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Patient Safety Learning

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  1. Patient Safety Learning
    A criticised maternity service needs 37 more midwives, about a fifth of its total midwifery workforce.
    The Care Quality Commission has said Northampton General Hospital did not always have enough qualified and experienced staff to keep women safe from avoidable harm.
    Figures obtained by the BBC show that 49 serious incidents have occurred in its maternity services in four years.
    The hospital said it had undertaken "a lot of work" in the past 18 months and a recruitment process was under way.
    According to a Freedom of Information Act response, between November 2018 and November 2022, the hospital had 278 serious incidents, with the highest level coming across maternity services, including gynaecology and obstetrics.
    There are currently 37 vacancies for midwives but the trust said it manages staffing levels "closely and ensure that all shifts are covered by bank or midwives working altered shift patterns, to ensure that we are able to provide a safe maternity experience".
    Read full story
    Source: BBC News, 27 February 2023
  2. Patient Safety Learning
    Urgent action is needed to prevent people dying from eating disorders, the parliamentary and health service ombudsman for England has warned, as he said those affected are being “repeatedly failed”.
    The NHS needs a “complete culture change” in how it approaches the condition, while ministers must make it a “key priority”, according to Rob Behrens.
    Little progress has been made since the publication of a devastating report by his office in 2017, which highlighted “serious failings” in eating disorder services, he said.
    Lives continue to be lost because of “the lack of parity between child and adult services”, and “poor coordination” between NHS staff involved in treating patients. There remain issues with the training of medical professionals, Behrens added.
    “We raised concerns six years ago in our ignoring the alarms report, so it’s extremely disappointing to see the same issues still occurring,” he said. “Small steps in improvements have been taken, but progress has been slow, and we need to see a much bigger shift in the way eating disorder services are delivered."
    Read full story
    Source: The Guardian, 27 February 2023
  3. Patient Safety Learning
    Ministers have spent only £15m in five years on research into tackling brain tumours, the biggest killer of adults and children under 40, while boasting about delivering £40m, MPs have found.
    The revelation emerged in a damning report seen by the Guardian that is due to be published this week by the all-party parliamentary group (APPG) on brain tumours after a two-year inquiry.
    The research system is “unfit for purpose”, patients are being denied access to clinical trials, and families have been let down by promises of “millions of pounds of investment which hasn’t materialised”, the report says.
    The APPG report also highlights a “valley of death” in which potential new treatments developed in the laboratory “fail to reach patients” because of unnecessary red tape. Some children are being denied access to clinical trials, and the national brain tumour research database is “not reliable”.
    Read full story
    Source: The Guardian, 27 February 2023
  4. Patient Safety Learning
    The adoption of AI tools to simplify processes and workflows is slowly occurring across all industries, including healthcare — though patients largely disagree with clinicians using those tools when providing care, the Pew Research Center survey found.
    The potential for AI tools to diminish personal connections between patients and providers is a key concern, according to the survey, which included responses from over 11,000 adults in the USA collected in December. Patients also fear their health records could become less secure.
    Respondents, however, acknowledged potential benefits, including that AI could reduce the number of mistakes providers make.
    They also expressed optimism about AI’s potential impact on racial and ethnic biases in healthcare settings, even as the technology has been criticised for exacerbating those issues.
    Among respondents who believe racial biases are an issue in healthcare, about half said they think the tools would reduce the problem, while 15% said it would make it worse and about 30% said it would stay the same.
    Read full story
    Source: Healthcare Dive, 23 February 2023
  5. Patient Safety Learning
    British health officials are preparing plans to deploy lateral flow tests if signs emerge that avian flu has begun to spread from one person to another.
    The programme would provide rapid information about the dangers posed by the disease.
    The UK Health Security Agency (UKHSA) is also working on blood tests to detect antibodies against the virus and officials will analyse the disease’s genetic mutations to reveal data about the increased risk to human health from avian flu.
    The moves follow last week’s news that an 11-year-old girl in Cambodia has died from H5N1, the flu strain that is being spread around the globe by migrating birds and is infecting poultry farms.
    At present, evidence suggests the H5N1 virus does not pass easily to people although scientists have urged care and caution. “The risk to humans is still very low, but it’s important that we continue to monitor circulation of flu in both bird and mammal populations", said Prof Jonathan Ball, of Nottingham University.
    Read full story
    Source: The Guardian, 26 February 2023
  6. Patient Safety Learning
    Over half of men with an eating disorder have never had any treatment, according to new research.
    Despite typically being linked with females, males account for a quarter of all eating disorder cases – and many are not getting any support, the eating disorder charity Beat is highlighting
    “Eating disorders affect 1.25 million people in the UK, and we estimate one in four of those are men,” says Tom Quinn, Beat’s director of external affairs – speaking to mark this year’s Eating Disorders Awareness Week (February 27 – March 5).
    “We surveyed men across the UK about their experiences of an eating disorder and, alarmingly, we discovered over half have never had treatment for their eating disorder, and one in three have never tried to get treatment in the first place.
    “There’s a harmful misconception that eating disorders are female illnesses, which creates a great deal of shame and can entrench harmful behaviours for men who are unwell,” Quinn adds.
    Read full story
    Source: The Independent, 27 February 2023
    Further reading on the hub: Top picks: Eight resources on eating disorders
     
  7. Patient Safety Learning
    NHS waiting times, staff shortages and service backlogs have been flagged as concerns in relation to dozens of patient deaths across England and Wales since the start of last year, the Observer can reveal, with coroners facing a succession of inquests concerning ambulance delays.
    Coroners issue prevention of future deaths reports (PFDs) when they believe preventive action should be taken, and send them to relevant individuals or organisations, which are expected to respond.
    Among 55 cases identified by the Observer are 24 patient deaths where coroners raised concerns about ambulance delays – all of them occurring before this winter’s ambulance crisis, when response times rocketed to their worst-ever levels.
    Wes Streeting, shadow health and social care secretary, said: “The NHS is in the biggest crisis in its history – and the crisis has a cost in lives. Patients are waiting for far longer than is safe, with terrible consequences.”
    But the issues highlighted by coroners in relation to patient deaths are wider than ambulance delays. They include: lengthy elective surgery backlogs; high referral thresholds and long waiting times for children’s mental health services; a national shortage of neurologists; long waiting times for psychological therapies; a lack of mental health beds and unfilled mental health staff vacancies; and a shortage of cardiologists compounded by a shortage of theatre capacity and beds.
    Read full story
    Source: The Guardian, 26 February 2023
    Further reading on the hub - see a selection of Prevention of Future Deaths reports in our dedicated coroner's report section of the hub.
  8. Patient Safety Learning
    When Amy Fantis gave birth to her first child two years ago, the labour was rapid, lasting only about four hours, and she was reliant on gas and air. Her second baby is due in just a few days — but the hospital has, like others around Britain, imposed a ban on the popular form of pain relief.
    Fantis, 36, from Broxbourne, Hertfordshire, is one of many women affected by the decision of several NHS trusts to suspend the use of the gas because of fears that midwives and doctors have been exposed to unsafe levels for prolonged periods. In some hospitals, levels of the nitrous oxide and oxygen mix are more than 50 times higher than the safe workplace exposure limits.
    In a survey of more than 16,600 women who gave birth last year, the Care Quality Commission found that 76% of respondents used gas and air at some point during labour.
    Although short-term use of the gas in childbirth is harmless to women and their babies, long-term exposure for midwives and doctors can affect the body’s ability to absorb vitamin B12, damaging nerves and red blood cells and causing anaemia. It is not believed that any NHS staff have become ill as a result of long-term exposure to gas and air.
    NHS England and the Health and Safety Executive recently warned other hospitals that they need to check the ventilation on maternity wards and ensure staff are kept safe. NHS England is planning to send out new guidance to trusts on the issue after a series of hospitals had to stop using the gas.
    Read full story (paywalled)
    Source: The Times, 25 February 2023
  9. Patient Safety Learning
    The health safety watchdog has said that doctors, ambulance dispatchers and other NHS staff in England have faced "significant distress" and harm over the past year as a result of long delays in urgent and emergency care.
    The Healthcare Safety Investigation Branch (HSIB), which monitors safety in the health service in England, said many staff it interviewed for a national investigation "cried or displayed other extreme emotions" when asked about their working environment.
    "The bad sides [of my job] give me nightmares, flashbacks and fear, but they can also make me hyperactive, sleepless and sometimes not care about the danger I put myself in," one paramedic told the BBC.
    Sarah, not her real name, has worked in the ambulance service for more than a decade, but describes the last 12 months as the most difficult she can remember.
    "Over the winter I have witnessed and helped with cardiac arrests in the corridors of hospitals and in the back of ambulances," she said.
    "I spent four hours with an end-of-life patient. There was no hospice or district nurse available, so I had to make the choice to give them meds for a peaceful, expected death and prepare the family.
    "I felt ashamed that I could not stay till the end, but I had to move on to the next job as I had done all I could."
    The HSIB found NHS staff were reporting increased levels of stress, worry and exhaustion because they were not always able to help the sickest patients. HSIB has now urged trusts to do more to protect workers’ mental health, saying there is an “intrinsic link” between patient safety and staff wellbeing.
    Read full story
    Source: BBC News, 27 February 2023
  10. Patient Safety Learning
    Women are being misled and manipulated about abortion by some crisis pregnancy advice centres in the UK, according to evidence from a BBC Panorama investigation.
    The centres operate outside the NHS and tend to be registered charities.
    Most say they don't refer women for abortions, but offer support and counselling for unplanned pregnancies.
    But the BBC's investigation reveals more than a third of these services give misleading medical information or unethical advice, and sometimes both.
    Pregnancy counselling is available through the NHS and regulated abortion providers, but searching online, Panorama identified 57 crisis pregnancy advice centres advertising.
    The BBC decided to investigate after hearing from women who had been to these centres. One said she had been "traumatised" and that the centre had tried to "manipulate" her into not having an abortion.
    Some 21 centres gave misleading medical information and/or unethical advice about abortion
    Seven centres said having a termination could lead to "post-abortion syndrome" - a mental health condition likened to post traumatic stress disorder, which is not recognised by the NHS. Eight centres linked abortion to infertility and problems carrying future pregnancies to term. Five centres linked abortion to an increased risk of breast cancer. Leading medic in the field of obstetrics, and director of an abortion provider, Dr Jonathan Lord, said women needed an "informed choice" which required "good quality unbiased information".
    Read full story
    Source: BBC News, 27 February 2023
  11. Patient Safety Learning
    A mental health trust is to be prosecuted after three patients died in its care.
    The Care Quality Commission (CQC) is bringing charges against the Tees, Esk and Wear Valleys (TEWV) NHS Trust.
    It is thought they relate to the deaths of Christie Harnett, 17, Emily Moore, 18, and a third person.
    The trust is said to have failed "to provide safe care and treatment" which exposed patients to "significant risk of avoidable harm".
    Both Christie Harnett and Emily Moore had complex mental health issues and took their own lives.
    The CQC said the trust "breached" the Health and Social Care Act, which relates to healthcare providers' responsibility to "ensure people receive safe care and treatment".
    In response, a spokesperson for the trust said: "We have fully cooperated with the Care Quality Commission's investigation and continue to work closely with them.
    "We remain focused on delivering safe and kind care to our patients and have made significant progress in the last couple of years."
    Read full story
    Source: BBC News, 25 February 2023
  12. Patient Safety Learning
    Only half the recommended number of medical staff were on duty at the O2 Brixton Academy on the night of a crush at the south-west London venue.
    Industry guidelines suggest there should have been medical cover of at least 10 people, including a paramedic and a nurse, but no paramedics or nurses were present.
    Rebecca Ikumelo, 33, and security guard Gaby Hutchinson, 23, died in hospital following the crowd surge on 15 December 2022 at the concert.
    The medical provider, Collingwood Services Ltd, said it was "fully confident" its team had "responded speedily, efficiently and with best practice".
    Two whistleblowers who regularly work for Collingwood Services Ltd at Brixton told BBC Radio 4's File on 4 programme that medical cover at the south London gig had been "inadequate".
    Neither of them was there when the crush happened, but one said he had spoken to colleagues who were.
    "[They] had two student paramedics, so they're basically unqualified," said one whistleblower. "They have to be supervised by a paramedic, not by anybody of a lower grade. They didn't have appropriate supervision."
    Read full story
    Source: BBC News, 23 February 2023
  13. Patient Safety Learning
    NHS Ambulance service have a “fear of speaking up” amid pervasive “cliquey”, sexist, racist and homophobic cultures, a watchdog has warned.
    A national guardian has warned of negative cultures in trusts preventing workers from raising concerns as she called for a “cultural review” of ambulance organisations.
    The review into whistleblower concerns, by the Freedom to Speak Up Guardian’s office, has found widespread cultural issues including clique-like behaviour and bullying and harassment.
    Dr Jayne Chidgey-Clark, the NHS National Freedom to Speak Up Guardian, has now called on ministers and the NHS to independently review ambulance services, after speaking with ambulance staff across five NHS trusts.
    The report has called for a cultural review of the ambulance service by NHS England, the Care Quality Commission, the Association of Ambulance Chief Executives and ministers.
    Read full story
    Source: The Independent, 24 February 2023
  14. Patient Safety Learning
    Experts are assessing a very rare but potentially serious brain side effect of nasal decongestants bought on the High Street.
    Ones containing pseudoephedrine are being reviewed because they may cause vessels supplying the brain to contract or spasm, reducing blood flow.
    The concern is this could lead to seizures and even a stroke. However, drug regulators stress the likelihood of this happening is extremely low.
    The UK-wide review for pseudoephedrine was initiated after regulators in France alerted European drugs regulator the EMA, which is also conducting a review, about some recent, rare cases.
    Experts say anyone with concerns about medication should speak to a doctor or pharmacist. 
    Read full story
    Source: BBC News, 23 February 2023
  15. Patient Safety Learning
    Progress to cut the number of women dying in pregnancy or childbirth has stalled or even reversed in recent years, with a death recorded every two minutes, the United Nations has said.
    Years of gains had begun to plateau even before the pandemic and there had been “alarming setbacks for women’s health,” according to a new report from several UN agencies, including the World Health Organization (WHO).
    Maternal mortality rates had fallen widely in the first 15 years of the century, but since 2016, they had only dropped in two UN regions: Australia and New Zealand, and in Central and Southern Asia.
    The rate went up in Europe and North America by 17% and in Latin America and the Caribbean by 15%. Elsewhere it stagnated.
    Read full story (paywalled)
    Source: The Telegraph, 23 February 2023
  16. Patient Safety Learning
    An ‘outstanding’ rated acute trust has been served with a warning notice by the Care Quality Commission (CQC) and told to make ‘significant and immediate improvements’ to its mental health and learning disabilities services.
    The CQC said staff at Newcastle upon Tyne Hospitals Foundation Trust had not always carried out mental capacity assessments when people presented with mental health needs. And this included when decisions were made to restrain patients in the emergency department.
    A CQC warning notice, published alongside a report of an inspection between 30 November and 1 December last year, says the trust must make “significant and immediate improvements in the quality of care being provided” to people with mental health issues, learning disabilities or autism.
    The warning notice also says the trust must ensure people with a learning disability and autistic people “receive care which meets the full range of their needs”. The trust’s records “did not show evidence that staff had considered patients’ additional needs,” the regulator said.
    Read full story (paywalled)
    Source: HSJ, 24 February 2023
  17. Patient Safety Learning
    Nearly half of NHS patients with a learning disability or autism are still being kept inappropriately in hospitals, several years into a key programme to reduce inpatient care, a national review reveals.
    The newly published review by NHS England suggests 41% of inpatients, assessed over an eight-month period to May 2022, should be receiving care in the community.
    Reasons given for continued hospital care in the NHSE review included lack of suitable accommodation, with 19% having needs which could be delivered by community services; delays in moving individuals into the community with appropriate aftercare; legal barriers, with one region citing “ongoing concerns for public safety” as a barrier for discharge; and no clear care plans.
    In some cases, individuals were placed in psychiatric intensive care units on a long-term basis, because “there was nowhere else to go”, while another instance cited a 20-year stay in hospital.
    Other key themes included concerns about staff culture, particularly “institutionalisation” and suggestions that discharge delays were not being sufficiently addressed.
    The report adds: “While the process around discharge can be time consuming, staff may perpetuate this by accepting such delays as necessary or inevitable.”
    Read full story (paywalled)
    Source: HSJ, 22 February 2023
  18. Patient Safety Learning
    Britain could double the number of doctors and nurses it trains under NHS plans to tackle a deepening staffing crisis, according to reports.
    The proposal to increase the number of places in UK medical schools from 7,500 to 15,000 is contained in a draft of NHS England’s long-awaited workforce plan, which is expected to be published next month.
    Labour has already announced this policy as a key element of its plans to revive the NHS. However, it could face opposition from the Treasury because of how much it would cost, according to the Times, which reported on the plan.
    The NHS in England alone is short of 133,000 staff – equating to about a tenth of its workforce – including 47,000 nurses and 9,000 doctors, according to the most recent official figures.
    There are also shortages of midwives, paramedics and operating theatre staff. Staff groups say routine gaps in NHS care providers’ rotas are endangering patients’ safety, increasing workload and costing the service money.
    Read full story
    Source: The Guardian, 22 February 2023
     
  19. Patient Safety Learning
    Wearable fitness and wellness trackers could interfere with some implanted cardiac devices such as pacemakers, according to a study.
    Devices such as smartwatches, smart rings and smart scales used to monitor fitness-related activities could interfere with the functioning of cardiac implantable electronic devices (CIEDs) such as pacemakers, implantable cardioverter defibrillators (ICDs), and cardiac resynchronisation therapy (CRT) devices, the study published in the Heart Rhythm journal found.
    Researchers found that the electrical current used in wearable smart gadgets during “bioimpedance sensing” interfered with proper functioning of some implanted cardiac devices from three leading manufacturers.
     Lead researcher, Dr Benjamin Sanchez Terrones, of the University of Utah. said the results did not convey any immediate or clear risks to patients who wear the trackers. However, the different levels of electrical current emitted by the wearable devices could result in pacing interruptions or unnecessary shocks to the heart. Further research was needed to determine the actual level of risk".
    “Our research is the first to study devices that employ bioimpedance-sensing technology as well as discover potential interference problems with CIEDs such as CRT devices. We need to test across a broader cohort of devices and in patients with these devices. Collaborative investigation between researchers and industry would be helpful for keeping patients safe,” Sanchez said.
    Read full story
    Source: The Guardian, 22 February 2023
  20. Patient Safety Learning
    Prostate cancer screening may be a step closer after a study suggested that harms linked to testing have reduced thanks to advances in medical technology.
    Screening for prostate cancer has been heavily debated in medical circles due to potential harms including side effects from biopsies and unnecessary testing for those with no clinically significant cancer.
    A new study set out to examine whether the “seesaw has been tipped” in favour of screening.
    Researchers from Prostate Cancer UK combined the results of the latest clinical trials and real-world data on the “prostate cancer screening pathway” to examine the risk-to-harm benefit.
    Prostate Cancer UK said that on average 67%t fewer men experienced harm during the diagnostic process with the newer techniques compared with older methods.
    Prostate Cancer UK said the UK National Screening Committee, which makes recommendations to the Government, is to re-examine prostate cancer screening.
    Dr Matthew Hobbs, lead researcher on the analysis and director of research at Prostate Cancer UK, said: “We’ve known for some time now that testing more men reduces prostate cancer deaths, but there have always been concerns about how many men would be harmed to achieve this.
    “However, our evidence shows that screening may now be a lot safer than previously thought. That’s why we are so pleased that the committee is going to review the evidence once more.
    Read full story
    Source: The Independent, 23 February 2023
  21. Patient Safety Learning
    An acute trust and its integrated care system have said they risk missing the imminent waiting list target, after struggling to get as many patients treated in the independent sector as they hoped.
    University Hospitals of North Midlands Trust and Staffordshire and Stoke-on-Trent ICS have found that some patients who had earlier been referred to independent providers, had then, while waiting for IS treatment, got sicker or became high risk to such an extent that they needed to be referred back to UHNM.
    Other patients have declined being transferred to the independent sector, board meetings heard. 
    Phil Smith, chief delivery officer at Staffordshire and Stoke-On-Trent Integrated Care Board, told its meeting last week he needed to “flag an escalated risk” to meeting the target, after deterioration in activity “linked to industrial action, linked to the willingness of patients to be treated in the independent sector and the independent sector’s ability to treat patients”.
    Read full story (paywalled)
    Source: HSJ, 22 March 2023
  22. Patient Safety Learning
    Record levels of NHS staff are seeking mental health help as clinicians warn the “crisis” facing workers is “worse than the pandemic”.
    Hundreds of staff are being referred to the specialist mental health service, NHS Practitioner Health, with 842 workers referred in October 2022 – up from 534 in the same month the year before and 371 in 2020.
    Around 40% of the staff seeking the service are GPs and 50% are hospital doctors.
    The news comes as The Independent reported that the NHS and government are set to axe funding for 40 mental health hubs set up for health and social care workers following the pandemic.
    Amandip Sidhu, of Doctors in Distress, which offers workers mental health support, said: “Health workers believe that the crisis they are currently dealing with is worse than during the pandemic and exacerbated by the fact there is no end in sight, with little evidence that decision-makers are taking steps to improve the situation.
    “The fact that the public, their patients, lack sympathy or understanding is making many medics feel isolated and completely unappreciated.”
    Read full story 
    Source: The Independent, 23 February 2023
  23. Patient Safety Learning
    White applicants remain 54% more likely to be appointed from NHS job shortlistings compared to ethnic minority candidates, a metric that has hardly budged since 2016, a NHS England report has revealed.
    The 2022 NHS workforce race equality standard report, revealed a significant rise in the proportion of staff from ethnic minority backgrounds. And while there had been progress on some key targets since last year, others have stagnated.
    NHSE’s report showed ethnic minority staff comprise 24.2% of the workforce in 2022, up from 22.4% last year and from 17.7% six years ago.
    However, it also revealed the likelihood of white applicants being appointed from shortlists was 1.54 in 2022 than minority ethnic applicants – only a very small improvement on 1.57 in 2016, when WRES began
    Read full story (paywalled)
    Source: HSJ, 22 February 2023
  24. Patient Safety Learning
    A trust has admitted it ‘missed opportunities’ to identify that a locum doctor – who was arrested on hospital premises for two sexual offences — had already been cautioned for indecent exposure.
    Salman Siddiqi admitted two offences – attempting to engage in sexual communication with a child and attempting to arrange or facilitate a meeting with a child for sexual offences – last month.
    East Kent Hospitals University Foundation Trust, where he was working as a locum paediatric registrar at the time of the January offences, has now said there had been “missed opportunities” to identify his previous caution.
    Chief medical officer Rebecca Martin told HSJ the trust had taken steps to ensure that these missed opportunities could not happen again. She said in a statement: “This includes standardising DBS checks for temporary workers booked through an agency and escalating all DBS and General Medical Council checks that feature conditions, cautions or warnings.”
    Read full story (paywalled)
    Source: HSJ, 23 February 2023
  25. Patient Safety Learning
    People from ethnic minority backgrounds are no longer significantly more likely to die of Covid-19, new Office for National Statistics (ONS) data shows.
    Early in the pandemic, deaths involving coronavirus were higher among black and Asian people than white people, with the highest risk among Bangladeshi, Black Caribbean and Pakistani groups.
    Covid mortality rates for all ethnic minorities decreased last year. The latest data shows there is no significant statistical difference between the number of Covid deaths among ethnic minorities and the white population.
    The ONS also said that "all cause" mortality rates - measuring how likely people are to die of any cause, including Covid-19 - have returned to pre-pandemic patterns.
    The reasons for this change are complex, and experts say there are "various factors" to consider.
    Read full story
    Source: BBC News, 22 February 2023
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