Clive Flashman

C2.AI has formally launched its Maternity and Neonatal Observatory at the NHS ConfedExpo in Manchester (Government and Public Sector Journal). The observatory is intended to give hospitals and clinicians a detailed picture of the performance of maternity units and the health trajectories of individual women, so areas of concern can be identified and acted on. The system works by calculating and comparing observed outcomes for women and babies with expected outcomes for these individuals. To do this, it uses AI and machine learning to assess clinical factors, case-mix, and the social determinants of health. Early adopters within the NHS, where maternity services are under intense scrutiny, are expected soon.

Female health monitoring apps are putting women at risk by "coercing" them into disclosing - and then poorly handling - highly sensitive data, according to new research. The study examined the privacy policies and data safety labels of 20 of the most popular of these kind of apps, which are commonly used to help women conceive. It found a host of poor data-management practices, including some apps not having a delete function, even for highly personal information such as menstrual cycles and miscarriages. Its authors say it is the most extensive evaluation its kind completed to date. They say the apps are used by hundreds of millions of people. The BBC has contacted a number of app providers - none have responded to a request for comment. "While female health apps are vital to the management of women’s health worldwide, their benefits are currently being undermined by privacy and safety issues," the lead author of the study, Dr Ruba Abu-Salma, from King's College London, told the BBC. Other key findings from the study include: 35% of apps claimed not to share personal data with third parties but contradicted this in their privacy policies 50% assured users that health data would not be shared with advertisers, but were ambiguous about other data collected 45% of privacy policies denied responsibility for third-party practices, despite claiming to vet them. Female-focused technology has boomed in recent years, with the market expected to exceed $75 billion by 2025. But Lisa Malki, another of the study's authors, said the industry needed to get better at protecting the women whose data it was using. Read full article on the BBC here.

Hi, we at patient Safety Learning are looking to hold a virtual round table in the last week of June to look at how to improve patient safety related to the implementation of EPRs. If you are a clinician who has been directly involved with the roll out of an EPR, then you could be part of the event. All notes taken at the event will follow Chatham House rules and your participation will not be disclosed outside the round table group if that is your preference. If you'd like to be involved, please contact me (Clive Flashman) directly at support@pslhub.org Many thanks, Clive

and an update on this article published in the Health Service Journal today

One of the best doctors in the UK died on an understaffed Manchester hospital ward after falling sick with a condition he was an expert in treating, an inquest has heard. Professor Amit Patel was among the ‘best doctors in the UK’, the first person in the country to be qualified in stem cell transplantation and cellular therapy, and intensive care medicine. He was also a beloved husband and father-of-two. “He looked liked a corpse, 70 per cent of his blood was in his lungs, he was freezing cold and he looked like he was dead," his heartbroken wife told an inquest at Manchester Coroners Court. "I told my daughters, ‘daddy is dead’ – I didn’t have much hope he would be able to come out of that.” Professor Patel's condition was being investigated by doctors at Wythenshawe Hospital, Manchester Royal Infirmary, and across the country. But, he was in the unimaginable position of being a nationally recognised expert in the illness. During his career, he had formed ‘national guidance’ on the illness and sat on the national multi-disciplinary panel to which the most serious cases, including his own, were referred. The court heard how he was experiencing the symptoms of hemophagocytic lymph histiocytosis (HLH) – a rare and life-threatening immune disorder where the body reacts inappropriately to a 'trigger’, such as an infection or cancer, and leads to inflammation. Patients can be predisposed to HLH by Still’s disease, another rare autoimmune condition also causing inflammation, which Professor Patel was suspected to have had. Full article here.

Presymptom Health’s technology provides early and reliable information about infection status and severity in patients with non-specific symptoms, helping doctors make better treatment decisions. The company’s tests can be run on NHS PCR platforms, which were widely deployed during the COVID pandemic and are now often under-utilised. By detecting true infection and sepsis earlier, it’s possible to save lives and significantly reduce the incorrect use of antibiotics. When it comes to sepsis, Presymptom’s technology could revolutionise treatment. According to The UK Sepsis Trust, every 3 seconds, someone in the world dies of sepsis. In the UK alone, 245,000 people are affected by sepsis with at least 48,000 people losing their lives in sepsis-related illnesses every year. This is more than breast, bowel and prostate cancer combined. When diagnosed at a late stage, the likelihood of death increases by 10% for every hour left untreated. Yet, for many patients, with early diagnosis it is easily treatable. “We’re confident that our first product can play a big part in tackling Anti-Microbial Resistance (AMR), which has been identified by the World Health Organisation as one of the top 10 global public health threats,” said Dr Iain Miller, CEO of Presymptom Health. “By understanding the presence, or absence, of infection as early as possible, doctors can be more confident in their diagnosis and avoid unnecessarily prescribing antibiotics – something that is a growing concern in the NHS and globally. “If we take Sepsis as an example. Sepsis diagnostics hasn’t moved on in more than a century, and currently doctors can only diagnose it when advanced symptoms and organ failure are present – which is often too late. Our technology enables doctors to diagnose both infection and sepsis up to three days before formal clinical diagnosis, radically transforming the process and preventing unnecessary deaths. The science behind Presymptom’s technology is based upon 10 years of work conducted at Defence Science and Technology Laboratory (Dstl) and originated from £16m of sustained Ministry of Defence investment in a programme of research designed to help service personnel survive infection from combat injuries. The technology is currently undergoing clinical trials at nine NHS hospitals in the UK, with results anticipated later in 2024. In addition, Presymptom is working on additional UK and EU trials.

Hi @Kenny Fraser, thanks for taking the time to respond. Yes, not having an EPR is definitely risky as it precludes the sharing of information, certainly within a single organisation. In terms of an assessment, I would guess that something like that was done at the beginning of the National Programme for IT back in 2003, but I've not seen anything more recently. With regard to benefits realisation, this is a useful document to look at: https://www.ouh.nhs.uk/patient-guide/documents/epr-case-study.pdf In terms of the safety reviews that EPRs have to go through, as you can imagine, they are a lot more robust than DTAC. There is an extremely detailed safety hazard assessment that was created by Dr Maureen Baker and others as part of the NPfIT roll out in the mid 2000s. That is where much of the slimmed down DCBs and DTAC material has come from. However, there are limitations to the self-assessed reviews, and there will always be 'snags' picked up post implementation. My key worry is that this 'post-market surveillance' is not sufficiently specified, or generally done, and while DCB0129 and DCB0160 are meant to be repeated also as part of this process, that hardly every happens.

That's great news @Chris W, would be good to share the results of that with the wider group @Patient_Safety_Learning

I am glad that the remit of PSPs has gone far beyond that originally envisaged by NHS E. This can only be a good thing. It would be interesting to collate this into a master job spec that can be shared across Trusts so that all can fully benefit from the input of their PSPs. Perhaps this can be done via the relevant area on this site @Claire Cox, @HelenH, @PatientSafetyLearning Team

If it is correct that the babies' deaths were reported into the local risk management system as medication errors, they would also have been reported onwards to the National Reporting and Learning System (NRLS); run by NHS England and all data analysed by them also. Given that these death records in the NRLS would have shown that they all occurred at the same Trust, involving babies, in the space of a 12-18 month period, I wonder whether this should have been picked up centrally?

The exodus of healthcare workers from Nigeria, Ghana and Zimbabwe continues, despite the WHO red list and a range of laws to keep them at home. It took nearly three hours of queueing in Ikorodu general hospital in Lagos state, Nigeria, before Hadijat Hassan, a retired civil servant, could see a nurse. The 66-year-old has attended the clinic for health checks since being diagnosed with diabetes nearly 10 years ago. But since May, she says, the delays, often while suffering from excruciating pain in her legs, are worse than ever. “You can get there [the hospital] and meet about 50 people waiting to be attended to,” Hassan says. “They said all of their nurses and doctors have been leaving for abroad. Just a few are left.” In Nigeria, there is one doctor for every 5,000 patients, whereas the average in developed countries is one doctor for about every 254 people. A hospital official said the Ikorodu management get resignation notices from nurses and doctors almost every month. “Many leave for the US, Canada, UK and, most recently, Australia,” says the official, who asked to remain anonymous. The National Association of Nigeria Nurses and Midwives has reported there is now a ratio of one nurse to 1,160 patients. Its president, Michael Nnachi, said that more than 75,000 nurses had left Nigeria since 2017. “If you look at the conditions of service of health workers generally, you’ll see the difficult challenges complicated by the current economic realities,” he said, adding that rising inflation has compounded the problems. The World Health Organization predicts a worldwide shortage of 10 million health and care workers by 2030 – mostly in low-income countries, where people are leaving for opportunities abroad. This is despite the WHO’s introduction of a safeguard list to stop rich countries poaching from poorer countries with staff shortages. The “red list”, launched in 2020 with plans to update it every three years, includes Nigeria, Ghana, Zimbabwe and 34 other African countries. Yet the UK’s nursing regulator, the Nursing and Midwifery Council, says more than 7,000 Nigerian nurses relocated to the UK between 2021 and 2022. Data from the Ghana Registered Nurses and Midwives Association shows that nearly 4,000 nurses left the country in 2022. In Zimbabwe, more than 4,000 health workers, including 2,600 nurses, left in 2021 and 2022, the government said. The WHO has no powers to prohibit recruitment of doctors from countries on the list, but recommends “government-to-government health worker migration agreements be informed by health labour market analysis and the adoption of measures to ensure adequate supply of health workers in the source countries”. Read the full article here

Making data on medical interventions easier to collect and collate would increase the odds of spotting patterns of harm, according to the panel of a recent HSJ webinar When Baroness Julia Cumberlege was asked to review the avoidable harm caused by two medicines and one medical device, she encountered no shortage of data. “We found that the NHS is awash with data, but it’s very fractured,” says Baroness Cumberlege, who chaired the Independent Medicines and Medical Devices Safety Review and now co-chairs the All-Party Parliamentary Group which raises awareness of and support for its findings. And it is that fracturing that can make patterns of harm difficult to spot. The report concluded that many women and children experienced avoidable harm through use of the hormone pregnancy test Primodos, the epilepsy drug sodium valproate, and the medical device pelvic mesh – simply because it hadn’t been possible to connect the dots. “It’s very hard to collect things together and to get an overall picture. And one of the things that we felt very strongly about was that data should be collected once, but used often,” said Baroness Cumberlege at a recent HSJ webinar. Run in association with GS1 UK, the event brought together a panel to consider how better data might help address patient safety challenges such as problems with implants. “But the big problem was they couldn’t identify who had which implants. No doubt somebody somewhere had written this down with a fountain pen and then someone spilt the tea over it and the unique information was lost,” recalled Sir Terence Stephenson , now Nuffield professor of child health at Great Ormond Street Institute of Child Health and chair of the Health Research Authority for England. The review he chaired therefore suggested establishing a concept of person, product place – “for everybody who had something implanted in them, we should have their name, the identifier of what had been put in, and where it had been put in. And one of my panel members said: ‘Well, how are we going to record this? We don’t want the fountain pen and the teacup.’” Ultimately the answer suggested was barcode scanning. By scanning the wristband of a patient, that on the product being implanted, and one for the hospital theatre or department at which it was being implanted, the idea was to create an immediate and easy-to-create record. For those long convinced of the virtues of barcode scanning in health, it is a welcome development Two years later, the then Department of Health launched the Scan4Safety programme, in which six “demonstrator sites” implemented the use of scanning across the patient journey. At these organisations, barcodes produced to GS1 standards – meaning they are globally unique – are present on patient wristbands; on equipment used for care, including implantable medical devices; in locations; and sometimes on staff badges. Link to full article here (paywalled)

A group of potent synthetic opioids called nitazenes have been linked to a rise in overdoses and deaths in people who use drugs, primarily heroin, in England over the past two months, drug regulators have warned. The Office for Health Improvements and Disparities has issued a National Patient Safety Alert on potent synthetic opioids implicated in heroin overdoses and deaths. In the past 8 weeks there has been an elevated number of overdoses (with some deaths) in people who use drugs, primarily heroin, in many parts of the country (reports are geographically widespread, with most regions affected but only a few cities or towns in each region). Testing in some of these cases has found nitazenes, a group of potent synthetic opioids. Nitazenes have been identified previously in this country, but their use has been more common in the USA. Their potency and toxicity are uncertain but perhaps similar to, or more than fentanyl, which is about 100x morphine. The National Patient Safety Alert provides further background and clinical information and actions for providers.