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Patient Safety Learning

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  1. Content Article
    The Department of Health and Social Care is consulting jointly with the Department of Health Northern Ireland to seek your views on amending the Human Medicines Regulations 2012 to enable pharmacy technicians to supply and administer medicines using patient group directions (PGDs). This proposal supports the ambitions of NHS systems across the UK to maximise the use of the skill mix within pharmacy teams, enabling them to meet more of the health needs of their local populations. Deadline: 29 September 2023.
  2. News Article
    A hospital trust failed to send out 24,000 letters from senior doctors to patients and their GPs after they became lost in a new computer system, the BBC has learned. Newcastle Hospitals warned the problem, dating back to 2018, is significant. The BBC has been told the problems occurred when letters requiring sign-off from a senior doctor were placed into a folder few staff knew existed. The healthcare regulator has sought urgent assurances over patient safety. Most of the letters explain what should happen when patients are discharged from hospital. But a significant number of the unsent letters are written by specialist clinics spelling out care that is needed for patients. It means that some crucial tests and results may have been missed by patients. Staff have been told to record any resulting incidents of patient harm and ensure these are addressed. Following a routine inspection by the regulator - the Care Quality Commission (CQC) - in the summer, staff at the trust raised concerns about delays in sending out correspondence. A subsequent review of the trust's consultants revealed that most had unsent letters in their electronic records. Read full story Source: BBC News, 26 September 2023
  3. News Article
    A coroner has warned that a private hospital is relying on NHS ambulances to transport patients despite “being fully aware” of the pressures on the ambulance service and resulting delays. The warning came at the end of an inquest into a patient who died after a 14-hour wait for an ambulance to transfer him from the private Spire hospital in Norwich to the NHS-run Norfolk and Norwich university hospital a few minutes’ drive away. The last two years have seen a succession of inquests relating to ambulance delays. But in the latest case Jacqueline Lake, senior coroner for Norfolk, expressed concerns over Spire hospital’s use of NHS ambulances when complications and emergencies mean its patients need NHS care. “Spire Norwich hospital does not deal with multi-disciplinary and emergency treatment at its hospital and transfers patients requiring such treatment to local acute trusts, usually the Norfolk and Norwich university hospital,” Lake wrote in a prevention of future deaths (PFD) report. “Spire Norwich hospital continues to rely on EEAST [East of England Ambulance Service NHS Trust] to transport such patients to the acute hospital, being fully aware of the demands placed on the EEAST generally and the delays which occur as a result.” Research suggests that nearly 600 patients were urgently transferred from private healthcare to NHS emergency care in the year to June 2021 across the UK – around one in a thousand private healthcare patients. But previous analysis by the Centre for Health and the Public Interest (CHPI) thinktank found that some private hospitals were transferring more than one in every 250 of their inpatients to NHS hospitals. ‘“Transferring unwell patients from a private hospital to an NHS hospital is a known patient safety risk which all patients treated in the private sector face – including the increased numbers of NHS patients who are now being treated in private hospitals because of government policy,” said David Rowland, director of the CHPI. “And despite numerous tragedies and despite the fact that politicians and regulators are fully aware of this risk, nothing has been done to address it.” Read full story Source: The Guardian, 23 September 2023
  4. Content Article
     On 3 August 2022, Geoffrey Hoad underwent a total hip replacement at The Spire Hospital. On 5 August 2022, Mr Hoad was diagnosed with a paralytic ileus and some respiratory compromise with gradually deteriorating renal function. On 6 August 2022, Mr Hoad’s transfer to Norfolk and Norwich University Hospital was agreed due to possible bowel obstruction, possible pulmonary infection and deteriorating renal function.   Ambulance service was called at 18:16 hours and again at 23.45. On 7 August 2022, the ambulance service was called again at 07.38 hours. The ambulance was on scene at 08:26 hours.         The medical cause of death was: 1a) Sub Acute Myocardial Infarction 1b)  Coronary Artery Atherosclerosis 2) Hospital Admission for Post Operative lieus.
  5. Content Article
    In October, the Healthcare Safety Investigation Branch will tweak its name, become independent from NHS England and the UK government, and gain new powers to strengthen investigations. With the announcement of the change in status, Health Secretary, Steven Barclay, reported it would be leading an investigation into inpatient mental health. This follows swiftly on the heels of the Strathdee rapid review into data on mental health inpatient settings, which itself was launched in response to well-documented failures in these settings. The aim of this new investigation into mental health is simple: to improve safety. In this blog, Karen West, Head of Transformation (Mental health) at Oxehealth, and Professor Dan Joyce from the University of Liverpool, discuss the importance of data in patient safety improvement and explain why inpatient mental health data is so difficult to collect and what can be done to improve this.
  6. Content Article
    The Health Service Executive (HSE) is a large organisation of over 100,000 people, whose job is to run all of the public health services in Ireland. The HSE manages services through a structure designed to put patients and clients at the centre of the organisation. 
  7. News Article
    A trust chief executive has warned of a ‘really significant increase’ in patient anxiety and frustration created by the ongoing doctors’ strikes. Lance McCarthy, the chief executive officer of Princess Alexandra Hospital Trust, made the comments during the most recent four-day junior doctors’ strike, which also coincided with two days of consultant strike action. The trust leader told Hertfordshire and West Essex integrated care board on Friday: “We shouldn’t underestimate the impact industrial action is having.” Mr McCarthy said this impact was not just confined to strike days but also affected the run-up and aftermath of each bout of industrial action. He said every series of strike days caused service disruption for at least another 72 hours. He said: “We are seeing increasing frustration [from] our colleagues around it, because we are constantly duplicating work, cancelling patients, rebooking the same patients, etc. “We are [also] quite understandably starting to see in the last two months a really significant increase in anxiety and concern and frustration from our patients, who took it quite well the first couple of rounds but are understandably really frustrated. It is having a really significant impact.” In a further statement to HSJ, Mr McCarthy reiterated comments that trust staff had noticed an increase in anxiety, concern and frustration among both patients and colleagues in recent months. Read full story (paywalled) Source: HSJ, 25 September 2023
  8. News Article
    People living with long Covid after being admitted to hospital are more likely to show some damage to major organs, according to a new study. MRI scans revealed patients were three times more likely to have some abnormalities in multiple organs such as the lungs, brain and kidneys. Researchers believe there is a link with the severity of the illness. It is hoped the UK study will help in the development of more effective treatments for Long Covid. The study, published in Lancet Respiratory Medicine, looked at 259 patients who fell so ill with the virus that they were admitted to hospital. Five months after they were discharged, MRI scans of their major organs showed some significant differences when compared to a group of 52 people who had never had Covid. The biggest impact was seen on the lungs, where the scans were 14 times more likely to show abnormalities. MRI scans were also three times more likely to show some abnormalities in the brain - and twice as likely in the kidneys - among people who had had severe Covid. Dr Betty Raman, from the University of Oxford and one of the lead investigators on the study, says it is clear that those living with long Covid symptoms are more likely to have experienced some organ damage. She said: "The patient's age, how severely ill they were with Covid, as well as if they had other illnesses at the same time, were all significant factors in whether or not we found damage to these important organs in the body." Read full story Source: BBC News, 23 September 2023
  9. News Article
    The BMA’s GP Committee (GPC) has demanded an investigation into the Government and NHS England’s ‘mismanagement’ of this year’s vaccination programmes. A motion was passed at the GPC England meeting today which called for a review of the ‘circumstances which led to muddled and mismanaged communications’ and for reflection on how to ‘prevent a repeat occurrence’. Last month, there was confusion over the start date for the adult flu and Covid vaccination programmes, which usually start in September. NHS England said the programmes would start in October this year – a move which the BMA said would cause ‘serious disruption’. But the Government then announced that vaccination will begin on 11 September, in what the BMA has called a ‘u-turn’, following the identification of a new Covid variant. GPs were asked to vaccinate ‘as many people as possible’ by the end of October. The GPC has said today that these ‘conflicting instructions’ led to confusion among GPs while also impacting on patient safety. Read full story Source: Pulse, 21 September 2023
  10. Content Article
    Extensive cultural change is needed in the NHS to tackle sexual violence and prevent further institutional harm to patients and staff, writes Philippa Greenfield, co-presidential lead for women and mental health, consultant general adult psychiatrist, named doctor for adult safeguarding and trauma informed lead.
  11. Content Article
    The report from the International Labour Organization describes the results of a special analysis of data from the Labour Force Surveys (LFS) of 56 countries which provided data about health and social care workers in sufficient detail to distinguish between different occupational groups within the workforce. The report covers analyses for 29 countries in Europe and 27 from other regions of the world. This analysis can help to highlight specific occupation groups and countries which are at heightened risk of decent work deficits and demographic imbalances.
  12. Content Article
    The adoption of virtual consultations, catalysed by the COVID-19 pandemic, has transformed the delivery of primary care services. Owing to their rapid global proliferation, there is a need to comprehensively evaluate the impact of virtual consultations on all aspects of care quality. This study aims to evaluate the impact of virtual consultations on the quality of primary care. It found that virtual consultations may be as effective as face-to-face care and have a potentially positive impact on the efficiency and timeliness of care; however, there is a considerable lack of evidence on the impacts on patient safety, equity, and patient-centeredness, highlighting areas where future research efforts should be devoted. Capitalising on real-world data, as well as clinical trials, is crucial to ensure that the use of virtual consultations is tailored according to patient needs and is inclusive of the intended end users. Data collection methods that are bespoke to the primary care context and account for patient characteristics are necessary to generate a stronger evidence base to inform future virtual care policies.
  13. Content Article
    ‘Compassionate communication, meaningful engagement’ is a handbook for all NHS staff which aims to improve collaboration with patients, their families and carers following a patient safety event. Developed with NHS Trusts across England in partnership with Making Families Count, the guide includes principles of compassionate engagement, roles and responsibilities of healthcare professionals, and information about the processes following an incident. It also brings together a range of signposting information and resources for families and staff.
  14. Content Article
    Unable to work or to play with their children, forced to sell their homes or facing insolvency—doctors with Long Covid deserve more support from the government and the NHS, writes Adele Waters in this BMJ article.
  15. Content Article
    The important issue of a patient’s right to a second medical opinion has recently hit the headlines with Martha’s Rule, which relates to the tragic death of 13-year-old Martha Mills in NHS care and the circumstances surrounding this. There is a groundswell of support for Martha’s Rule, with Health and Social Care Secretary Steve Barclay committed to introducing the rule in England. This is excellent news, but development and implementation must not be rushed writes John Tingle, Dr Dita Wickins-Drazilova and Steve Gulati from the University of Birmingham.
  16. News Article
    The US Food and Drug Administration (FDA) has sent warning letters to pharmacy chains Walgreens and CVS accusing them of illegally marketing eye care products. The FDA’s warning letters said the products in question, which were falsely labelled as potential treatments for conditions like glaucoma, cataracts, and pink eye, should be modified if the companies and manufacturers that make and distribute them want to avoid legal action. “The FDA is committed to ensuring the medicines Americans take are safe, effective and of high quality,” Jill Furman, Director of the Office of Compliance at the FDA’s Center for Drug Evaluation and Research, said in a statement. “When we identify illegally marketed, unapproved drugs and lapses in drug quality that pose potential risks, the FDA works to notify the companies involved of the violations.” Ms Furman wrote in the letter sent to Walgreens: “Your ‘Walgreens Allergy Eye Drops,’ ‘Walgreens Stye Eye Drops,’ and ‘Walgreens Pink Eye Drops’ products are especially concerning from a public health perspective. Ophthalmic drug products, which are intended for administration into the eyes … pose a greater risk of harm to users because the route of administration for these products bypasses some of the body’s natural defences.” Read full story Source: The Independent, 21 September 2023
  17. News Article
    The family of a young trans woman who is believed to have taken her own life have said she was “failed by those tasked with her care”, as the coroner investigating her death described services for transgender people as “underfunded and insufficiently resourced”. Alice Litman had been waiting to receive gender-affirming healthcare for more than three years when she died in Brighton at the age of 20 in May 2022. Ahead of an inquest which began in Hove on Monday, her mother, Dr Caroline Litman, described Alice’s death as “preventable with access to the right support”. Adjourning the inquest on Wednesday to give a narrative conclusion in two weeks’ time, the coroner Sarah Clarke told the court: “It seems to me that all of these services are underfunded and insufficiently resourced for the level of need that the society we live in now presents". Describing the trans healthcare system as “not fit for purpose”, Alice's family, who are being supported by the Good Law Project, added: “We are grateful that the coroner has agreed that the conditions of Alice’s death warrant a report to prevent future deaths.” Read full story Source: The Guardian, 20 September 2023
  18. News Article
    Hospital bosses fear that further strikes by doctors will push the NHS “close to breaking point” as it struggles to cope with its winter crisis in the months ahead. NHS leaders are concerned that medics’ plans to continue their campaign of stoppages until February will make it even harder for the service to manage what is always its toughest period. Four days of strikes this week in England have included the first-ever 24-hour joint strike over pay on Wednesday by consultants and junior doctors. This latest series of stoppages – two days by consultants and three days by junior doctors – has forced hospitals to reschedule many thousands of outpatient appointments and non-urgent operations because of the lack of staff. “Winter pressures, respiratory illness and rising Covid again mean that the next six months will be exceptionally difficult. Winter always is,” said one hospital trust chief executive, who asked not to be named. “The NHS is effective at absorbing pressure but the industrial action may, at times, take us close to breaking point and often patient harm and the impact on NHS staff is not fully recognised,” he said. Read full story Source: The Guardian, 20 September 2023
  19. News Article
    Certain spina bifida-related surgeries remain suspended at Children's Health Ireland at Temple Street (CHI) for almost a year amid serious allegations that unlicensed devices made with non-medical parts have been implanted in child patients. In two cases where these devices were used, the implants had to be removed from patients after causing significant harm, while the efficacy of a third is yet to be determined. One senior member at the hospital has raised concerns about the number of repeat operations required on young spina bifida patients and associated rates of reinfection, with disquiet in the hospital eventually leading to first an internal review of operations in October 2022 and later an external probe by US clinicians. In June this year there were 287 children on waiting lists in Ireland for life-changing spinal surgery. Despite a commitment first given by then health minister Simon Harris in 2017 that no child would be on the waiting list for more than four months, there are still more than 120 children waiting more than a year for scoliosis surgery, according to the Ombudsman for Children. CHI has declined to comment on allegations that one of its surgeons has used the unlicensed, failed implants, as well as its decision to cease operations on spina bifida patients. Patient advocate Amanda Santry, who took part in the external review on behalf of Spina Bifida & Hydrocephalus Paediatric Advocacy, has said she has been denied access to the review findings and has also called for a “full investigation” into the allegations of the use of non-medical parts. Read full story Source: The Ditch, 15 September 2023
  20. Content Article
    The Australian Disability Royal Commission was established in April 2019 in response to community concern about widespread reports of violence against, and the neglect, abuse and exploitation of, people with disability. These incidents might have happened recently or a long time ago. The Disability Royal Commission will investigate: preventing and better protecting people with disability from experiencing violence, abuse, neglect and exploitation. achieving best practice in reporting, investigating and responding to violence, abuse, neglect and exploitation of people with disability. promoting a more inclusive society that supports people with disability to be independent and live free from violence, abuse, neglect and exploitation. The Disability Royal Commission gathers information through research, public hearings, the personal experiences people tell us about and submissions, private sessions, and other forums. It will deliver a final report to the Australian Government by 29 September 2023.
  21. Content Article
    In April 2023, National Voices held a workshop with members, supported by The Disrupt Foundation, on the unequal impact of the Covid-19 pandemic. It explored how communities and groups were affected differently by both the virus itself and the measures brought in to control it.   It painted a grim picture of the ways in which the pandemic response exacerbated existing, deep-rooted inequalities across the UK and compounded the disadvantages experienced by people from minoritised communities, by disabled people and by people living with long term conditions.  Just some examples include people who are immunocompromised, who were asked to go into isolation for huge periods of time and still feel completely overlooked as control measures have been lifted. Or the use of DNRs (Do Not Resuscitate orders) which were disproportionately applied to people with learning disabilities.  With the Covid-19 Inquiry underway, it is imperative that we capture the lessons learnt from the pandemic, and use them to suggest action for the future.
  22. Content Article
    MEG interviews Patient Safety Learning's Chief Executive, Helen Hughes, for this year's World Patient Safety Day. Helen discusses how Patient Safety Learning contributes to improving patient safety, the 'Blueprint for Action', how the new LFPSE service will impact patient engagement and the role leadership plays in patient safety.
  23. News Article
    NHS England’s national mental health director admitted she was ‘concerned’ that 20% of mental health nurse roles were unfilled and about the impact this could have on a nationwide push to improve safety and tackle closed cultures. Claire Murdoch was speaking to HSJ a year on from a series of high-profile documentaries exposing abuse and poor care at mental health trusts. In their wake, Ms Murdoch urged providers to urgently review safeguarding, while a separate three-year quality programme was also launched to look at closed cultures and improve safety. Now in the middle of that programme, Ms Murdoch stressed that stability in staffing is “vital” to developing safe and therapeutic care, but that many services across the country are struggling with significant nursing vacancies. She said: “The bit that absolutely we need to acknowledge [around changing cultures] is there are some significant workforce and staffing challenges, which I’m concerned about, with a 20%t vacancy of qualified registered mental health nurses nationally. “There are new support roles, psychology assistant roles, physician associates – there are all sorts coming into being in inpatient care, but a lot of services are still struggling with staffing". Read full story (paywalled) Source: HSJ, 21 September 2023
  24. News Article
    A mental health provider has apologised after telling a whistleblower he was being declined treatment due to an employment tribunal he had brought against a neighbouring trust. Andrew Wardley was among a group of staff who raised concerns over a major research project at The Christie, a prominent cancer trust in Greater Manchester. Dr Wardley, a leading oncologist, has claimed he was sidelined and effectively bullied out after raising legitimate concerns. He has brought an employment tribunal against the specialist trust. The ongoing case has caused him severe stress and anxiety, prompting him to seek psychological treatment with South West Yorkshire Partnership Foundation Trust, which runs services near his home in Huddersfield. He told HSJ an initial phone conversation with trust staff had been positive and ended with an agreement he would benefit from treatment with the Improving Access to Psychological Therapies team. But he subsequently received a letter from the trust, which said: “Given the ongoing litigation IAPT would not be in a position to offer any therapy". Read full story (paywalled) Source: HSJ, 20 September 2023
  25. News Article
    The death of a mentally ill teenager who died after drinking an excessive amount of water was preventable, an investigation has found. The 18-year-old, known at Mr D, was being detained under the Mental Health Act at the time of his death. An inquiry by the Mental Welfare Commission said he had previously been treated for drinking too much water. It found several areas where a different course of action could have prevented his death. The teenager was admitted out-of-hours to an adult mental health service (AMHS) inpatient unit in a health board neighbouring his own on 5 December 2018 as there were no local beds available. This move was described in the report as a "high-risk action". On the evening of 7 December he suffered a seizure after drinking too much water and was transferred to intensive care. He died three days later from the consequences of water intoxication. Suzanne McGuinness, executive director (social work) at the Mental Welfare Commission, said: "This was a tragic death of a young man while he was being cared for in hospital. "We found that a more assertive approach to the treatment of Mr D's psychotic illness in the two years before his death was warranted. The risks associated with psychotic illness were not coherently managed." Read full story Source: BBC News, 21 September 2023
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