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Patient Safety Learning

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  1. Patient Safety Learning
    Ministers have ordered an inquiry into the quality of care in mental health inpatient units in England after a series of scandals in which vulnerable patients were abused or neglected.
    Maria Caulfield, the mental health minister, announced the establishment of a “rapid review” in a written ministerial statement in the House of Commons on Monday.
    The inquiry “is an essential first step in improving safety in mental health inpatient settings”, she said. In recent years, coroners and the Care Quality Commission, the NHS care watchdog, have repeatedly raised concerns about dangerously inadequate care that inpatients have received.
    It will examine the evidence of “patient safety risks and failures in care” in units that hold and treat patients who have serious conditions including psychosis and personality disorder. It will look in particular at evidence of failings brought forward by patients and their families and how better use of data can help show that care has fallen below acceptable levels.
    The inquiry will be headed by Dr Geraldine Strathdee, a psychiatrist who used to be NHS England’s national clinical director for mental health. She is likely to look at problems including patients being subjected to controversial restraint techniques, left at risk of being able to take their own lives and segregated from fellow inpatients, and the impact of their experiences on their recovery.
    Read full story
    Source: The Guardian, 23 January 2023
  2. Patient Safety Learning
    Cathy Rice had been in all-consuming pain for 18 months when she decided to fly to Lithuania. “I was going up the stairs on my hands and knees. I couldn’t get to the shop. I had no quality of life,” she says.
    Rice, 68, who has four grandchildren, had been told she needed a knee replacement for an injury caused by osteoarthritis but – like millions of NHS patients – faced a gruelling wait.
    At a clinic in Kaunas, Lithuania’s second largest city, the operation was arranged within weeks and cost €6,800 (£5,967) – around half the cost in the UK. The price included a pre-travel consultation, return flights, airport transfers, two nights in an en suite hospital room, pre-surgery check-ups and post operative physio.
    “I thought, ‘Just look at your choices. You can stay here and be in this kind of pain for another couple of years or you can take a decision’,” Rice says.
    The former health sector worker, from Glasgow, is one of a growing number of Britons going abroad for routine medical care. She had never gone private before and never had a desire to. But last week, a year after the first surgery, she returned to Lithuania to have the same procedure on her other knee. This time, she says the wait she faced on the NHS was three years.
    She explains tearfully that to cover the costs of the surgeries in Lithuania, she sold her house. “People think that if you’re doing this you’ve got a wonderful pension or you’re very well off. But the driver here is that people are in pain,” she says. “This is not medical tourism; it’s medical desperation.”
    Read full story
    Source: The Guardian, 21 January 2023
  3. Patient Safety Learning
    A record number of patients suffered “severe harm” as a result of ambulance delays in December, soaring by nearly 50 per cent in just one month as the NHS crisis deepened.
    Almost 6,000 suffered permanent or long-term harm due to long waits to hand over patients outside A&Es – up from just over 4,000 in November.
    A further 14,000 patients were likely to have suffered “moderate harm”, an analysis by The Independent of NHS ambulance data and estimates of harm by the Association of Ambulance Chief Executives (AACE) found.
    This includes incidents that resulted in patients needing further treatment or procedures, the cancelling of treatment, or being transferred to another area.
    Miriam Deakin, director of policy and strategy at NHS Providers, said the figures are a “worrying reminder of the huge pressure the NHS is under”.
    She said: “Trust leaders are doing everything they can to provide patients with safe, high-quality care but they know patients face lengthy handover delays far too often, contributing to avoidable harm.”
    Read full story
    Source: The Independent, 20 January 2023
  4. Patient Safety Learning
    A record 350,000 patients waited more than 12 hours to be admitted to hospital from A&E last year, according to figures that raise fears about unsafe care as the NHS faces further waves of strike action.
    The figures, uncovered in an analysis by the Liberal Democrats, show a steep rise in delays since 2015, when just 1,306 patients waited 12 hours. Senior doctors described the situation as “unbearable” for patients and staff, ahead of a strike in which thousands of ambulance workers will walk out across England and Wales on Monday.
    The Liberal Democrat leader, Ed Davey, warned that frequent and lengthy delays in emergency medicine are “needlessly costing lives of patients” and said that the government is in “total denial” about the scale of the problem facing hospitals, social care and GP services.
    “The failure of the Conservative government to grip this crisis is simply unforgivable,” he said. “Instead they have shamefully allowed the situation to go from bad to worse through years of neglect and failure.”
    Read full story
    Source: The Guardian, 23 January 2023
  5. Patient Safety Learning
    The chairman of Covid vaccine giant AstraZeneca has said that investment in technology can help the NHS cut costs.
    Leif Johansson said more spending on areas such as artificial intelligence and screening could prevent illness and stop people going to hospital.
    The NHS is under severe pressure, with A&E waits at record levels and strike action exacerbating ambulance delays.
    Mr Johansson said about 97% of healthcare costs come from "when people present at the hospital".
    He said only the remaining 3% is made up of spending on vaccination, early detection or screening.
    Mr Johansson told the BBC at the World Economic Forum in Davos: "If we can get into an investment mode in health for screening or prevention or early diagnostics on health and see that as an investment to reduce the cost of sickness then I think we have a much better model over time that would serve us well."
    Commenting on the UK, he said: "All countries have different systems and the NHS is one which we have learned to live with and I think the Brits, in general, are quite appreciative about it."
    He said he was not talking about "breaking any healthcare systems down". Rather, he said, "we should embrace technology and science".
    Read full story
    Source: BBC News, 23 January 2023
  6. Patient Safety Learning
    A growing number of patients deemed to require a hospital admission are waiting so long in A&E that they end up being discharged before being admitted to a ward, HSJ has been told.
    A senior emergency clinician, who has delivered improvement support to multiple emergency departments across the NHS, said such cases have become a regular occurrence – describing it as a “terrible experience” for some patients.
    The clinician, who asked not to be named, said: “I suspect every ED in the country are having patients who are spending 24 to 48 hours in ED under the care of a specialist, that in a better time they would have gone onto a ward. That’s happening every day in every department.
    “If you have been seen by the ED crew and referred to the medics who say ‘you need to be admitted to hospital’, the chances are that they are sick enough that they really do need that bed.
    “It’s a terrible experience [for the patients]. EDs are busy, noisy and crowded. This is not the place where, if you were feeling ill, to get better in a calm, relaxing area. This idea that somehow it’s OK because these people are not that sick, it’s pretty poor.
    “It feels very much like battlefield medicine – slap a patch on and try and get them back into battle as quickly as possible. It shouldn’t be the way with civilian healthcare.”
    Read full story (paywalled)
    Source: HSJ, 23 January 2023
  7. Patient Safety Learning
    A hernia mesh lawsuit recently filed by a Washington woman alleges that a Strattice “pig skin” mesh product used during her hernia repair was defective and failed, resulting in the need for two additional revision surgeries.
    The Strattice Reconstructive Tissue Matrix is a hernia repair mesh introduced in 2008, which is constructed from porcine, or pig skin. The mesh is then preserved in a phosphate buffered aqueous solution. It is marketed as a cross-linked graft device, which is intended to chemically link the proteins in the tissue together. However, a growing number of lawsuits allege that the design actually increases the risk of foreign body responses, infections and other complications.
    Hundreds of injuries and several deaths have been linked to the Strattice hernia mesh made from pig skin, according to the lawsuit.
    Read full story
    Source: About Lawsuits.com, 20 January 2023
  8. Patient Safety Learning
    Two in five GPs are facing verbal abuse every single day, a new poll suggests.
    Some 74% of family doctors have claimed they or their staff have experienced verbal abuse on a weekly basis, including almost 40% who say it occurs daily, according to the survey conducted by GP publication Pulse. And 45% said practice staff experience physical abuse every year, according to the poll of 1000 GPs.
    As well as facing abuse in GP surgeries, a third reported practice staff have faced abuse on social media on a weekly basis.
    The Royal College of GPs described the survey findings as deeply disturbing.
    One GP told the journal: "Last week a patient, without any mitigating circumstances, was desperately abusive to one of my receptionists bemoaning the fact it wasn’t the US where she could buy a gun and 'sort us all out'.
    "Primary care seems to be bearing the brunt and blamed by all and sundry for the current issues and the public are picking up on this."
    Read full story
    Source: Medscape, 19 January 2023
  9. Patient Safety Learning
    An NHS trust has introduced pharmacy changes to help patients who are medically fit to leave hospital sooner.
    Gloucestershire Hospitals NHS Foundation Trust is focusing on getting TTOs (drugs To Take Out) to the pharmacy by 13:00 GMT each day.
    It says this reduces the length of stay for patients by several hours and can release up to 20 beds a day.
    "That's 20 people not waiting in the emergency department," said medical director, Professor Mark Pietroni.
    The plan has been called 'Early Meds to Release Beds' by the trust.
    Patients whose TTOs are with the pharmacy by 13:00 GMT are usually discharged about four hours later.
    Read full story
    Source: BBC News, 20 January 2023
  10. Patient Safety Learning
    The percentage of Americans reporting they or a family member postponed medical treatment in 2022 due to cost rose 12 points in one year, to 38%, the highest in Gallup’s 22-year trend.
    The latest double-digit increase in delaying medical treatment came on the heels of two consecutive 26% readings during the COVID-19 pandemic that were the lowest since 2004. The previous high point in the trend was 33% in 2014 and 2019. An average 29% of U.S. adults reported putting off medical treatment because of cost between 2001 and 2021.
    Americans were more than twice as likely to report the delayed treatment in their family was for a serious rather than a nonserious condition in 2022. In all, 27% said the treatment was for a “very” or “somewhat” serious condition or illness, while 11% said it was “not very” or “not at all” serious. 
    Lower-income adults, younger adults and women in the U.S. have consistently been more likely than their counterparts to say they or a family member have delayed care for a serious medical condition.
    In 2022, Americans with an annual household income under $40,000 were nearly twice as likely as those with an income of $100,000 or more to say someone in their family delayed medical care for a serious condition (34% vs. 18%, respectively). Those with an income between $40,000 and less than $100,000 were similar to those in the lowest income group when it comes to postponing care, with 29% doing so.
    Read full story
    Source: Gallup News, 17 January 2023
  11. Patient Safety Learning
    Dentists have told the BBC that demand for Instagram smiles has left people with damage from wearing clear braces or "aligners" ordered online.
    One man said aligners weakened his front teeth, leaving him unable to bite into an apple.
    Smile Direct Club, the largest company selling clear aligners remotely, says they straighten teeth faster and cheaper than traditional braces. Its aligners have been successful for the majority of users, it says.
    But some dentists and orthodontists believe customers of so-called remote dentistry are unaware of harm that can be caused by aligners if not fitted by a dentist in person.
    The General Dental Council (GDC), responsible for regulating UK dentists, says for some cases remote dentistry can be "provided safely". It urges consumers to consult its guidelines.
    However, Dr Crouch of the BDA believes such guidelines are insufficient compared with "rules and regulation to protect patients". Otherwise, dentists will be left picking up the pieces when "patients have undergone wholly inappropriate treatment".
    The UK's health watchdog, the Care Quality Commission (CQC) announced last summer any company providing remote orthodontic services will have to register with it.
    Read full story
    Source: BBC News, 20 January 2023
     
  12. Patient Safety Learning
    A private psychiatric hospital provided “inadequate care” for a woman who killed herself by swallowing a poisonous substance, a jury has found.
    Beth Matthews, a mental health blogger, was being treated as an NHS patient for a personality disorder at the Priory hospital Cheadle Royal in Stockport.
    The 26-year-old, originally from Cornwall, opened the substance, which she had ordered online, in close proximity to two members of staff and told them it was protein powder, BBC News reported.
    An inquest jury concluded she died from suicide contributed to by neglect, after hearing Matthews was considered a high suicide risk. She had a history of frequent suicide attempts, the inquest heard.
    A BBC News investigation also found that two other young women died at the Priory in Stockport in the two months before her death.
    A spokesperson for the Priory Group said: “We fully accept the jury’s findings and acknowledge that far greater attention should have been given to Beth’s care plan.
    Read full story
    Source: The Guardian, 19 January 2023
  13. Patient Safety Learning
    During the pandemic, nearly half a million people in the UK missed out on starting medication to help prevent heart attacks and strokes, a new study suggests.
    The British Heart Foundation (BHF) team looked at prescribing data for the first 18 months after Covid hit.
    Some 491,000 people (27,000 a month) appear to have missed out on blood pressure pills, and 316,000 did not get treatment to lower their cholesterol.
    The team says more needs to be done to make sure that anyone who needs treatment gets it.
    During the pandemic, normal NHS services were severely disrupted. For example, there was a reduction in diagnosis, monitoring and treatment of high blood pressure, and other heart and circulation disease risk factors.
    Although the NHS took action, including providing more than 220,000 blood pressure monitors for people to use at home, data shows two million fewer people in England were recorded as having controlled hypertension in 2021 compared to the previous year.
    Lead investigator Prof Reecha Sofat, who is based at the University of Liverpool, said the findings, published in the journal Nature Medicine, highlight the impact Covid has had on other important health conditions: "Despite the incredible work done by NHS staff, our data show that we're still not identifying people with cardiovascular risk factors at the same rate as we were before the pandemic. "
    Read full story
    Source: BBC News, 20 January 2023
  14. Patient Safety Learning
    Inspectors raised serious concerns around leadership and safety at Lister Hospital in Stevenage, run by East and North Hertfordshire Trust, when they visited in October. The maternity service was also rated inadequate for leadership.
    The CQC also raised concerns about staffing shortages, infection prevention control, care records, cleanliness, waiting times and training.
    The inspection did, however, find staff worked well together, managers monitored the effectiveness of the service and findings were used to make improvements.
    Carolyn Jenkinson, the CQC’s head of hospital inspection, said: “This drop in quality and safety was down to insufficient management from leaders to ensure staff understood their roles, and to ensure the service was available to people when they needed it.”
    Read full story (paywalled)
    Source: HSJ, 20 January 2023
  15. Patient Safety Learning
    Ask any MP or local Healthwatch what health issue sits at the top of their inbox, and there is a good chance it will be the public’s access to NHS dentists. The launch of a Health and Social Care Committee inquiry into dentistry is therefore welcome news.
    The inquiry is well timed, coming after a recent BBC investigation showing that 90% of practices across England were not accepting new adult NHS patients.
    The severe access problems stem from several factors. Longstanding issues relating to the dental contract not offering high enough rates for dentists to provide NHS care, for example, have contributed to a decline in the availability of NHS dentistry. This has led to thousands of people across the country going private or, very concerningly, turning to self-care. 
    Accident and emergency departments are over-flowing with people in severe dental distress, with tooth decay being the most common reason for hospital admission among children aged five to nine in recent years. 
    Read full story (paywalled)
    Source: HSJ, 19 January 2023
  16. Patient Safety Learning
    An invitation to a cervical screening test upon your 25th birthday has become a necessary but often unwanted coming-of-age present. Despite years of education and advocacy about the benefits of screening, many women still do not attend. About 16 million women in the UK aged 25-64 are eligible for testing, but only 11.2 million took a test in 2022, the lowest level in a decade.
    There unfortunately remains a false narrative that there are good reasons to be nervous about cervical screening tests. In reality, the test is not physically painful for the vast majority of women, although it can be a bit uncomfortable. However, the test can be needlessly emotionally painful, and for no good reason. This is in part because some women go through the experience of sitting with legs spread apart and “private parts” out, and then hear the nurse call for “the virgin speculum” to be used.
    This is the archaic and unnecessarily sexualised term for the extra-small speculum. It should have no place being used in 2023, and it clearly creates feelings of vulnerability.
    Next week it is Cervical Cancer Awareness week, and campaigners are hoping to shine a light on barriers to cervical screening testing that must be removed.
    By creating feelings of vulnerability around testing, we are allowing cervical cancer to continue to go undetected. All women should be aware of the importance of attending their cervical screening test and do so with confidence, regardless of their sexual status. This will play a valuable role in reducing the mortality rate.
    Read full story
    Source: The Guardian, 19 January 2023
    Further hub reading:
    Doctors’ shocking comments reveal institutional misogyny towards women harmed by pelvic mesh Misogyny is a safety issue: a blog by Saira Sundar Gender bias: A threat to women’s health (August 2020)
  17. Patient Safety Learning
    High risks relating to the ordering, prescribing, storing and administration of medicines have been found by the Mental Health Commission in a series of inspections of mental health centres in Dublin.
    The commission emphasised the need to have appropriate practices including the recording of the minimum dose interval information; where medication has been stopped, the stop date to be recorded; and the need to always have the prescriber’s signature recorded.
    The inspector of mental health services Dr Susan Finnerty said it was positive to see centres maintaining high compliance rating, but spoke of concerns around the administration of medication.
    “We know that medication is an important tool in treatment of mental illness. In order to reduce the risk of medication errors, we need to be sure that medication prescription and administration records are completed correctly,” Dr Finnerty said.
    Read full story
    Source: Independent Ireland, 18 January 2023
  18. Patient Safety Learning
    Pressures on emergency health services are so bad that the UK government should declare a “national emergency” and call a meeting of the Civil Contingencies Committee (COBRA)—the body summoned periodically to deal with matters of major disruption—peers have said.
    The cross party House of Lords Public Services Committee said in a report that the government needed to respond with an emergency approach and steps to remedy the situation in the longer term.
    A recurring theme of the report is the substantial delays highlighted by the media in recent months, which peers said were caused by a “broken” model of primary and community care. This was driving unmet need in directing patients to hospitals where many remained longer than clinically necessary because of inadequate social care.
    The report recommended that the Department of Health and Social Care should mandate a greater presence of clinical staff in NHS 111 control centres to help boost numbers of clinicians in the 999 and 111 services. This would mean that patients were directed to the right services more quickly thanks to better triaging of calls, which could mean fewer patients being passed to emergency or urgent care services.
    Another suggestion was for the government to introduce more incentives for faster safe discharges from hospitals, with more capacity in hospitals and social care to help people move through the health system more quickly.
    Read full story
    Source: BMJ, 19 January 2023
    Further reading on the hub:
    Patient safety impact of hospital bed shortages – A Patient Safety Learning blog  
  19. Patient Safety Learning
    Hospital inspectors have raised safety concerns over maternity care at an NHS trust where dozens of babies died unnecessarily.
    The Care Quality Commission (CQC) is threatening the East Kent Hospitals trust with enforcement action to ensure patients are protected.
    An independent review in October found that at least 45 babies might have survived with better care at the trust.
    The East Kent Hospitals trust has been approached for comment.
    Inspectors carried out an unannounced inspection of the trust's maternity services over two days last week.
    Following the visit, the CQC has now written to the trust "to request evidence of the steps it is taking to ensure people are safe and protected from risk."
    In a statement to the BBC, Deanna Westwood, a director of operations with the CQC, said they would "review the trust's response to determine whether the use of our enforcement powers is required."
    The warning comes just four months after the trust was severely criticised for its maternity care between 2009 and 2020.
    Read full story
    Source: BBC News, 18 January 2023
    Further reading:
    Patient Safety Learning - Mind the implementation gap: The persistence of avoidable harm in the NHS
  20. Patient Safety Learning
    Ambulance workers are to join nurses in taking strike action on 6 February in England and Wales in what will be the biggest NHS walkout in this dispute.
    The GMB announced four new stoppages for ambulance staff - one of which coincides with a nurses' strike date.
    It is the first time both ambulance staff and the Royal College of Nursing (RCN) have acted on the same day.
    GMB national secretary Rachel Harrison said: "Ambulance workers are angry. Our message to the government is clear - talk pay now."
    The walkouts by staff including paramedics, call handlers and support workers in seven of the 10 English ambulance services along with the national Welsh service will take place on 6 and 20 February, and 6 and 20 March.
    Under trade union laws, both unions will have to provide emergency cover.
    But it raises the prospect of urgent 999 calls for falls not being responded to, and a huge chunk of pre-planned hospital care such as hernia repair, hip replacements or outpatient clinics not being done.
    Read full story
    Source: BBC News, 18 January 2023
  21. Patient Safety Learning
    Young people in the midst of a mental health crisis need to have attempted suicide several times before they get a bed in an inpatient unit in England, a report has revealed.
    Admission criteria for beds in child and adolescent mental health units are now so tight that even very vulnerable under-18s who pose a clear risk to themselves cannot get one.
    The practice – caused by the NHS’s lack of mental health beds – leaves young people at risk of further harm, their parents confused, exhausted and worried, and the police and ambulance services potentially having to step in.
    The high thresholds for admission to a child and adolescent mental health services (Camhs) unit are detailed in a report on NHS mental health care for under-18s in England based on interviews with patients, their parents and specialist staff who look after them.
    The report says a young person has to “have attempted suicide multiple times to be offered inpatient support”.
    Olly Parker, the head of external affairs at the charity Young Minds, said: “It is shameful that children and young people are reaching crisis point before they get any support for their mental health. We know from our own research that thousands have waited so long for mental health support or treatment that they have attempted to take their own life.
    “Those who end up in A&E are often there because they don’t know where else to turn. But A&E can be a crowded and stressful environment, and is usually not the best place to get appropriate help.”
    Read full story
    Source: The Guardian, 18 January 2023
  22. Patient Safety Learning
    The fact that the NHS is under enormous pressure is undisputed. Almost everything else is debated, including the question of how many patients are dying as a result of the chaos in hospitals.
    The proportion of patients who wait more than 12 hours in A&E departments to be admitted to a ward has risen from 2% to 7% over the past year.
    The Royal College of Emergency Medicine has estimated that delays in A&E are leading to 300-500 additional deaths per week. However, officials at NHS England do not accept this figure.
    The data suggest that something is very awry. 
    Read full story (paywalled)
    Source: The Economist, 11 January 2023
  23. Patient Safety Learning
    Patients will suffer if ministers bow to nurses’ demands for pay rises, the health secretary has warned as tens of thousands of NHS staff walk out on today.
    Steve Barclay told the Independent said any boost to wages would “take billions of pounds away from where we need it most”.
    He wrote: “Unaffordable pay hikes will mean cutting patient care and stoking the inflation that would make us all poorer.”
    Today tens of thousands of nurses will strike across 55 trusts. NHS data shows 4,567 operations and 25,009 outpatient appointments were cancelled during the nurse’s strikes on 15 and 20 December.
    The NHS also faces further ambulance strikes next Monday, which sources indicate will go ahead, and new strikes are to be announced for February by union GMB.
    The Royal College of Nursing (RCN) criticised Mr Barclay for “pitting nurses against patients”, branding the comments “a new low for the health secretary”.
    Read full story
    Source: The Guardian, 18 January 2023
  24. Patient Safety Learning
    An acute trust chief executive has criticised the lack of communication during last month’s nursing strike, warning that he and other accountable officers could face manslaughter charges if patients are put in danger by decisions made by senior colleagues elsewhere in the system.
    Matthew Hopkins told a board meeting that Worcestershire Royal Hospital’s emergency department was “pushed to the extreme” on 20 December, with 176 people squeezed into a facility originally built for 50.
    He said that without warning from regional colleagues, an additional 18 people were brought in to the hospital by the ambulance service and ended up in corridors, at which point the trust declared a critical incident.
    The chief executive officer said he wanted to put on record an apology to staff for the incident, adding that he was “not aware” of the situation until it unfolded.
    Read full story (paywalled)
    Source: HSJ, 17 January 2023
  25. Patient Safety Learning
    A series of concerns about serious incidents at a mental health trust are being investigated by the Care Quality Commission, with a referral also made to the police, HSJ has learned.
    HSJ understands that various incidents at Black Country Healthcare Foundation Trust have been raised with the Care Quality Commission by whistleblowers.
    According to a well-placed source, one of the alleged incidents involved alleged inappropriate sexual behaviour, and this has been referred to West Midlands police.
    Other complaints are understood to include staff using mental health inpatients’ rooms to sleep in, and an information governance breach in which patient information was shared with members of staff who did not need to receive them. It is understood this was in an email raising patient safety concerns.
    Read full story (paywalled)
    Source: HSJ, 17 January 2023
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