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Patient Safety Learning

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  1. Patient Safety Learning
    Acute trusts are reporting high demand at emergency departments (EDs) despite junior doctor strikes, which in some cases threaten to lead to overflowing wards and long ambulance handover delays.
    Chief executives and directors from trusts around England told HSJ their EDs had been as busy or busier than usual.
    Many had hoped prominent media coverage and NHS announcements about the strikes would lead to reduced demand, helping them cope with fewer doctors on duty. Several claimed it showed national communications about the strikes were lacking.
    NHS England has said some hospitals saw their busiest Monday of the year so far yesterday, which it said “presents a major challenge as our staff continue to do all they can to mitigate the impact of the industrial action for patients.”
    Read full story (paywalled)
    Source: HSJ, 14 March 2023
  2. Patient Safety Learning
    The patient safety commissioner has complained to MPs that she does not have enough staff to cope with her ‘significant workload’, it has emerged.
    Henrietta Hughes’ concerns are revealed in a letter from Commons health and social care committee chair Steve Brine to health and social care secretary Steve Barclay.
    Mr Brine asks for assurances over the commissioner’s resources and says he was “concerned” Dr Hughes had told him her current funding was “too little to make the necessary improvements” to safety oversight.
    Mr Brine wrote on 6 March: “I am in regular contact with Dr Hughes and the matter of resources for her office is something that she has raised with me. She tells me that her office is under extreme pressure, with a significant workload, including correspondence from patients.”
    Mr Brine told Mr Barclay he shared Dr Hughes’ concerns that without “sufficient resourcing” there was a risk that the safety commissioner role would – according to Dr Hughes – “let down the hopes of patients that were raised by the publication of Baroness Cumberlege’s report”.
    Read full story (paywalled)
    Source: HSJ, 14 March 2023
  3. Patient Safety Learning
    A new US study highlights a striking racial disparity in infant deaths: Black babies experienced the highest rate of sudden unexpected deaths (SIDS) in 2020, dying at almost three times the rate of White infants.
    The findings were part of research by the Centers for Disease Control and Prevention, which also found a 15% increase in sudden infant deaths among babies of all races from 2019 to 2020, making SIDS the third leading cause of infant death in the United States after congenital abnormalities and the complications of premature birth.
    “In minority communities, the rates are going in the wrong direction,” said Scott Krugman, vice chair of the department of pediatrics and an expert on SIDS at Sinai Hospital in Baltimore.
    The study found that rising SIDS rates in 2020 was likely attributable to diagnostic shifting — or reclassifying the cause of death. The causes of the rise in sleep-related deaths of Black infants remain unclear but it coincided with the arrival of the coronavirus pandemic, which disproportionately affected the health and wealth of Black communities.
    Read full story (paywalled)
    Source: The Washington Post, 13 March 2023
  4. Patient Safety Learning
    Data revealed for the first time shows nearly three-quarters of adult patients needing community mental health care are waiting more than four weeks for treatment to start, which is the timeframe that NHS England wants to introduce as a national standard.
    Figures shared with HSJ also show two-thirds of children needing community care are waiting more than four weeks from referral to treatment.
    In 2021, NHS England proposed a series of new waiting time standards in mental health, including a four-week standard for non-urgent community care.
    A lack of new funding, as well as data recording problems, mean the new standards have not so far been introduced, and no timeline set for implementation.
    Read full story (paywalled)
    Source: HSJ, 14 March 2023
  5. Patient Safety Learning
    A couple whose baby died after he was starved of oxygen during a home birth are campaigning for risky breech deliveries to be spotted earlier.
    Arthur Trott was an undiagnosed breech baby, born after a planned home birth in Burgess Hill on 24 May 2021.
    A breech delivery is when a baby's bottom or feet will emerge first.
    An inquest into his death found a delay in transfer to hospital "materially contributed" to his brain injury.
    The South East Coast Ambulance Service Trust said it welcomed "any changes to national breech birth guidance".
    Arthur's parents believe a breakdown in communication between the paramedics who attended and their control room meant Mrs Trott was kept at home too long.
    Arthur's father, Matt Trott, said: "You could hear the panic and confusion in everyone's voices. One minute they were told to go to hospital, the next minute to stay."
    As a result of Arthur's death, all planned home births in Sussex are being offered a presentation scan at 38 weeks.
    Read full story
    Source: BBC News, 14 March 2023
     
  6. Patient Safety Learning
    NHS England was aware of concerns about upper gastrointestinal surgery at a hospital nearly three years before the Care Quality Commission intervened to stop it being carried out, HSJ can reveal.
    NHSE in the South East commissioned a report into upper GI cancer services in parts of the region in January 2020. In particular, HSJ understands the review was prompted by concerns the small number of surgeries carried out at the Royal Sussex County Hospital in Brighton meant it may be unable to comply with parts of the service specification and face difficulties maintaining an adequate surgical workforce rota.
    Despite these concerns, Brighton continued to carry out upper GI surgery until the CQC suspended planned oesophagic-gastric resections last August.
    Read full story (paywalled)
    Source: HSJ, 14 March 2023
  7. Patient Safety Learning
    An NHS England investigation into claims of a toxic culture at a hospital trust has been described as lacking transparency and undermining trust.
    The Parliamentary Health Service Ombudsman also said there were "very serious" patient safety issues at University Hospitals Birmingham (UHB).
    Criticism is contained in letters seen by the BBC between the ombudsman, the trust and NHS England.
    The inquiries, commissioned by the Birmingham and Solihull Integrated Care Board and the local NHS, were begun in response to an investigation by BBC Newsnight and BBC West Midlands which heard from current and former clinicians from the trust, who accused it of being "mafia-like".
    One of England's biggest hospital trusts, UHB has been in the spotlight for months after three probes were started following allegations doctors there were threatened for raising safety concerns.
    The trust denies this and says its "first priority is patient safety".
    The ombudsman, however, said he was sceptical about the reviews' transparency and independence.
    His finding of "very serious" patient safety issues at UHB is based on the trust's response to the ombudsman's recommendations and findings, including a case of an avoidable patient death.
    Read full story
    Source; BBC News, 14 March 2023
  8. Patient Safety Learning
    The patient lay slumped next to a pile of pills and a personally signed note reading: 'do not resuscitate me'. His breathing was agonal, his skin mottled, his pupils fixed, no pulse discernible. The attending doctor, in agreement with both paramedics and family member, decided to respect his wishes. Yet, this GP was placed under investigation for gross negligence manslaughter by the Crown Prosecution Service (CPS) for not resuscitating the patient, setting in motion a sequence of investigations, including by the coroner and the General Medical Council (GMC), that were triggered by the statement of one policeman at the scene. 
    All investigations and allegations were eventually dismissed but not until the GP had been through years of significant physical and mental stress. Still today, questions remain unanswered – in particular, concerning the actions of the police and the CPS.
    Speaking under the condition of anonymity, the GP spoke to Medscape News UK, and said that now, over 7 years after that fateful home visit, she remained resolute that she made the correct clinical decisions at the time.
    "It has all been very stressful for me. What was behind this case? What was driving this potential prosecution? And throughout, the patient, the family and their concerns were completely forgotten in the pursuit of so-called justice," she pointed out.
    Read full story
    Source: Medscape News, 9 March 2023
  9. Patient Safety Learning
    Hospitals are being asked to offer a wider range of gown sizes to better protect patients' dignity.
    It follows the experience of a patient from Wiltshire who said she was offered a gown that was "far too small" during a hospital stay in Bristol.
    Barbara Gale said it gaped at the back and made her feel "embarrassed".
    The experience sparked calls for more sizing options..
    An independent study conducted by the University of Strathclyde in Glasgow in 2019 asked patients across the UK for their thoughts on the issue of hospital gowns.
    Consultant clinical psychologist for the NHS, Nicola Cogan, led the research and said the findings showed Ms Gale's experience was not an isolated case.
    She said: "We spoke to a 1,000 patients and found over two thirds reported they struggled to get a gown on themselves and 70% reported the gown did not fit".
    "It's not cost effective for the NHS, but also it shows that the gown is currently not fit for purpose."
    Read full story
    Source: BBC News, 13 March 2023
  10. Patient Safety Learning
    More than 100,000 patients, including children, have been treated in so-called virtual wards over the last year, NHS officials have said.
    Leading medics said that the use of the system to monitor patients at home has been a “real game changer”.
    Officials say virtual wards can help patients avoid unnecessary hospital trips altogether, or enable them to be sent home from hospital sooner.
    Using various equipment and technology, clinicians can monitor vital signs such as a patients’ heart rate, oxygen levels and temperature remotely.
    NHS England’s national medical director, Professor Sir Stephen Powis, said: “The advantages of virtual wards for both staff and patients have been a real game-changer for the way hospital care is delivered and so it is a huge achievement that more than 100,000 patients have been able to benefit in the last year alone, with the number of beds up by nearly two thirds in less than a year.
    “With up to a fifth of emergency hospital admissions estimated to be avoided through better supporting vulnerable patients at home and in the community, these world-leading programmes are making a real difference not just to the people they directly benefit but also in reducing pressure on wider services.”
    Read full story
    Source: The Independent. 11 March 2023
  11. Patient Safety Learning
    MPs from across the political spectrum have called for a ban on electroconvulsive therapy (ECT) as a treatment for mental illness in England, and want the practice to be subject to an urgent inquiry.
    MPs told The Independent they have serious concerns that women are disproportionally given electroconvulsive therapy, and argued that patients are not properly notified of the treatment’s potential side effects. Some patients have also reported that they weren’t asked to provide consent before it was administered.
    Dr Pallavi Devulapalli, a GP, called for the government to undertake an “urgent and comprehensive review” of the treatment as she warned that patients’ wellbeing was “at stake”.
    The calls come after The Independent previously reported that thousands of women were being given ECT despite concerns that it can cause irreversible brain damage.
    It comes after Dr Sue Cunliffe, who began receiving ECT in 2004, previously told The Independent that the treatment had “completely destroyed” her life despite a psychiatrist having told her there would be no long-term side effects.
    Dr Cunliffe, a former children’s doctor, said: “By the end of it, I couldn’t recognise relatives or friends. I couldn’t count money out. I couldn’t do my two times table. I couldn’t navigate anywhere. I couldn’t remember what I’d done from one minute to another.”
    Read full story
    Source: The Independent, 12 March 2023
  12. Patient Safety Learning
    Bereaved families are having to report maternity blunders because watchdogs and hospitals are unable to spot failings, an expert has warned.
    Bill Kirkup said avoidable deaths were "a badge of shame" but would continue without urgent change.
    Eight years on from his report into the Morecambe Bay maternity scandal, he said the failure of officials to act had needlessly cost more lives.
    "I am very disappointed – and surprised – that we're still where we are", he said. "That's a terrible badge of shame for the health service that it takes families to come and tell us what's wrong. 
    "Yet just about every tragedy that I've ever been involved with investigating has come to light when there's a group of families who say 'You've got a problem here'.
    "People are lying, they're not being open and they're concealing what's happening.
    "If we can't bring this change, I'm not confident that there won't be another East Kent, Morecambe Bay or Nottingham, somewhere else."
    Read full story
    Source: Mail Online, 10 March 2023
  13. Patient Safety Learning
    A cross-border trial has improved care for patients prescribed multiple medicines.
    The iSIMPATHY project, funded by the European Union's INTERREG VA Programme, worked with professionals in Scotland, the Republic of Ireland and Northern Ireland to comprehensively review patient medication.
    Taking multiple medicines can be problematic if the increased risk of harm from interactions between drugs, or between drugs and diseases, outweighs the intended benefits.
    Interim findings showed these interventions potentially prevented major organ failure, adverse drug reactions, avoided hospital admissions and saw patients moved to more appropriate medication.
    Scotland’s Public Health Minister Maree Todd said: “This project looked at some of our most vulnerable patients taking more than five medications. The reviews have avoided adverse combinations of drugs and hospitalisations while also reducing prescriptions and drugs costs.
    “We will know more when the full evaluation is published in June, we will work with partners to see how we can these improvements can be applied more widely, potentially saving lives and money.”  
    Read full story
    Source: Scottish Government, 10 March 2023
  14. Patient Safety Learning
    The drug giant behind weight loss injections newly approved for NHS use spent millions in just three years on an “orchestrated PR campaign” to boost its UK influence.
    As part of its strategy, Novo Nordisk paid £21.7m to health organisations and professionals who in some cases went on to praise the treatment without always making clear their links to the firm, an Observer investigation has found.
    Among the vocal champions of the Wegovy jabs was a clinical expert who gave evidence to the National Institute for Health and Care Excellence (NICE) and others who publicly praised the so-called “skinny jabs” as a “gamechanger”.
    The revelations come as the Danish drug giant is investigated by the UK’s pharmaceutical watchdog after it was found to have breached the industry code seven times in relation to a “disguised promotional campaign” of another of its weight loss drugs via online webinars for healthcare professionals.
    Prof Allyson Pollock, professor of public health at Newcastle University, said Novo’s campaign was “not unusual” in the drugs industry and called for measures to improve trust. “The public really aren’t being made aware enough about the potential for bias and over-claiming,” she said.
    Read full story
    Source: The Guardian, 12 March 2023
  15. Patient Safety Learning
    The rising number of women who have caesarean sections instead of natural births is causing concern for the National Childbirth Trust (NCT).
    The trust, which supports women through pregnancy, childbirth and early parenthood, says it does not know why the rate of caesareans is increasing.
    One in four maternity services showed a caesarean rate of between 20% and 29.9%, and 2% of services had a rate of more than 30%, according to latest figures. The World Health Organization recommends that the acceptable rate is 10 to 15%.
    The maternity care working party, a multi-disciplinary group set up by the NCT, said there was an urgent need to address the problem.
    "A caesarean is major abdominal surgery," the working party said in a statement to a conference in London with the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists
    "Most women would prefer to give birth normally, provided that a normal birth is considered safe for them and their baby. It is important that health professionals' advice does not have the effect of denying them this opportunity without good reason."
    The working party is calling for data to be published on caesarean section rates and for obstetricians to justify in each case that the benefits outweigh the hazards. It also wants action to be taken to prevent any inappropriate use of caesarean sections.
    Belinda Phipps, chief executive of the NCT, said: "We know that in many cases caesareans are necessary for good clinical reasons. However, in our view rates have reached unacceptable levels and we want to know why."
    Read full story
    Source: The Guardian, 24 November 2022
  16. Patient Safety Learning
    A review into the culture at Birmingham's biggest hospitals trust amid allegations of bullying and undue pressure on staff has found 'substantial issues' of concern, a brief report has revealed. A short briefing for councillors by NHS Birmingham and Solihull chief executive David Melborne offers the first insight into the findings of Professor Mike Bewick and his review team who were tasked with investigating damning allegations made by current and former staff at University Hospitals Birmingham.
    More than 50 medics, including some with decades of experience, came forward to criticise a 'toxic' working culture at the trust, many sharing their experiences with MP Preet Kaur Gill (Birmingham Edgbaston). Among the most serious claims that emerged were that whistleblowers concerned about patient safety were silenced with threats of disciplinary action.
    In a written report to Birmingham and Solihull councils' joint health overview and scrutiny committee, meeting Monday, Mr Melborne says the rapid review into the Newsnight allegations and subsequent complaints has found 'no fundamental safety issues at the Trust'.
    However, he goes on: "That said, there are substantial issues around culture, behaviour, leadership and governance that will need to be addressed". 
    Read full story
    Source: Birmingham Live, 10 March 2023
  17. Patient Safety Learning
    The U.S. Food and Drug Administration (FDA) is providing an update on reports of squamous cell carcinoma (SCC) in the scar tissue (capsule) that forms around breast implants. Previously, on 8 September 2022, the FDA released a safety communication informing the public of reports of cancers, including SCC and various lymphomas, in the capsule that forms around breast implants.  The various lymphomas are not the same as the lymphomas described previously by the FDA as breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).  
    This update includes information from the FDA’s review of literature and medical device reports (MDRs). The FDA is aware of 19 cases of SCC in the capsule around the breast implant from published literature. There have been reports in the literature of deaths from progression of the disease.  While the FDA continues to believe that occurrences of SCC in the capsule around the breast implant may be rare, the cause, incidence and risk factors remain unknown. 
    Read full story
    Source: US FDA, 8 March 2023
  18. Patient Safety Learning
    GPs are facing “insurmountable pressures”, experts have said as they warned that the NHS “will not survive” without general practice.
    A new report into GP pressures suggests one in four staff fear their practice is in danger of closing because of unmanageable workloads and rising demand.
    The document, from the Royal College of GPs (RCGP), says general practice is “in crisis”, and makes a series of calls to help ease pressures and stop the growing number of GPs from quitting.
    The report says GPs are bracing for “winter-style pressures” well into spring and summer.
    “The workload pressures in general practice over this winter have been immense, and high levels of patient demand are set to continue for some time,” the report authors wrote.
    “General practice is in crisis. We cannot rely on short-term emergency funding pots over winter to try and paper over the cracks."
    Read full story
    Source: The Independent, 10 March 2023
  19. Patient Safety Learning
    More than 500 seriously ill patients died last year before they could get treatment in hospital after the ambulance they called for took up to 15 hours to reach them, an investigation by the Guardian reveals.
    The fatalities included people who had had a stroke or heart attack or whose breathing had suddenly collapsed, or who had been involved in a road traffic collision. In every case, an ambulance crew took much longer to arrive than the NHS target times for responding to an emergency.
    Bereaved relatives have spoken of how the pain of losing a loved one has been compounded by the ambulance crew having taken so long to arrive and start treatment. Coroners, senior doctors and ambulance staff say the scale of the loss of life illustrates the growing dangers to patients from the implosion of NHS urgent and emergency care services.
    “These 500-plus deaths a year when an ambulance hasn’t got there in time are tragic and avoidable,” said Dr Adrian Boyle, the president of the Royal College of Emergency Medicine, which represents A&E doctors. “These numbers are deeply concerning. This is the equivalent of multiple airliners crashing.”
    Read full story
    Source: The Guardian, 9 March 2023
  20. Patient Safety Learning
    The crisis in the NHS is leading to continued higher-than-usual death levels in England and Wales, experts have said.
    Figures from the Office for National Statistics reveal that almost 170,000 more people than normal died in England and Wales between March 2020, when coronavirus was declared a pandemic, and the end of 2022 – 11% higher than the five-year average.
    However, the new data also shows that the number of excess deaths has continued, even as the virus’s fatality rate has declined thanks to vaccinations and weaker strains, with 90% of the excess deaths in 2022 occurring in the second half of the year, coinciding with recent NHS pressures and the impact of a cold winter.
    Prof David Spiegelhalter of Cambridge University said that “analyses have suggested that delays in ambulance arrivals and in A&E will have had a substantial impact, as well as the cold weather and the early flu season”.
    Read full story
    Source: The Guardian, 9 March 2023
  21. Patient Safety Learning
    A trust has been issued with a warning notice after the Care Quality Commission (CQC) raised concerns about parts of its maternity services.
    Following a focused inspection at University Hospitals Dorset Foundation Trust in September and November last year, the CQC has rated maternity services at Poole Hospital “inadequate”, down from “good”. The service was also rated “inadequate” in the safety and well-led domains. 
    The CQC report warned that Poole Hospital’s maternity unit did not always have enough midwifery or medical staff to keep mothers and babies safe. The inspectors noted this had led to delays to induction of labour and caesarian sections, including emergency sections. 
    A warning notice was also issued over concerns about the unit’s emergency call bell system, which worked “intermittently” due to poor wireless signal, and processes used to summon help during an emergency. The trust said it had since “taken action to address this risk”. 
    Read full story (paywalled)
    Source: HSJ, 10 March 2023
  22. Patient Safety Learning
    In posts on two Facebook forums, GP Survival and Resilient GP, family doctors write anonymously, revealing their concerns about how hard they sometimes find it to get an ambulance to attend to a sick patient – and the risks that can pose.
     “I ended up in the back of a police car with sirens going with a stranger who’d had a probable stroke on the street. Category 2 ambulance hadn’t come after 45 minutes so flagged down a cop car. They bundled us in.
    “Emergency department full of waiting ambulances unable to unload and I eventually left him in the very capable hands of the stroke team. Terrifying how broken our system is and how many people had likely just walked past him before I spotted him from my car."
     “Our emergency care practitioner called an ambulance at 6pm on Wednesday 6 July. Very elderly gentleman. Off legs, urinary symptoms, not eating/drinking. Guess when crew arrived? This morning, Friday 8 July, around 10am – 40 hours [later]. And the ECP had to wait 35 minutes just for 999 call to be answered!”
     “I recently complained [to the local ambulance service] for first time ever when ambulance refused to take a very sick patient of mine into hospital that I’d assessed over the phone because ‘her obs are normal’. They weren’t but even if they had been the reliance on these alone, ignoring the medical background, the family history and my history was just wrong.
    “I then had to go out and see her, re-call 999 (with many hours additional delay) and she died after a few days in hospital.”
    Read full story
    Source: The Guardian, 9 March 2023
  23. Patient Safety Learning
    A new scheme in Wales to help people who have suffered falls has prevented 50 ambulances being unnecessarily sent this year.
    St John Ambulance works with Hywel Dda health board in Pembrokeshire to send its people when someone calls 999.
    The pilot has been used 96 times since January but it needs more health board funding to continue after March.
    Ageing Well in Wales estimates that between 230,000 and 460,000 over 60s fall each year.
    When people dial 999, it can be directed to the St John Ambulance falls response team, who are sent to perform an assessment and identify whether the person can stay home or needs an ambulance to take them to hospital.
    St John Ambulance operational team leader Robert James said in 60% of cases, the person was well enough to stay at home.
    "You can imagine if you were sending an ambulance crew out and it has wasted 60% of the crew's time, well it's a big saving towards the NHS and the ambulance service in itself," he added.
    "Provided there are no injuries, or reason for them to go to hospital, they can be discharged on the scene."
    Read full story
    Source: BBC News, 10 March 2023
  24. Patient Safety Learning
    A newly approved weight loss jab should be used with caution as it could be harmful to those vulnerable to eating disorders, doctors have warned.
    Thousands struggling with obesity could be prescribed Wegovy, or semaglutide, which scientists have described as a “game changer”, after the National Institute for Health and Care Excellence (NICE) approved its use.
    However, eating disorder experts have warned the NHS to proceed with caution in prescribing the drug, with one GP accusing NICE of being “absolutely reckless” in approving it.
    The drug was approved on Wednesday for use in adults who have at least one weight-related condition, such as type 2 diabetes, high blood pressure, high cholesterol sleep apnoea and heart disease, and a body mass index score of at least 35. It can only be prescribed to those undergoing weight management treatment.
    Read full story
    Source: The Independent, 8 March 2023
  25. Patient Safety Learning
    Progress being made on tackling the hospital waiting backlog will be put at risk by next week's junior doctors' strike, NHS bosses are warning.
    NHS England medical director Prof Sir Stephen Powis said there had been huge achievements over the winter.
    But he said it was inevitable the 72-hour walkout in England, which starts on Monday, would have an impact.
    It comes as the annual NHS staff survey shows a falling number happy to recommend the care at their service.
    The poll found 63% would be happy to see a friend or relative treated - down by five percentage points in the past year and 11 over two years.
    Meanwhile, latest performance data shows NHS emergency services are continuing to miss their targets, although the situation is not getting worse.
    Dr Tim Cooksley, president of the Society for Acute Medicine, said despite the situation not getting worse it still presented a "damning" picture, and warned it was "increasingly causing harm to patients".
    Read full story
    Source: BBC News, 9 March 2023
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