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Patient Safety Learning

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  1. Patient Safety Learning
    Nurse Lucy Letby sent a sympathy card to the grieving parents of a baby girl just weeks after she allegedly murdered the infant, a court has heard.
    She is accused of trying to kill the premature baby, referred to as Child I, three times before succeeding on a fourth attempt on 23 October 2015.
    She denies murdering seven babies and attempting to murder 10 others.
    Manchester Crown Court was shown an image of a condolence card Ms Letby sent to the family of Child I ahead of her funeral on 10 November.
    The card was titled "your loved one will be remembered with many smiles".
    Inside, Ms Letby wrote: "There are no words to make this time any easier.
    "It was a real privilege to care for [Child I] and get to know you as a family - a family who always put [Child I] first and did everything possible for her.
    "She will always be part of your lives and we will never forget her.
    "Thinking of you today and always. Lots of love Lucy x."
    It is alleged that before murdering Child I, Ms Letby attempted to kill the infant on 30 September and during night shifts on 12 and 13 October.
    The prosecution said she harmed the premature infant by injecting air into her feeding tube and bloodstream before she eventually died in the early hours of 23 October 2015.
    Read full story
    Source: BBC News, 2 February 2023
  2. Patient Safety Learning
    An acute trust has discovered an IT issue which appears to have led to ‘very high’ numbers of patients not turning up for their appointments.
    Bedfordshire Hospitals Foundation Trust discovered appointment letters were being lost, and not sent to patients, during intermittent server failures, its board was told yesterday.
    The trust’s “did not attend“ rate has been between 10% and 12% over the last year, compared to the national average of 7%, according to its board papers.
    The issue relates to patients with appointments booked at Luton and Dunstable Hospital. It is not yet clear how many patients were affected.
    The trust is now planning to ensure every patient with an appointment booked this year receives a new appointment letter, and an apology if they did not previously receive one.
    Read full story (paywalled)
    Source: HSJ, 2 February 2023
  3. Patient Safety Learning
    A long-running public inquiry into what has been called the worst treatment disaster in the history of the NHS will hear its final evidence on Friday.
    It is thought tens of thousands were infected with HIV and hepatitis between 1970 and 1991 after being given a contaminated drug or blood transfusion.
    The inquiry, which started in 2018, has reviewed thousands of documents and heard testimony from 370 witnesses.
    A total of 1,250 people with haemophilia and other bleeding disorders contracted HIV after being given a protein made from blood plasma known as Factor VIII.
    About half of that group later died of an Aids-related illness.
    Researchers found that 380 of those infected with HIV - about one in three - were children, including some very young toddlers.
    One of the key questions the inquiry will now have to answer is whether more could and should have been done to prevent those infections and deaths.
    Hundreds of victims of the scandal have received annual support payments but - before this inquiry - no formal compensation had ever been awarded for loss of earnings, care costs and other lifetime losses
    Further recommendations on compensation are expected when the inquiry publishes its final report, which is likely to be around the middle of the year.
    Read full story
    Source: BBC News, 3 February 2023
  4. Patient Safety Learning
    Ministers are considering putting a cancer warning on all breast implants a decade after women had ‘a cocktail of chemicals intended for mattresses’ put into their bodies.
    Experts and MPs are calling for tighter regulation and better support after the PIP faulty breast implant scandal left women – including breast cancer survivors – ‘suffering and dying in silence’.
    Health minister Maria Caulfield pledged on Monday to consider a so-called ‘black-box’ warning on breast implant packaging like in the US.
    It came during a debate on the faulty breast implant scandal which saw 47,000 British women given ‘ticking time bomb’ implants made by Poly Implant Prothese (PIP).
    PIP implants were outlawed in 2010 when they were revealed to be made with substandard silicone and up to six times more likely to rupture.
    Victims of the scandal have reported a wide range of serious side-effects as experts say they are linked to a raft of health problems including the new form of cancer.
    Anyone with a PIP implant can officially apply to have it removed by the NHS, but Labour MP Fleur Anderson said: ‘Many applications have been turned down, leaving women with a ticking time bomb in their body.
    ‘They are unable to afford to get their implants removed privately, are worried that they will rupture further, and are experiencing clear side-effects.’
    The MHRA acknowledged the risk of cancer for all breast implants but said PIP implants are not at greater risk than any other. 
    Read full story
    Source Mail Online, 31 January 2023
  5. Patient Safety Learning
    A seismic shift is needed in the way that patients’ and families’ voices are heard, with shared decision-making and patient partnership as the destination, says Patient Safety Commissioner, Dr Henrietta Hughes, on the day the Patient Safety Commissioner 100 Days Report is published.
    In the report, Henrietta reflects on her first 100 days in this new role. She sets out what she has heard, what she has done and her priorities for the year ahead.
    "Everyone... has a part to play in delivering safe care – know that you can make a difference by putting safety at the top of your agenda. Introduce patient voices into your governance – in your board meetings, commissioning and contracts meetings, design of strategies, policies and processes, team meeting agendas, annual objectives, appraisals, reviews of complaints and incidents, inspections, and reward and recognition.
    "I want us to be able to look back in astonishment on the way that we operate now. This is the moment to set a new course with shared decision-making and patient partnership as our destination. Without listening and acting on patient voices, safety will continue to be compromised and patients and families will continue to suffer the consequences of harm."
    Read full story (paywalled)
    Source: HSJ, 2 February 2023
  6. Patient Safety Learning
    The CEO of a troubled trust has said evidence is emerging of ‘massively reduced’ length of stay in a new hospital criticised for being too small.
    Emergency staff have raised concerns about a lack of space and bed capacity at the new Royal Liverpool Hospital, which opened in October, as services have come under severe pressure this winter. The new building, on a next-door site to the old hospital, has fewer beds, although more have opened elsewhere in the city.
    In an interview with HSJ, Liverpool University Hospitals Foundation Trust chief executive officer James Sumner acknowledged aspects of the new building have created difficulties, including in relation to accident and emergency configuration and capacity, but added the move’s benefits are beginning to be seen.
    He said a new care model and single rooms throughout the whole hospital are helping to reduce length of stay, as well as eliminating bed closures due to infection outbreaks.
    He said: “We’ve got really good evidence of massively reduced length of stay in this new building, [with] about 70 fewer people every day waiting over seven, 14 and 21 days in hospital.
    Read full story (paywalled)
    Source: HSJ, 1 February 2023
  7. Patient Safety Learning
    Hepatitis B transmission from mothers to babies has been eliminated in England, according to the World Health Organisation (WHO).
    The WHO elimination target is that less than 2% of babies born to mothers with hepatitis B go on to develop the infection.
    And data from the UK Health Security Agency (UKHSA) shows the figure for England currently stands at 0.1%
    The UKHSA said progress had been made in tackling the viral infection, which can cause liver damage, cancer and death if left untreated.
    A six-in-one vaccine is offered to all babies on the NHS when they are eight, 12 and 16 weeks of age.
    Health and Social Care Secretary Steve Barclay said: “We are paving the way for the elimination of hepatitis B and C, with England set to be one of the first countries in the world to wipe out these viruses.”
    Read full story
    Source: The Independent, 2 February 2023
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  8. Patient Safety Learning
    Community health workers are stepping in to provide critical services and information in rural areas in Texas, USA, with few hospitals or doctors.
    When Claudia Salazar and her family migrated to San Elizario, Texas, a small city in El Paso county, they settled into a colonia – informal, low-income housing often found in rural parts along the US-Mexico border.
    But the remoteness of their new home soon presented problems – Salazar suddenly found herself in a medical desert. The nearest hospital is a 35-minute drive away. Even that is challenging to get to – the community’s mostly farm worker population works 10- to 12-hour days, and often lacks adequate time to travel for medical attention between workdays.
    The lack of consistent medical access is just one of the many public health issues that colonias face, and a group of women familiar with the dynamics in this region thought of a relatively simple solution: bringing medical care to the people who need it most in these borderland communities. “Familias Triunfadoras has been really helpful since they provide a mobile unit clinic,” Salazar said. “That’s when we get a chance to visit a doctor or get a doctor’s appointment.”
    Familias Triunfadoras is a San Elizario-based non-profit that is composed of women who step in as community organizers to connect residents like Salazar to resources they may not know exist. Their efforts to make healthcare more accessible in medical deserts like San Elizario has proven invaluable to residents.
    Read full story
    Source: The Guardian, 2 February 2023
  9. Patient Safety Learning
    A major hospital in the UK has declared a critical incident, warning it is facing “immense pressures” on its services.
    Wigan’s Royal Albert Edward Infirmary urged people to avoid its A&E unless suffering a “life or limb-threatening emergency”.
    Wrightington, Wigan and Leigh (WWL) Teaching Hospitals NHS Foundation Trust warned that “unprecedented attendances” meant the emergency department was “full”. It said it is working with partners to discharge patients who are ready to leave hospital.
    The trust, which previously declared a critical incident in December, said the safety of its patients is the “top priority”.
    By declaring a critical incident, hospitals are able to take action so that safe services are maintained despite increasing pressures.
    Read full story
    Source: The Independent, 1 February 2023
  10. Patient Safety Learning
    Some ambulance trusts are not sending paramedics to up to around a quarter of their most serious calls, according to figures obtained by HSJ.
    HSJ submitted data requests to all 10 English ambulance trusts after the Care Quality Commission raised concerns about the proportion of category one calls not being attended by a paramedic at South Central Ambulance Service Foundation Trust.
    The regulator said in a report published in August last year that between November 2021 and April 2022 around 9% of the trust’s category one calls were not attended by a paramedic. Inspectors said this meant some patients “did not receive care or treatment that met their needs because there were not appropriately qualified staff making the decisions and providing treatment.”
    But data obtained via freedom of information requests reveals other ambulance trusts had far lower proportions of category one calls attended by paramedics than the South Central service last year.
    Read full story
    Source: HSJ, 2 February 2023
  11. Patient Safety Learning
    Researchers have warned there is a lack of evidence around prescribing antidepressants for chronic pain.
    Guidance from the National Institute for Health and Care Excellence (Nice) in 2021 recommends that an antidepressant (amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline) can be considered for people aged 18 and over with pain lasting longer than three months which cannot be accounted for by another diagnosis.
    The guidance said the drugs may help with quality of life, pain, sleep and psychological distress, even if the patient is not suffering depression.
    A separate guideline on neuropathic (nerve) pain recommends offering a choice of treatments, including amitriptyline and duloxetine, alongside a discussion on possible benefits and side-effects.
    However, researchers writing in the BMJ have warned that recommending antidepressants for pain is not always backed by evidence.
    Professor Martin Underwood from the University of Warwick, said: “There is a role for antidepressants in helping people living with chronic pain, however, this is more limited than previously thought.
    “Antidepressants may have unpleasant side effects that patients may wish to avoid.
    “We need to work harder to help people manage their pain and live better, without relying on the prescription pad.”
    Read full story
    Source: The Independent, 1 February 2023
  12. Patient Safety Learning
    Donna Ockenden, who is leading an independent review examining how dozens of babies died or were injured at the Nottingham University Hospitals (NUH) trust, is due to meet with chief executive of NUH, Anthony May, and other members of the NUH executive team.
    Speaking ahead of the meeting, she said: "The commitment I want to give to the women and families of Nottingham is that real learning, real improvement in maternity safety will happen throughout the life of this review.
    "It won't be a case of waiting until the end and then presenting the trust with a huge amount of learning that they then have to start putting in place.
    "Today's meeting with the trust is at executive level. Along with colleagues from NHS England, I'll be meeting with the chief executive and some of his colleagues to talk about how we will ensure that learning reaches the trust on a regular basis and in a timely way so families can be assured that the maternity improvement plan is including learning from our review."
    Read full story
    Source: BBC News, 2 February 2023
  13. Patient Safety Learning
    NHS England has effectively admitted the backlog of cancer long-waiters will still be higher in March 2024 than before covid hit, in a document seen by HSJ.
    The consultation document, detailing trajectories for reducing numbers waiting 62 days or more from referral, shows the expected national total in March 2024 is 18,755.
    NHS England previously committed to reducing this to pre-pandemic levels (14,226) by March 2022, then delayed the target until March this year. 
    There are now significant backlogs in diagnostics, with particular challenges in endoscopy and breast screening.
    NHS Providers director of policy and strategy Miriam Deakin said: “Cancer is a key priority for trusts. They understand the risk to patients who have to wait.
    “The pandemic left people waiting longer than NHS trusts wanted for diagnosis or to start treatment, with some people not coming forward, but now urgent referrals for suspected cancer are far higher than pre-pandemic.
    Read full story (paywalled)
    Source: HSJ, 1 February 2023
  14. Patient Safety Learning
    Ambulance crews in the North East frequently responded to emergencies without access to life-saving drugs, a damning inspection report has found.
    The study of North East Ambulance Service NHS Trust (NEAS) concluded patients were potentially put at risk by the poor management of medicines.
    The Care Quality Commission (CQC) found a deterioration of services and rated NEAS's urgent care as "inadequate".
    In response, NEAS said it had faced a year of "unprecedented pressures".
    The damaging assessment follows the launch of a full independent NHS review into numerous "tragic failings" involving patients.
    Announcing the review, the then health secretary Sajid Javid said he was "deeply concerned" about claims NEAS had covered up mistakes.
    Whistleblowers have told Newsnight multiple deaths were not investigated properly because information was not always provided to coroners and families.
    Read full story
    Source: BBC News, 1 February 2023
  15. Patient Safety Learning
    A mental health trust has received a warning from the Care Quality Commission over staff sleeping on duty and other serious concerns.
    Essex Partnership University Foundation Trust was sent a “letter of intent”, which warns the CQC is considering taking urgent enforcement action, following an unannounced visit in November, according to a board report last week.
    The trust is already subject to a high-profile inquiry into hundreds of patient deaths.
    Natalie Hammond, executive nurse, said this would be “a fine tuning of our health roster which will be an early warning system that will determine and flag all staff members that may be at risk of working too much or their hours of working might perform a pattern that means they are at risk more of falling asleep on duty.”
    She added: “We’ve done learning lessons and videos that link the importance of being fit and alert for work and how when you’re not, what mitigation and what steps you should undertake and what risk there is to patient safety.”
    Read full story (paywalled)
    Source: HSJ, 1 February 2023
  16. Patient Safety Learning
    A prolific surgeon accused of poor care — some with a ‘catastrophic outcome’ — and altering patient notes has been found guilty of misconduct following a tribunal hearing. 
    Jeremy Parker, who performed hundreds of operations at Colchester Hospital and the private Oaks Hospital until his suspension in 2019, faced a misconduct hearing in December and January.
    The medical practitioners tribunal investigated allegations that between August 2015 and November 2018, Mr Parker failed to provide good clinical care to six patients. It was also alleged he performed surgery in breach of restrictions on his clinical practice between October 2018 and January 2019 and that his actions were dishonest.
    Richard Holland, opening the tribunal case for the General Medical Council, said Mr Parker’s care of six patients – referred to as patients A-F – was “deficient” in a number of ways, with that provided to patient A leading to a “catastrophic outcome” where their leg was amputated below the right knee following “catastrophic blood loss” caused by severing of an artery during surgery.
    Read full story (paywalled)
    Source: HSJ, 1 February 2022
  17. Patient Safety Learning
    The amount of time people over 80 spend in A&E in England has almost doubled in a year, leaving them at increased risk of coming to harm and dying, emergency care doctors are warning.
    An analysis by the Royal College of Emergency Medicine (RCEM) found that people of that age are spending 16 hours in A&E waiting for care or a bed, a huge rise on the nine hours seen in 2021.
    The college, which represents the UK’s A&E doctors, warned that long waits, allied to overcrowding in hospitals and older people’s often fragile health, is putting them in danger.
    Doctors specialising in emergency and elderly care warned that older people forced to spend a long time in A&E are more likely to suffer a fall, develop sepsis, get bed ulcers or become confused.
    Dr Adrian Boyle, the RCEM’s president, said that it is also likely that some older people are dying as a result of the delays they are facing, combined with their often poor underlying health.
    The risks older people face while waiting in sometimes chaotic A&E units are so great that they are likely to be disproportionately represented among the 500 people a week who the RCEM estimates are dying as a direct result of delays in accessing urgent medical help.
    Read full story
    Source: The Guardian, 31 January 2023
  18. Patient Safety Learning
    A woman who died shortly after giving birth to her daughter did not receive the correct medication, a coroner has ruled.
    Jess Hodgkinson, 26, from Chesterfield, died from a pulmonary embolism in 2021.
    Assistant coroner Matthew Kewley said there was a "failure" to ensure Ms Hodgkinson received blood thinners right up until the birth.
    Chesterfield Coroner's Court heard Ms Hodgkinson had a high risk pregnancy due to severe hypertension.
    On 21 April 2021, a consultant in Chesterfield prescribed a prophylactic dose of tinzaparin due to an increased risk of clotting, the inquest heard.
    During the inquest, the consultant said the intention was for Ms Hodgkinson to continue to receive a daily dose of anticoagulant medication up until birth.
    Ms Hodgkinson was transferred to a hospital in Sheffield the next day, but there was a "failure to communicate" the medication plan, Mr Kewley said.
    After being discharged, clinicians in Chesterfield "failed to identify" Ms Hodgkinson was no longer receiving the medication, the coroner said in his ruling.
    On 13 May, Ms Hodgkinson attended Chesterfield Royal Hospital and a decision was made to carry out an emergency Caesarean section. The procedure was successful and Ms Hodgkinson's baby was born. But after delivery, Ms Hodgkinson went into cardiac arrest and later died.
    In his concluding remarks, Mr Kewley said: "There was a failure to ensure that Jess received anticoagulant medication that a clinician had intended should be taken until birth. This failure made a more than minimal, negligible or trivial contribution to Jess' death".
    Read full story
    Source: BBC News, 31 January 2023
     
  19. Patient Safety Learning
    A further 1,500 patients of convicted breast surgeon Ian Paterson are to be recalled and their treatment investigated.
    Spire Healthcare, which runs private hospitals, said patients were being contacted after a trawl of IT systems.
    Paterson was jailed for 20 years in 2017 for 17 counts of wounding people with intent.
    The healthcare provider said it remained committed to tracking down all "outstanding patients".
    The former surgeon subjected hundreds of patients to needless and damaging surgery over 14 years.
    A 2020 independent inquiry ruled "a culture of avoidance and denial" left him free to perform botched operations in NHS and private hospitals in Birmingham and Solihull.
    The inquiry recommended all 11,000 patients Paterson treated should be recalled for review.
    Read full story
    Source: BBC News, 1 February 2023
  20. Patient Safety Learning
    “I was worried it would grow and spread,” Charlotte Park, a breast cancer patient tells The Independent. “What happens if I hadn’t been that really pushy person? Sometimes I still go into a dark place and I think: I am so lucky to be here.”
    The 50-year-old, from Richmond in Yorkshire, found a lump in her breast in June 2020 and went straight to see her GP who informed her she would have to wait two weeks to see a specialist. After a fortnight of waiting, she started to panic and rang the clinic who said they were still working through referrals from four to six weeks prior to her referral.
    “I was getting frustrated and impatient by this point,” Ms Park recalls. “There was no leeway and they didn’t see if they could squeeze me in. I just felt frustrated. There was nothing I could do. It was all out of my hands. I was feeling teary.”
    Ms Park is one of thousands of women with breast cancer in England facing delays of weeks or months to see a specialist or receive treatment. Data, shared exclusively with The Independent, shows delays were substantially worse for those with breast cancer than other forms of cancer.
    In the end, Ms Park was forced to wait 25 days to see a specialist. The wait was “agony”, she said. It was difficult to definitively determine if the delays caused her cancer to grow, she noted.
    Her comments come in the context of thousands of women with breast cancer being forced to wait longer than the NHS-recommended time of two months to get treatment, in a situation branded “perilous” by healthcare professionals. Exclusive data shows only seven in ten women in England received treatment for breast cancer two months after getting an urgent doctor’s referral between January and November 2022.
    This amounts to just more than 16,500 women and is way below the NHS target for 85% of breast cancer patients diagnosed via an urgent GP referral to start their cancer treatment within two months of their GP visit.
    Read full story
    Source: The Independent. 31 January 2023
  21. Patient Safety Learning
    Thousands of ambulance staff across five services in England - London, Yorkshire, the South West, North East and North West - will walk out on Friday 10 February, Unison says.
    It means strikes over pay will now be happening across the NHS every day next week, apart from Wednesday.
    Life-threatening 999 calls will be attended to but others may not be.
    Downing Street says the continuing industrial action will concern the public.
    The NHS's biggest day of industrial action is set to happen on 6 February, when many nurses and ambulance crews across England and Wales will be on strike.
    Unison says the government must stop "pretending the strikes will simply go away" and act decisively to end the dispute by improving pay.
    The union warned that unless the government had a "major rethink" over NHS pay, and got involved in "actual talks" with unions, it would announce strike dates running into March.
    The government says the above-inflation pay rises requested are unaffordable.
    Read full story
    Source: BBC News, 31 January 2023
  22. Patient Safety Learning
    A health minister has called for more staff to take part in an inquiry into deaths at a mental health trust.
    An independent review into 1,500 deaths at the Essex Partnership University Trust (EPUT) over a 21-year period was launched in 2020.
    It emerged earlier this month that 11 out of 14,000 staff members had come forward to give evidence to an independent inquiry.
    The trust said it was encouraging staff to take part in the inquiry.
    During a parliamentary debate, Health Minister Neil O'Brien said the trust was being given a "last chance" before the government intervened and instigated a statutory inquiry.
    A statutory inquiry would allow staff to be compelled to give evidence.
    In December, a further 500 deaths were made known to the review chair, Dr Geraldine Strathdee.
    She said the inquiry could not continue without full legal powers.
    Chelmsford MP Vicky Ford said she had been told by the chief executive of EPUT that staff were "very scared" to give evidence.
    Read full story
    Source: BBC News, 31 January 2023
  23. Patient Safety Learning
    All three acute trusts in an integrated care system are failing to meet national requirements to tackle health inequalities after being overwhelmed by emergency and elective care pressures.
    A report by Devon Integrated Care Board found progress on addressing variation in poor health outcomes had “slipped due to capacity issues.” Both Royal Devon University Healthcare Foundation Trust and Torbay and South Devon FT were rated “red” for a lack of headway.
    All trusts were told by NHSE in 2021 to undertake a range of actions as part of work to reduce health inequalities during 2022-23.
    These included publishing analyses of waiting times disaggregated by ethnicity and deprivation, using the waiting list data to identify disparities between different patient groups, and measuring access, experience and outcomes for patients from a deprived community or an ethnic minority background.
    Sarah Sweeney, interim chief executive of National Voices, which represents health and care charities and patients, said she was “really concerned to see that some ICSs are not making as much progress on reducing health inequalities as expected and hoped”.
    “These inequalities are completely unjust and preventable,” she said. 
    Read full story (paywalled)
    Source: HSJ, 30 January 2023
  24. Patient Safety Learning
    Six wards in a busy London Hospital, added at a cost of £24 billion during the pandemic, are lying empty because the builders did not install sprinklers. 
    With the NHS in crisis, the Royal London Hospital in east London, has had to mothball the space, which is large enough to take 155 intensive care beds, while officials work out what to do with it. They have no patients in it since last May.
    Source: The Sunday Times, 29 January 2023
    Shared by Shaun Lintern on Twitter
  25. Patient Safety Learning
    A dementia home care agency spent as little as three and a half minutes on taxpayer-funded care visits and filed records claiming far more care was given, according to evidence seen by the Guardian.
    The hasty care was exposed by Susan Beswick’s family, who called it “totally inadequate”. They say they had been told visits to 78-year-old Beswick, who has Alzheimer’s disease, were supposed to last 30 or 45 minutes.
    Across nine visits this month, care workers formally logged close to six hours of care. But security cameras suggest they were in the house for under one hour 20 minutes – less than nine minutes a visit on average.
    On one evening visit, footage showed two carers entering, asking if Beswick had eaten and checking her incontinence pad, before leaving three minutes and 15 seconds later. But they appeared to log on a care tracking app that they had been with her for one hour and 16 minutes.
    Beswick, who for years was a care worker herself, “deserves so much better”, said her daughter-in-law Karen Beswick.
    “It’s upsetting us the way mum is being cared for here,” she said. “They come in and check her [incontinence] pad and go. They are supposed to be encouraging her to drink. They don’t really talk to mum a lot. It’s not good at all. I will start crying. We are all trying to get the best for mum.”
    Read full story
    Source: The Guardian, 30 January 2023
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