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Patient Safety Learning

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  1. Patient Safety Learning
    Leaders at a mental health trust tolerated high levels of safety incidents and accepted verbal assurance with ‘insufficient professional curiosity’, a critical report has found.
    An NHS England-commissioned review into governance at Tees, Esk and Wear Valleys Foundation Trust has been published, reviewing the organisation’s response to serious safety concerns flagged at the former West Lane Hospital in Middlesbrough.
    It follows separate reports identifying “systemic failures” over the deaths of inpatients Christie Harnett, Nadia Sharif and Emily Moore.
    The new report, conducted by Niche Consulting, criticises board and service leaders’ handling of concerns about the regular occurrence of restraint and self-harm.
    More than a dozen incidents of inappropriate restraint, some seeing patients dragged along the floor, were identified in November 2018, resulting in multiple staff suspensions and some dismissals. 
    Niche found there was a “lack of accountable leadership at all levels” and lack of evidence for decisions in response to the November 2018 incidents.
    Read full story (paywalled)
    Source: HSJ, 21 March 2023
  2. Patient Safety Learning
    A hospital trust has been told to pay almost a quarter of a million pounds after pleading guilty to failing to provide safe care to a patient with advanced dementia who fatally injured himself. 
    The Care Quality Commission (CQC) brought the prosecution against University Hospitals of Derby and Burton Foundation Trust after an incident in July 2019, when a patient died after absconding from the hospital.
    Peter Mullis – who had advanced dementia – was admitted to Queen’s Hospital Burton emergency department and absconded twice. When he tried to a third time, he was followed by trust staff.
    The CQC described how, despite being followed, Mr Mullis was able to climb over a barrier, fall down a grass bank and hit his head on concrete at the bottom. He was airlifted to the local trauma centre, but died of multiple traumatic injuries.
    The CQC said UHDB did not take “reasonable steps” to ensure safe care was provided and that failure exposed Mr Mullis to “significant risk of avoidable harm”.
  3. Patient Safety Learning
    The United States remains one of the most dangerous wealthy nations for a woman to give birth.
    Maternal mortality rose by 40% at the height of the pandemic, according to new data released by the US Centers for Disease Control and Prevention.
    In 2021, 33 women died out of every 100,000 live births in the US, up from 23.8 in 2020. That rate was more than double for black women, who were nearly three times more likely to die than white women, according to the CDC.
    Compared to other countries, the maternal mortality rate was twice as high in the US than in the UK, Germany and France; and three times higher than in Spain, Italy, Japan and several other countries, according to the most recent global comparison data kept by the World Bank.
    "Clearly the US is an outlier," said Joan Costa-i-Font, a professor of health economics at the London School of Economics. "Covid has made [maternal mortality] worse, but it was already a major issue in the US."
    Read full story
    Source: BBC News, 18 March 2023
  4. Patient Safety Learning
    The pressure to tackle long waiting lists in children’s community services is impacting care quality, clinical leaders have warned.
    It comes after community health services waiting list figures were published for the first time by NHS England last week.
    They revealed more than 200,000 children were waiting, of whom 12,000 had been waiting more than a year, and 65,000 more than 18 weeks. While adult community services lists have been coming down fairly steadily since the autumn, children’s services are failing to make progress.
    The children’s services with the longest lists are community paediatrics (which mostly deals with neurological development issues such as autism and ADHD), speech and language therapy, and children’s occupational therapy.
    Specialists in those areas told HSJ it was the result of staffing gaps, rising and more complex demand, Covid backlog, and years of underfunding.
    Read full story (paywalled)
    Source: HSJ, 20 March 2023
  5. Patient Safety Learning
    Twenty years ago, David Freedman helped to conduct an audit of the first 124 young people referred to the gender clinic, now he discovers it was never followed up.
    David Freedman, 73, helped to conduct a clinical audit of the first 124 young people referred to the Gender Identity Development Service (Gids) from its inception in 1989. The London-based service, part of the Tavistock and Portman NHS Foundation Trust, is the only dedicated NHS clinic for transgender children.
    When he discovered his clinical audit from two decades ago remained the only one conducted by the service, Freedman said he was “gobsmacked”, adding: “This was a service that was sailing into uncharted territory with vulnerable children and adolescents, where one has an extra duty of care, and the failure to collect any data in a coherent form to look at what they were doing . . . it’s pretty mind-boggling.”
    Read full story (paywalled)
    Source: The Times, 19 March 2023
  6. Patient Safety Learning
    Women have been left in extreme pain from an invasive procedure that’s been described as the “next big medical scandal”.
    The Campaign Against Painful Hysteroscopy (CAPH) has collated more than 3000 accounts of “pain, fainting and trauma during outpatient hysteroscopy” throughout the UK – including more than 40 so far from Scotland.
    CAPH said female patients are being subjected to barbaric levels of pain and claim hospitals prioritise efficiency and cost-cutting over their needs and welfare.
    The group believes the issue could become as bad as the vaginal mesh scandal, which saw women left in severe pain and with life-changing side effects after being treated with polypropylene mesh implants for stress urinary incontinence and pelvic organ prolapse.
    Katharine Tylko, of CAPH, said: “Severely painful outpatient hysteroscopy is the next medical scandal after vaginal mesh. Cheap, quick and easy-ish NHS outpatient hysteroscopy without anaesthesia/sedation causes severe pain/distress/trauma to approximately 25 per cent of patients.”
    Margaret Cannon, from Rutherglen in Lanarkshire, told how she had an “excruciatingly painful” hysteroscopy at Stobhill Hospital in April 2020 without anaesthetic or analgesia.
    She said: “I am a qualified nurse and midwife, so have good insight into how all the medical and nursing professionals failed me. I had been told to expect mild cramp and I kept thinking, ‘What’s wrong with me that I can’t tolerate the pain?’ I felt violated and assaulted.”
    She felt so strongly about her experience that she complained. When she finally received a response, she said it “was dismissive and none of my points were addressed”.
    Read full story
    Source: Daily Record, 19 March 2023
    See also our 'Painful hysteroscopy' thread in the hub Community.
  7. Patient Safety Learning
    More than 175,000 patient appointments and surgeries were postponed this week during the three-day junior doctor walk-out, it has emerged.
    NHS leaders have warned the strikes were the most disruptive yet with more appointments cancelled across three days than across any of the previous nurse strikes.
    Data published by the NHS showed in total 181,049 patients had their care postponed, this included more than 5,000 mental health and hundreds of community health appointments. 
    The news comes after nursing and ambulance unions accepted a pay offer from the government, for a 5.3 per cent increase in 2023-24, which their members will now vote on.
    Read full story
    Source: The Independent, 18 March 2023
  8. Patient Safety Learning
    Four in 10 NHS hospitals in England are using outdated medical equipment including 37-year-old X-ray machines, according to research from the Lib Dems, who are calling for extra funding to replace outdated devices.
    NHS hospitals are using hundreds of old X-ray machines, CT scanners and radiotherapy machines, with some dating back to the 1980s, according to research based on freedom of information requests to 69 hospital trusts. Of these, 41 said they had at least one X-ray machine that was more than 20 years old.
    The Liberal Democrat leader, Ed Davey, said he would call for urgent government investment in medical equipment at the party’s spring conference.
    “It beggars belief that NHS staff are having to rely on results from decades-old hospital scanners, machinery that may have been built before they were even born. Understaffed and exhausted NHS staff are being pushed to breaking point, while patients are treated in crumbling hospitals with outdated equipment,” he said.
    “The potential for error from poor-quality machines doesn’t bear thinking about. People up and down the country will be worried about whether they will get an accurate reading from these decades-old machines.”
    Read full story
    Source: The Guardian, 20 March 2023
  9. Patient Safety Learning
    The NHS’s efforts to prop up emergency departments with thousands of additional medical staff has been the wrong approach to solving the crisis in these services, experts have argued.
    Analysis of NHS staffing data by HSJ shows the emergency care medical workforce has grown by almost two-thirds since 2016, far outstripping the growth in other specialties. Despite this, waiting times in accident and emergency have deteriorated significantly over the same period.
    John Appleby, chief economist at the Nuffield Trust think tank, said: “Cramming the A&E department with more doctors doesn’t look like it’s having the intended effect over the last four to five years. Waiting times have got worse and we have more staff.
    “Increasing staffing has helped with waiting times in the past, but maybe we have reached a point where it’s not staffing in A&E which is the issue. The issue is the front door and the backdoor of the A&E.”
    Read full story (paywalled)
    Source: HSJ, 17 March 2023
  10. Patient Safety Learning
    US health officials say that eyedrops may have killed one person and severely injured several others due to drug-resistant bacterial contamination.
    The Centers for Disease Control and Prevention (CDC) have identified 68 patients across 16 states with a rare strain of Pseudomonas aeruginosa.
    The strain had never been found in the US before this latest outbreak.
    In addition to the one death, eight patients have suffered vision loss, and four have had eyes surgically removed.
    Most of the patients diagnosed with the infection reported using eyedrops and artificial tears, according to the CDC.
    Ten different brands were initially identified as possibly linked to the outbreak, the CDC said. Eyedrops that are made in India and imported to the US under two brands were subsequently pulled from shelves in January and February.
    Read full story
    Source: BBC News, 17 March 2023
  11. Patient Safety Learning
    Health Education England (HEE) has outlined a new vision for general practice training which it says will better prepare GPs for future models of care.
    The programme will have greater focus on areas such as addressing health inequalities and managing the growing proportion of patients with mental health care needs seen in general practice, HEE said.
    Innovative placements, perhaps with charities, third sector organisations and services such as CAHMS will be explored, the Training the Future GP report said.
    And it should include educational opportunities around improving cancer detection and referral, the report said, as well as training in the harms of overdiagnosis.
    Overall the goal is to move to a flexible model of training that meets the needs, skills and experiences of the trainee as well as the area they are working in.
    HEE said it would also continue to work to address issues of discrimination, prejudice, bias and specifically racism at individual, institutional and systemic levels, and to reduce differential attainment.
    It will include plans to ensure patients in deprived areas are able to access care, with the development of specific training offers on these issues and prioritising expansion of training capacity to areas in need.
    Read full story
    Source: Pulse, 17 March 2023
  12. Patient Safety Learning
    A woman was denied the chance to have children with her husband after a contraceptive coil was accidentally left in place for 29 years.
    Jayne Huddleston, from Crewe, had eight rounds of fertility treatment she did not need because the correct checks were not carried out by her doctor.
    She said the mistake happened in 1990.
    "The GP said it couldn't be seen, so I was sent for a scan and the scan didn't pick anything up, the GP recommended another coil was fitted," she told the BBC.
    She was told the coil she had fitted around a year earlier had probably fallen out.
    When she and her husband, David, then decided they wanted to have a child, the second coil was removed, but the first coil, which had gone undetected, remained inside her.
    They tried for years to have a baby, with no success, including IVF treatment which cost them thousands of pounds.
    The mistake was only discovered when she went for an X-ray in 2019 after complaining of back pain and the original coil was revealed.
    Mr and Mrs Huddleston were awarded a six-figure out of court settlement after taking their case to Irwin Mitchell solicitors.
    Read full story
    Source: BBC News, 16 March 2023
  13. Patient Safety Learning
    An ambulance trust that was the subject of a documentary involving covert filming by an employee has warned staff they could be subject to ‘disciplinary action and even prosecution’ if they take this type of action.
    East of England Ambulance Service Trust sent an all staff email yesterday outlining the potential consequences of filming covertly and reminding staff they must adhere to the trust’s social media and digital guidelines.
    The email, seen by HSJ, followed Channel 4 broadcasting a documentary called Undercover ambulance: NHS Chaos – Dispatches which featured footage filmed covertly by one of the trust’s apprentice emergency technicians, and laid bare the extreme pressures on hospital and ambulance staff.
    The message sent on Thursday by the trust’s interim officer Melissa Dowdeswell, said the apprentice who carried out the filming had since resigned and then set out what support staff could access from the trust if they had been affected by “an incredibly difficult couple of weeks”.
    Read full story (paywalled)
    Source: HSJ, 17 March 2023
  14. Patient Safety Learning
    Healthgrades recognised 864 US hospitals with its 2023 Patient Safety Excellence Awards and Outstanding Patient Experience Award. Only 83 of those hospitals received both awards. 
    The dual recipients spanned 28 states. Texas had the most dual recipients with 12 honorees — including three Baylor Scott and White Health hospitals. 
    Read full story
    Source; Becker's Hospital Review, 14 March 2023
  15. Patient Safety Learning
    Deliberate attempts were made to “conceal the extent of racial discrimination” at a national NHS agency, according to a report leaked to HSJ.
    A highly critical internal report at NHS Blood and Transplant (NHSBT) also said fewer than half the recommendations made in 2020 by external mediation experts, around issues of racism, had so far been actioned.
    A review conducted by Globis Mediation Group in 2020 found “systemic racism” among management at the agency’s large Colindale site in north London, with ethnic minority staff being “ignored, being viewed as ineligible for promotion and enduring low levels of empathy”.
    It made nine recommendations, including exploring whether similar issues existed at the other 15 NHSBT sites.
    Read full story
    Source: HSJ, 16 March 2023
  16. Patient Safety Learning
    Following the Advanced cyber attack in August 2022, Phil Huggins has revealed to a Digital Health Rewired audience that the NHS has “seen no clinical impact or significant clinical harm”, after a review to be released in the near future.
    The national chief information security officer for health and care at NHS England was speaking alongside a panel on the Cyber Security Stage on day two of Digital Health Rewired 2023 in London.
    Huggins explained that although the impact of the Advanced attack was big on the system, in a clinical sense it was not particularly damaging, despite the fact that client data was confirmed to have been exfiltrated.
    However, Ayesha Rahim, clinical lead for digital mental health at NHS England and chief medical information officer at Surrey and Borders Partnership Foundation Trust, was also on the panel, and spoke of the huge impact the attack had on staff.
    “The date 4th August is imprinted in my brain”, Rahim said, which is when the attack first happened and was first reported. She explained that it is “quite difficult to fully convey the chaos this caused”, giving examples of staff having no idea what a patient’s background was and therefore having to do everything “blindfolded”.
    Rahim said staff could not tell if it was safe to go out on visits to mental health patients due to the lack of data and information on them, and every time a person saw a staff member they were retraumatised having to explain their past over and over, including experiences of sexual abuse.
    Read full story
    Source: Digital Health, 15 March 2023
  17. Patient Safety Learning
    Some hospitals are suspending supplies of gas and air, after it was found to pose health risks to midwives. What can be done to ensure pregnant women still get the help they need?
    When Leigh Milner was expecting her first baby, she knew exactly how she wanted her labour to go. Her birth plan included an epidural for the pain and she was hoping, she says ruefully, for “all the drugs”. But that is not how things worked out. Milner, 33, a BBC presenter, ended up giving birth to Theo at Princess Alexandra hospital in Harlow last month with nothing but paracetamol for pain relief, in what she calls a positively “Victorian” experience.
    “I kept begging over and over again – ‘I need something for pain relief’ – and the only thing they could give me was paracetamol because they didn’t have gas and air. I was quite frightened, I didn’t know what else to do,” says Milner.
    "Birth is painful, but it shouldn’t be traumatic.”
    Read full story
    Source: The Guardian, 16 March 2023
  18. Patient Safety Learning
    Gonorrhoea cases in England have resurged since the easing of Covid restrictions, health officials are warning people who are sexually active.
    The disease is caused by the bacterium Neisseria gonorrhoeae. The infection is spread by unprotected vaginal, oral and anal sex.
    Symptoms can include a thick green or yellow discharge from sexual organs, pain when urinating and bleeding between periods, but some people will have no symptoms.
    Condoms can stop the spread of this and other sexually transmitted infections. 
    Experts say people should practise safe sex and get tested regularly if they are having sex with new or casual partners. Testing is simple, free and discreet, they advise.
    Provisional data shows diagnoses in the first half of 2022 hit 56,327 - 21% higher than for the same period in 2019.
    An untreated infection can lead to infertility, pelvic inflammatory disease and can be passed on to a child during pregnancy.
    Read full story
    Source: BBC News, 16 March 2023
  19. Patient Safety Learning
    Life expectancy in the UK has grown at a slower rate than comparable countries over the past seven decades, according to researchers, who say this is the result of widening inequality.
    The UK lags behind all other countries in the group of G7 advanced economies except the US, according to a new analysis of global life expectancy rankings published in the Journal of the Royal Society of Medicine.
    While life expectancy has increased in absolute terms, similar countries have experienced larger increases, they wrote. In the 1950s, the UK had one of the longest life expectancies in the world, ranking seventh globally behind countries such as Denmark, Norway and Sweden, but in 2021 the UK was ranked 29th.

    The researchers said this was partly due to income inequality, which rose considerably in the UK during and after the 1980s.
    Prof Martin McKee, of the London School of Hygiene & Tropical Medicine, said: “That rise also saw an increase in the variation in life expectancy between different social groups. One reason why the overall increase in life expectancy has been so sluggish in the UK is that in recent years it has fallen for poorer groups".
    Read full story
    Source: The Guardian, 16 March 2023
  20. Patient Safety Learning
    NHS staff have accused Steve Barclay of breaking a pledge to publish details of how many of them are abused and assaulted in the course of their work.
    In 2018, when Barclay was a junior minister in the Department of Health and Social Care (DHSC), he promised he would resume publication of those statistics in the following year.
    However, five years later, Barclay has not fulfilled his pledge, despite being in his second stint as health secretary.
    Health unions and NHS leaders have warned that frontline staff have been on the receiving end of increased abuse, threats, aggression and assaults since the first outbreak of Covid. Long waiting times for care appear to be a particular source of frustration for some patients or their relatives.
    Growing numbers of ambulance crew personnel have begun using body-worn cameras in recent years to deter assaults and record any that do occur. In 2022, the London ambulance service recorded 877 reports of verbal abuse or threats of violence, 516 physical assaults – including kicking, punching, head-butting and use of a weapon – and 49 sexual assaults on staff.   Read full story   Source: The Guardian, 16 March 2023  
  21. Patient Safety Learning
    The disruption caused by the junior doctors' strike in England could take weeks to resolve, health bosses say.
    Tens of thousands of appointments and treatments, including cancer care, had to be cancelled during the three-day walkout.
    Patients with appointments coming up may see them cancelled to make room for high-priority cases hit by the strike.
    Hospitals are also reporting problems discharging patients from wards, as consultants were sent to cover A&E.
    Saffron Cordery, of NHS Providers, which represents NHS trusts, said the scale and length of the walkout, coupled with the fact it started on a Monday - traditionally the busiest day of the week - had made it more difficult than previous strikes by nurses and ambulance staff.
    "It will take weeks to recover - just rebooking patients who have treatments and appointments cancelled is a big job," she said.
    "Patients have to be individually prioritised - it may mean some patients with bookings in the coming weeks being pushed further back."
    Read full story
    Source: BBC News, 16 March 2023
  22. Patient Safety Learning
    A chief executive has apologised after a survey of his trust’s staff from minority ethnic backgrounds found many had been subjected to racist behaviour by colleagues.
    The staff at East of England Ambulance Service Trust said peers had made monkey noises and referred to banana boats in front of them, excluded them from social events, and assumed they could speak Middle Eastern and Asian languages just because of their skin colour, they told researchers.
    The trust has had substantial cultural problems for several years, and commissioned the survey to “better understand the experience, perceptions and realities of the trust BME staff”, a board paper said.
    The report on its findings, published this week in trust board papers, warns: “There are risks that a minority of EEAST employees are demonstrating behaviours or using language which could be perceived as racist. Reports of subsequent inaction by managers further risk this behaviour being normalised.”
    Read full story (paywalled)
    Source: HSJ, 15 March 2023
  23. Patient Safety Learning
    The US Emergency Care Research Institute (ECRI) has said the paediatric mental health crisis is the most pressing patient safety concern in 2023.
    ECRI, which conducts independent medical device evaluations, annually compiles scientific literature and patient safety events, concerns reported to or investigated by the organization, and other data sources to create its top 10 list.
    Here are the 10 patient safety concerns for 2023, according to the report: 
    1. The pediatric mental health crisis
    2. Physical and verbal violence against healthcare staff
    3. Clinician needs in times of uncertainty surrounding maternal-fetal medicine
    4. Impact on clinicians expected to work outside their scope of practice and competencies
    5. Delayed identification and treatment of sepsis
    6. Consequences of poor care coordination for patients with complex medical conditions
    7. Risks of not looking beyond the "five rights" to achieve medication safety
    8. Medication errors resulting from inaccurate patient medication lists
    9. Accidental administration of neuromuscular blocking agents
    10. Preventable harm due to omitted care or treatment
    For the number one spot, ECRI said the COVID-19 pandemic raised the situation, which includes high rates of depression and anxiety among children, to crisis levels. 
    ECRI President and CEO Marcus Schabacker, MD, PhD, said social media, gun violence and other socioeconomic factors were fueling the issue, but COVID-19 pushed it into a crisis.  
    "We're approaching a national public health emergency," Dr. Schabacker said in a statement. 
    Read full story
    Source: Becker's Hospital Review, 13 March 2023
  24. Patient Safety Learning
    A scandal-hit hospital group has been sanctioned by inspectors after The Independent revealed “systemic abuse” at a string of children’s mental health units.
    England’s safety watchdog issued an official warning to Ivetsey Bank Hospital in Staffordshire, run by The Huntercombe Group, after an extensive investigation by this newspaper found the private hospital had put the safety of young mental health patients at risk.
    The Care Quality Commission also downgraded the hospital’s rating to “inadequate”. If improvements are not made in line with the warning notice, the hospital could be forced to close.
    An inspection was carried out two weeks after The Independent revealed widespread allegations of abuse and excessive restraint across The Huntercombe Group’s hospitals.
    The investigation revealed the provider, which also runs Taplow Manor children’s hospital in Maidenhead, was facing allegations from more than 50 former patients as well as claims of poor care from staff whistleblowers and dozens of negligence claims.
    Read full
    Source:  The Independent, 15 March 2023
  25. Patient Safety Learning
    Certain cough medicines sold behind the counter at pharmacies are being withdrawn over safety concerns.
    Health experts say there is a very rare chance that some people could experience an allergic reaction linked to an ingredient called pholcodine.
    People should check the packaging of any cough tablets or syrups they have at home to see if pholcodine is listed among the ingredients. If it is, talk to your pharmacist about taking a different medicine.
    Products containing pholcodine do not need a prescription, but cannot be bought without consultation with the pharmacist as they are kept behind the counter.
    The Medicines and Healthcare Products Regulatory Agency (MHRA) described removing the products from sale as a precautionary measure.
    Read full story
    Source: BBC News. 15 March 2023
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