Middlesex Hospital’s maternity services, the Care Quality Commission also found examples of delays to induction of birth for women, and one case of a woman with a still-born baby who was left waiting for the unit to call her in for an induction. Inspectors have downgraded the maternity unit from “good” to the lowest possible rating “inadequate” following an inspection earlier this year. Staff reportedly told inspectors they felt they were “criticised” or “bullied” when reporting safety incidents within the unit. “We heard that the criticism or bullying was worse if the incident reported was relative to other staff and their perceived behaviours,” the report said. There was also evidence the hospital was not recording the severity of safety incidents correctly for example two “never events”, which are among the highest category incidents, were categorised as “low harm”. Other findings included women and babies came to harm as the hospitals did not follow standards to language interpretation despite covering a higher than average minority ethnic population. Read full story Source: The Independent, 11 December 2023
  11. News Article
    The risk of dying from cancer in England “varies massively” depending on where a person lives, according to a study that experts say exposes “astounding” health inequalities. Researchers who analysed data spanning two decades found staggering geographical differences. In the poorest areas, the risk of dying from cancer was more than 70% higher than the wealthiest areas. Overall, the likelihood of dying from cancer has fallen significantly over the last 20 years thanks to greater awareness of signs and symptoms, and better access to treatment and care. The proportion dying from cancer before the age of 80 between 2002 and 2019 fell from one in six women to one in eight, and from one in five men to one in six. However, some regions enjoyed a much larger decline in risk than others, and the new analysis has revealed that alarming gaps in outcomes remain. “Although our study brings the good news that the overall risk of dying from cancer has decreased across all English districts in the last 20 years, it also highlights the astounding inequality in cancer deaths in different districts around England,” said Prof Majid Ezzati, from Imperial College London, who is a senior author of the study. Read full story Source: The Guardian, 11 December 2023
  12. Content Article
    Cancers are the leading cause of death in England. This study from Rashid et al. published in Lancet Oncology aimed to estimate trends in mortality from leading cancers from 2002 to 2019 for the 314 districts in England. The study found that declines in overall cancer mortality have been unequal both geographically and among different groups of cancers. The greatest geographical inequality was observed for cancers with modifiable risk factors and potential for screening for precancerous lesions. Addressing risk factors such as smoking and alcohol use, expanding access to and utilisation of screening for prevention and early detection, and improving the quality of care should be used to reduce deaths in areas where they remain highest. High-resolution spatiotemporal data can help identify where intervention is required and track progress.
  13. News Article
    Campaigners have written to the chief constables of Norfolk and Suffolk to request an investigation into thousands of mental health deaths in those areas. They say coroners are raising safety issues but no improvements are being made. A report by independent auditors found as many as 8,440 patients had died unexpectedly over three years. Norfolk and Suffolk NHS Foundation Trust said it had started a review of patient deaths. Coroners worried about the risk of future deaths highlight unsafe practices in prevention of future deaths reports (PFDs). And authorities are required by law to respond with an action plan within 56 days. The Norfolk and Suffolk trust said it had responded to all PFDs and was working to ensure recommendations and actions were implemented. But Mark Harrison, from the Campaign to Save Mental Health Services in Norfolk and Suffolk, said: "There's a criminal case to answer. And we want the police to investigate, where the same mistakes have been repeated time and time again." He said coroners were repeatedly warning of risks such as delays to treatment, lack of patient follow-ups, chaotic record keeping and disorganised communication between teams. Mr Harrison said: "The mental health trust always responds saying they've learned lessons, they are changing policy and practices. "But then what we're seeing in analysing the orders from the coroner are repeat circumstances where other people have died in similar circumstances to a previous prevention-of-future-deaths notice." Read full story Source: BBC News, 12 December 2023
  14. News Article
    An overworked nurse who failed to give medication to a patient told a colleague “I don’t care anymore”, a hearing was told. Niall O’loingsigh was lead nurse in the Avon unit within the Charterhouse Care Home in Keynsham, Somerset, which looks after elderly residents and those with dementia. In 2020 a complaint was made by a colleague about him breaching safe medication management protocols and being dishonest in relation to medication administration. A misconduct hearing at the Nursing and Midwifery Council was told later, in May 2021, he was seen behaving in an “unsupportive manner” and told a colleague: “I don’t care anymore”. The panel also heard how on 18 May 2021, Mr O’loingsigh failed to record he had administered medication to three residents, BristolLive reported. A colleague wanted to report Mr O’loingsigh’s conduct, in which Mr O’loingsigh patted her on the back and said “well done mate, you did the right thing but I may lose my PIN though”. Mr O’loingsigh told his colleague of feelings of distress and anxiety about being reported and its impact on his career, but he wanted to reassure her. The colleague however felt “uncomfortable”. The panel found that he underwent “a course of conduct which put patients at risk of suffering harm at the time of the incidents” and noted “there were repeated failures over a period of time”. Read full story Source The Mirror, 10 December 2023
  15. News Article
    Physician Associates (PAs) and Anaesthesia Associates (AAs) will soon be regulated by the General Medical Council (GMC), improving patient safety and supporting plans to expand medical associate roles in the NHS to relieve pressure on doctors and GPs. The government will lay legislation this week to allow the GMC to begin the process of regulating medical associates, who are medically trained healthcare professionals who work alongside doctors to care for patients. The GMC will set standards of practice, education and training, and operate fitness to practice procedures, ensuring that PAs and AAs have the same levels of regulatory oversight and accountability as doctors and other regulated healthcare professionals. The regulations will come into force at the end of 2024. Physician Associates and Anaesthesia Associates are already making a great contribution to the NHS, supporting doctors to provide faster high quality care for patients. This new legislation paves the way for these professionals to be held to the same strict standards as doctors, boosting patient safety. Regulation and growth of these roles will support plans to reduce pressure on frontline services and improve access for patients. Health and Social Care Secretary, Victoria Atkins, said: "Physician Associates and Anaesthesia Associates are already making a great contribution to the NHS, supporting doctors to provide faster high quality care for patients. This new legislation paves the way for these professionals to be held to the same strict standards as doctors, boosting patient safety. This is part of our Long Term Workforce Plan to reform the NHS to ensure it has a workforce fit for the future." Read Press release Source: The Department of Health and Social Care and The Rt Hon Victoria Atkins MP, 11 December 2023
  16. News Article
    Doctors at a Black Country mental health trust have backed a vote of no confidence in their management team. Sources say that the Black Country Healthcare NHS Trust is not acting in the best interests of patients and they believe it wants to cut beds. They also have no confidence in the way that the trust has removed its chief medical officer, Mark Weaver. The NHS Trust said it was aware of concerns and had agreed to work on them going forward. The doctors wrote to the trust board following a meeting of the Medical Advisory Committee claiming that over the past two years the relationship with the board had become fractured. In the letter they claimed the voice of doctors was not being taken seriously by the board and that clinical priorities were secondary to financial performance. They also said they were seriously disturbed with the way in which Mr Weaver had been asked to step down and that the deputy chief medical officer Dr Sharada Abilash had not been asked to take over while due process occurred. Read full story Source: BBC News, 9 December 2023
  17. News Article
    The Care Quality Commission (CQC) has apologised after admitting it failed to act on whistleblowing concerns “in a timely manner”. Allegations had been made to the CQC about staff at Cambridgeshire and Peterborough Foundation Trust tampering with a patient’s record after they had died by suicide. As previously reported, the accusations by whistleblower Des McVey have sparked a review of the trust’s conduct in more than 60 suicide cases. Mr McVey says the trust only took action following media coverage and that the CQC had ignored his concerns. The regulator has now upheld a complaint from him, with operations manager James DeCothi writing to Mr McVey: “I have established that [the relevant CQC inspector] did not share your concerns with the provider in a timely manner and that our contact with you from July 2022 to June 2023 was inconsistent. I apologise on behalf of CQC for this. [The CQC inspector] has reflected on this and has asked me to offer her apologies to you also. “I can confirm that CQC have followed up the areas of concern that you have shared, and we will continue to use the information you have shared to inform future regulatory activity. I would like to thank you again for sharing this information with us.” Read full story (paywalled) Source: HSJ, 11 December 2023
  18. News Article
    Patients needing emergency treatment are becoming sicker in A&E as hospitals struggle to free up enough beds, top doctors have warned. Dr Adrian Boyle, president of the Royal College of Emergency Medicine (RCEM), told The Independent that elderly patients are waiting so long for treatment in A&E that they’re developing bed sores and delirium. Another senior NHS doctor, Dr Vicky Price, who is president-elect of the Society for Acute Medicine, warned that corridor care is now “routine practice” with the situation only set to worsen as A&E departments come under increasing pressure. Their comments highlight the ongoing chaos in emergency medicine, as strikes take place during the most difficult time of the year. The chief executive of the NHS, Amanda Pritchard, said on Thursday that last winter was the worst she’d ever seen for the health service, warning that strikes by junior doctors will only make the situation harder for hospitals this year The warnings come as the latest NHS data shows that the prime minister, Rishi Sunak, could fail in his promise to deliver 5,000 more acute hospital beds to the NHS this month. Current data shows that the NHS is falling short of the target by just under 1,200 beds, with 97,818 against a target of 99,000. Read full story Source: The Independent, 10 November 2023
  19. Content Article
    A patient safety incident investigation (PSII) is undertaken when an incident or near-miss indicates significant patient safety risks and potential for new learning. Investigations explore decisions or actions as they relate to the situation. The method is based on the premise that actions or decisions are consequences, not causes, and is guided by the principle that people are well intentioned and strive to do the best they can. The goal is to understand why an action and/or decision was deemed appropriate by those involved at the time.  This NHS England document provides an overview of patient safety incident investigation stages, tips and suggested structure for analysis.
  20. News Article
    The under delivery of intravenous antibiotics in some NHS hospitals due to lack of polices and compliance may be contributing to antimicrobial resistance (AMR), according to a parliamentary report. Findings in the report indicated that many health service organisations do not have policies in place to reduce the risk of under delivery and those that do can struggle to comply fully with them. The report’s authors warned that the residual volume of antibiotic remaining in the line of the IV administration set can result in under delivery of up to 30% of the prescribed dose. They said that, as a result, this could be leading to possible resistance within patients, owing to the accumulative effect. Nurses involved with compiling the document have called for action. Based on the findings, the report recommended that all NHS organisations implement line flushing policies by late 2024, with support from the Department for Health and Social Care. Read full story (paywalled) Source: Nursing Times, 9 December 2023 Further reading on the hub: Short-term intermittent IV antibiotics – Understanding the issue of under delivery Understanding the importance of accurate antibiotic administration through an IV administration set (drip): A patient’s guide Top picks: 10 key resources on antimicrobial resistance
  21. News Article
    Surgeons at one London hospital are performing an entire week’s operations in a single day as part of a ground-breaking initiative that could help tackle the record waiting lists in the NHS. Guy’s and St Thomas’ NHS Foundation Trust has already slashed its own elective backlog in certain specialities by running monthly HIT (High Intensity Theatre) lists at weekends. Under the innovative model, two operating theatres run side by side and as soon as one procedure is finished the next patient is already under anaesthetic and ready to be wheeled in. Nurses are on standby to sterilise the operating theatre and instead of taking 40 minutes between cases it takes less than two, the only delay is the 30 second it takes for the anti-bacterial cleaning fluid to work. Kariem El-Boghdadly, the consultant anaesthetist who designed the programme with his colleague Imran Ahmad, compares it to a Formula One pit stop. “They’ve got one person doing the rear right wheel, one person doing the front left wheel. It’s the same thing. The operating theatre is effectively like that.” Read full story (paywalled) Source: The Times, 10 December 2023
  22. News Article
    The health inequalities between different ethnicities, neighbourhoods and social classes are already stark, with millions of women in the most deprived areas in England dying almost eight years earlier than those from wealthier areas. But according to the UK Health Security Agency’s (UKHSA) report, these disparities will worsen as the impact the climate crisis has on health is disproportionately negative to the most disadvantaged groups. These particular groups include people with disabilities, homeless people and people living in local authorities with high levels of deprivation. Sir Michael Marmot, the director of the Institute of Health Equity and the author of the landmark Marmot review into health inequalities in 2010, said that climate breakdown can make health inequalities worse. Prof Lea Berrang Ford, the head of the Centre for Climate and Health Security at the UKHSA, made it clear that the negative health effects of climate breakdown will not be distributed equally across the UK, social determinants or generations. The report said that children and young people will experience increasingly severe weather into their retirement, with effects persisting or increasing for their children. Ford said: “The distribution of the impacts of climate change do not just differ across geographic regions, but also across different socio-demographic groups. “Climate change is well recognised as likely to exacerbate existing health inequalities, and across a range of health impacts the most vulnerable groups are adults over 65 years old, children and those with pre-existing medical conditions.” Read full story Source: The Guardian, 11 December 2023
  23. Content Article
    This is the fourth Health Effects of Climate Change in the UK report, which provides evidence, analysis and recommendations based on climate change projections for the UK. Climate change affects most health determinants directly or indirectly by influencing the weather conditions we experience on a day-to-day basis. Climate change can increase risks to health directly through greater severity and frequency of extreme weather events such as flooding, drought, heatwaves or wildfires. Heatwaves, for example, have already led to excess deaths in England and they can increase burden on health and care services, increase strain on water, energy and transportation infrastructure and can have implications such as crop loss and reduced air quality that can also impact health. Many infectious diseases are highly climate sensitive, and with warmer temperatures we can expect an increased risk of new and emerging infectious diseases in the UK, including those transmitted through mosquito and tick bites. The impact of climate change on individuals will vary, with the worst effects on disadvantaged and vulnerable populations, which could widen health inequalities further.
  24. Content Article
    Lucy Letby was allowed to continue working with new-born babies despite her colleagues raising concerns about her for months. Her conviction highlighted how NHS executives put the reputation of the Countess of Chester NHS Trust ahead of patient safety. But what happened in Cheshire was far from a one-off. File on 4 hears from doctors with unblemished medical careers who were sacked after raising patient safety concerns. The programme follows one medic through an Employment Tribunal as he attempts to save his career, and hears the emotional, brutal toll the process takes on him. For the first time, a top doctor who won record damages talks about the extraordinary steps her managers took to undermine her. Their tactics included relocating her to an empty office with a broken chair and telling colleagues that she agreed with their assessment she was incompetent. And a former NHS executive tells the programme that trusts are more interested in “flying LGBT flags” than tackling concerns about patient safety. With widespread calls for NHS managers to be regulated, File on 4 asks who should take on the role, given the willingness of the NHS to redeploy managers found to have ignored patient safety concerns, or even punished those who dared to raise them.
  25. Content Article
    Dr Chris Turner, of Civility Saves Lives and consultant in emergency medicine, was invited by the NHS Highland Medical Education team to lead a series of lectures and workshops exploring the impact of our behaviour on our colleagues and workplace.
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