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Sam

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  1. Sam
    Failures by a health board led to eight cancer patients not being appropriately monitored or included in treatment targets after being referred to England, the ombudsman has found.
    Of the 16 patients on Wale's Betsi Cadwaladr health board's prostatectomy waiting list in August 2019, eight were referred to England for treatment. None of those treated in England met the health board's targets.
    The health board, which covers north Wales, has apologised to the patients. It said it had accepted the findings of the report and agreed to implement its recommendations.
    The investigation was launched after a report into the case of a prostate cancer patient raised suspicion there were further incidents.
    Public Services Ombudsman for Wales Nick Bennett said: "Clearly there's consequences for any type of cancer treatment, where people who are treated in England do not receive the same monitoring, do not receive the same harm reviews...
    "Going forward, this must never happen again."
    Read full story
    Source: BBC News, 9 September 2021
  2. Sam
    NHS leaders are being urged to tackle racist abuse of staff as new figures reveal that a third of black, Asian or minority ethnic workers in mental health trusts in England have experienced harassment, bullying or attacks by patients, relatives or members of the public.
    One in three (32.7%) BAME staff in mental health settings have experienced abuse, according to analysis by the Royal College of Psychiatrists. For BAME workers across the NHS, the rate is more than one in four (28.9%).
    One medical director told the Guardian that hot tea had been thrown at them “because of the colour of my skin”. A psychiatrist told how they were left traumatised after they were racially abused – then threatened with a knife.
    The college is calling on health leaders to take a stand against discrimination by setting up better processes in NHS trusts to record and understand data about bullying and harassment.
    Dr Adrian James, president of the Royal College of Psychiatrists, said the findings were deeply concerning. He said: “NHS leaders and local health bosses must tackle this head-on.”
    Read full story
    Source: The Guardian, 9 September 2021
  3. Sam
    The father of a man who took his own life said the mental health unit where he was staying "failed him completely".
    Joshua Sahota, 25, died as a result of asphyxia and psychosis at the Wedgewood Unit in Bury St Edmunds, Suffolk, on 9 September 2019.
    Insufficient staffing levels at the unit contributed to his death, an inquest jury found.
    Mr Sahota, from Kennett in Cambridgeshire, was taken to the unit three weeks before his death as his mental health had declined.
    There was no psychologist in post and the jury at Suffolk Coroner's Court recorded this as having contributed to his death.
    It also found that a plastic bag which contributed to his death was on a restricted items list, but this was "unclear" and there were "inconsistencies of understanding this" by staff and visitors.
    Other factors that the jury said contributed to his death included insufficient observations and one-to-one processes, no clear and concise risk assessments, being slow to develop a care plan and the absence of a documented crisis plan.
    Read full story
    Source: BBC News, 10 September 2021
  4. Sam
    ‘Very heavy-handed, laborious and expensive’ inspections ‘have not been the right way’ of regulating hospitals, according to the Care Quality Commission’s (CQC) former chair.
    Speaking at a Royal Society of Medicine event on Wednesday, Lord David Prior, who is now the chair of NHS England, said “very few” physicians will have improved their work after reading a report from the regulator.
    He added that there is a role for the CQC to move in when “things are going wrong” although he is “sceptical” the regulator can actually drive improvement in hospitals.
    Lord Prior said: “I am highly sceptical as to whether or not CQC or any regulator can really drive improvement and drive the top hospitals to make them better.
    “And certainly I think there’ll be very few physicians who will say that their clinical work has improved as a result of reading a CQC report.
    “I think the sadness I have about CQC is that we have not been able, or it has not been able, to develop a series of predictive metrics that could replace these very heavy handed, very laborious and very expensive visits that we used to do.”
    Read full story (paywalled)
    Source: HSJ, 9 September 2021
  5. Sam
    The deaths of three adults with learning disabilities at a failed hospital should prompt a review to prevent further "lethal outcomes" at similar facilities, a report said.
    The report looked at the deaths of Joanna Bailey, 36, and Nicholas Briant, 33, and Ben King, 32, between April 2018 and July 2020. It found here were significant failures in the care of the patients at Jeesal Cawston Park, Norfolk.
    Ms Bailey, who had a learning disability, autism, epilepsy and sleep apnoea, was found unresponsive in her bed and staff did not attempt resuscitation, while the mother of Mr King said he was "gasping and couldn't talk" when she last saw him. Mr Briant's inquest heard he died following cardiac arrest and obstruction of his airway after swallowing a piece of plastic cup.
    The report found:
    "Excessive" use of restraint and seclusion by unqualified staff. Concerns over "unsafe grouping" of patients. Overmedication of patients. High levels of inactivity and days of "abject boredom". Relatives described "indifferent and harmful hospital practices" and said their questions and "distress" were ignored
    Joan Maughan, who commissioned the report as chairwoman of the Norfolk Safeguarding Adults Board, said: "This is not the first tragedy of its kind and, unless things change dramatically, it will not be the last."
    Read full story
    Source: BBC News, 9 September 2021
  6. Sam
    Becton Dickinson (BD), which manufactures most of the blood tubes used by the NHS, has alerted NHS England and NHS Improvement (NHSE/I) to a global shortage of some of its products, including two types of blood tubes: those with a yellow or purple top.
    BD says that the COVID-19 pandemic created the most unpredictable demand it has seen in the past 70 years. The company says that it has also been difficult for customers to predict the types and quantities of blood tubes they will be using from month to month, which affects manufacturers’ abilities to meet demand. “Adding to the issue are global transportation delays that have resulted in more products being tied up in transportation than is normal, creating additional delays in deliveries,” BD said in a statement. “Raw material suppliers are also challenged to keep up with demand for materials and components.”
    In the UK, BD has been authorised to import blood tubes that are approved for use in other regions of the world, including the United States. It plans to deliver nine million of these additional blood tubes to the NHS for immediate distribution. 
    Read full story (paywalled)
    Source: BMJ, 3 September 2021
  7. Sam
    A child safeguarding expert who faced vilification after raising concerns about the safety of children undergoing treatment at a London NHS gender identity clinic has won an employment tribunal case against the hospital trust.
    Sonia Appleby, 62, was awarded £20,000 after an employment tribunal ruled the NHS’s Tavistock and Portman trust’s treatment of her damaged her professional reputation and “prevented her from proper work on safeguarding”.
    Appleby, an experienced psychoanalytical psychotherapist, was responsible for protecting children at risk from maltreatment.
    The tribunal heard evidence she raised concerns about the treatment of increasing numbers of children being referred to the trust’s Gender Identity Development Service (Gids). The service in Hampstead has been at the heart of a controversy over its treatments, including the provision of drugs known as puberty blockers to children as young as 10.
    The tribunal heard evidence that after she raised the concerns, instead of addressing them, the trust management ostracised her and attempted to prevent her from carrying out her safeguarding role, by sidelining her. Appleby said the management’s action amounted to a “full-blown organisational assault”.
    Read full story
    Source: The Guardian, 4 September 2021
  8. Sam
    More than one in five ‘covid deaths’ were both probably hospital-acquired, and caused at least in part by the virus, at several trusts, according to analysis released to HSJ.
    HSJ obtained figures from more than 30 trusts which have looked in detail at cases where patients died after definitely, or probably, catching covid in hospital. 
    Thirty-two acute trusts provided HSJ with robust data, out of the total 120 in England. Across all 32, they had recorded 3,223 covid hospital deaths which were either “definitely” or ‘probably’ nosocomial — making up around 17% of their total reported 19,020 hospital deaths.
    The trusts said 2,776 of the 3,223 deaths also had covid listed on their death certificate, either as an “immediate cause” or as a contributory factor. That constitutes about 15% of all the hospitals’ covid deaths, and 86% of the nosocomial deaths.
    When approached by HSJ, these trusts said they followed robust infection control practices, and that high community covid prevalence, and covid admissions, were the main cause of hospital-acquired infection. Some trusts also cited their ageing infrastructure.
    Read full story (paywalled)
    Source: HSJ, 6 September 2021
     
  9. Sam
    Shortfalls in mental health services and staffing have been flagged as concerns in dozens of inquests since 2015, the Observer has revealed, with coroners issuing repeated warnings over patients facing long waiting lists or falling through gaps in service provision.
    The Observer has identified 56 mental health-related deaths in England and Wales from the start of 2015 to the end of 2020 where coroners identified a lack of staffing or service provision as a “matter of concern”, meaning they believed “there is a risk that future deaths could occur unless action is taken”.
    Coroners issue Reports to Prevent Future Deaths (PFD) when they believe action should be taken to prevent deaths occurring in future, and send them to relevant individuals or organisations, who are expected to respond. In one case, a woman referred to psychotherapy services had still not received any psychotherapy by the time she died 11 months later. In another, someone had endured a seven-month wait for a psychological assessment.
    Alison Cobb, senior policy and campaigns officer at the mental health charity Mind, said: “It’s shocking that so many should lose their lives because there isn’t enough capacity in mental health services to provide adequate care. These prevention of future deaths notices are meant to inform better ways of working, and it’s especially concerning that similar stories are repeating over and over again.”
    Read full story
    Source: The Guardian, 5 September 2021
    Coroner's reports on the hub
  10. Sam
    The family of a senior medic and lifelong NHS campaigner have called for an investigation into his death as it took paramedics more than half an hour to arrive at his home after operators were told he was suffering a cardiac arrest.
    Professor Kailash Chand, a former British Medical Association deputy chair, had complained of chest pains before one of his neighbours, a consultant anaesthetist at Manchester Royal Infirmary, called 111 for help before telling the call handler within three minutes that he believed his friend was having a cardiac arrest.
    “I was answering their questions when Kailash’s eyes began rolling and he slipped into unconsciousness. That’s when I said ‘this looks like a cardiac arrest’ and to upgrade the call. They kept asking questions as I started CPR and asked for an urgent ambulance. That was two or two and a half minutes into the call."
    Evidence seen by i News shows that it took another 30 minutes after the neighbour told the operator about the cardiac arrest for the paramedics to arrive at Professor Chand’s flat in Didsbury, Greater Manchester.
    National standards for ambulance trusts show that ambulance trusts must respond to category 1 calls – those that are classified as life-threatening and needing immediate intervention and/or resuscitation, such as cardiac or respiratory arrest – in 7 minutes on average, and respond to 90% of Category 1 calls in 15 minutes.
    Read full story
    Source: iNews, 3 September 2021
  11. Sam
    The Medicines and Healthcare products Regulatory Agency (MHRA) are warning that thermal cameras and other such “temperature screening” products, some of which make direct claims to screen for COVID-19, are not a reliable way to detect if people have the virus.
    In July 2020 the Agency told manufacturers and suppliers of thermal cameras that they should not make claims which directly relate to COVID-19 diagnosis, and now are reminding businesses to follow Government advice on safe working during COVID-19.
    Graeme Tunbridge, MHRA Director of Devices, said:
    "Many thermal cameras and temperature screening products were originally designed for non-medical purposes, such as for building or site security. Businesses and organisations need to know that using these products for temperature screening could put people’s health at risk. These products should only be used in line with the manufacturer’s original intended use, and not to screen people for COVID-19 symptoms. They do not perform to the level required to accurately support a medical diagnosis."
    Read full story
    Source: BBC News, 27 July 2021
  12. Sam
    Researchers from the 'Therapies for Long COVID (TLC) Study Group' at the University of Birmingham are studying long COVID is and what influences it by pooling data from lots of separate studies to find out the prevalence of reported symptoms and to see what the impacts and complications of long COVID are.
    Their review showed just how varied long COVID is. Patients may experience symptoms related to any system in the body – including respiratory, neurological and gastroenterological symptoms. The pooled data showed that the ten most commonly reported symptoms in long COVID are fatigue, shortness of breath, muscle pain, cough, headache, joint pain, chest pain, an altered sense of smell, diarrhoea and altered taste.
    Other common symptoms include “brain fog” – when thinking is fuzzy and sluggish – memory loss, disordered sleep, heart palpitations and a sore throat. Rare but important outcomes include thoughts of self-harm and suicide and even seizures.
    Most long COVID patients complain of symptoms experienced during their acute infection persisting beyond it, with the number of symptoms experienced tending to decline as patients move from acute to long COVID. Some, though, report developing new symptoms during their long COVID illness, while some also report symptoms reoccuring that had previously resolved themselves.
    What the huge variability of long COVID suggests is that it actually comprises a number of different syndromes, potentially with different underlying causes. A better understanding of the underlying biological and immunological mechanisms of long COVID is therefore urgently needed if we’re to develop effective treatments for it.
    Read full story
    Source: The Conversation, 27 July 2021
     
  13. Sam
    More than one in three middle-aged British adults are suffering from at least two chronic health conditions, including recurrent back problems, poor mental health, high blood pressure, diabetes and high-risk drinking, according to research that warned that health in midlife is on the decline.
    The study of “generation X” adults born in 1970 found that those who grew up in poorer families were 43% more likely to have multiple long-term health conditions than their peers from wealthier households. Those who had been overweight or obese as children, who had lower birthweight and who had experienced mental ill-health as teenagers were also at increased risk of poor health in midlife.
    Dawid Gondek, the UCL researcher who authored the paper, said: “This study provides concerning new evidence about the state of the nation’s health in midlife. It shows that a substantial proportion of the population are already suffering from multiple long-term physical and mental health problems in their late 40s, and also points to stark health inequalities, which appear to begin early in childhood.”
    Read full story
    Source: The Guardian, 28 July 2021
  14. Sam
    A review into the work of a locum consultant radiologist has so far identified "major discrepancies" affecting 12 cases.
    A full lookback review of 13,030 radiology images was launched last month.
    The doctor worked at hospitals run by the Northern Health Trust between July 2019 and February 2020.
    The review steering group chair said it was "images in levels one and two that we are most concerned about".
    "To date there are 12 level ones and twos [approximately 0.5% of the total number reviewed]," said Dr Seamus O'Reilly, the Northern Trust medical director.
    "Most of these concern CT scans where inaccurate initial reading of the scans could, or is likely to, have had an impact on the patient's clinical treatment and outcome."
    More than 9,000 patients have been contacted as part of the review, which is looking at radiology images taken in Antrim Area, Causeway, Whiteabbey and Mid Ulster Hospitals as well as the Ballymena Health and Care Centre.
    Read full story
    Source: BBC News, 28 July 2021
  15. Sam
    The boss of a NHS trust that asked hospital staff for fingerprints and handwriting samples as it hunted a whistleblower is stepping down.
    Dr Stephen Dunn will leave West Suffolk NHS Foundation Trust in the summer after seven years as chief executive.
    An independent inquiry into the way management handled the affair is expected to report in the autumn.
    In 2018, Jon Warby received a letter two months after the death of his wife, Susan. It claimed mistakes were made during her bowel surgery. An inquest into her death was subsequently told how she had been given glucose instead of saline fluid via an arterial line.
    The Doctors' Association described the hospital's attempt to find the author of the letter a "witch-hunt".
    A subsequent Care Quality Commission (CQC) inspection said the way internal investigations had been conducted by the hospital was "unusual and of concern".
    Read full story
    Source: BBC News, 28 July 2021
  17. Sam
    A woman was subjected to an unnecessary invasive procedure in an NHS outpatient clinic after she was confused for another patient, a safety watchdog has found.
    The Healthcare Safety Investigation Branch has called for a review of how the NHS can avoid the mishap happening again after investigating the case of a 39-year-old woman who was subjected to an unnecessary cervical examination.
    HSIB said a better system was needed as the number of outpatient appointments has increased from 54 million to 94 million during the last 10 years with many clinics carrying out more invasive procedures.
    According to its latest investigation, the female patient was attending a gynaecological outpatient clinic for a fertility treatment assessment.
    The error happened when she was called through from the waiting room as another patient had a similar sounding name.
    Read full story
    Source: The Independent, 2 June 2021
  18. Sam
    Self-harm among the over-65s must receive greater focus because of the increased risks associated with the pandemic, a leading expert has said.
    Loneliness, bereavement and reluctance to access GPs can all be causes in older adults, said Prof Nav Kapur, who has produced guidelines on the subject.
    He warned that in over-65s, without the right help, self-harm can also be a predictor of later suicide attempts.
    The NHS's mental health director said it had expanded its community support.
    Claire Murdoch added that its services, including face-to-face appointments, had "continued for all who needed them", and 24/7 crisis lines had been established.
    Over-65s are hospitalised more than 5,000 times a year in England because of self-harm and self-poisoning, figures obtained from NHS Digital show.
    Read full story
    Source: BBC News, 3 June 2021
  19. Sam
    Oversight failures, a fearful workplace culture and lax quality standards for years at a Veterans Affairs hospital in Arkansas, USA, allowed a pathologist who was routinely drunk on the job to misdiagnose thousands of veterans — sometimes with dire or deadly consequences, a new investigation has found.
    Hospital leaders “failed to promote a culture of accountability” that would have led more of the doctor’s colleagues to come forward with accounts that his behavior was putting patients at risk, according to the report released Wednesday by VA’s Office of Inspector General. But the staff members at the Veterans Health Care System of the Ozarks in Fayetteville feared that reporting their concerns would lead to retaliation from their bosses.
    “Any one of these breakdowns could cause harmful results,” Inspector General Michael Missal’s staff wrote in an 86-page report about the failures to stop the pathologist, Robert Morris Levy. “Together and over an extended period of time, the consequences were devastating, tragic, and deadly.”
    Read full story
    Source: The Washington Post, 2 June 2021
  20. Sam
    More than 20 healthcare organisations, including those representing nurses, doctors, surgeons and therapists, are calling for stricter UK guidelines to be introduced on face masks and other personal protective equipment (PPE).
    In a virtual meeting with officials, they will say existing rules leave them vulnerable to infection through the air, especially by new Covid variants.
    The unprecedented appeal will see them argue that other countries, such as the United States, protect their health workers with higher-grade equipment.
    It is thought to be the first time health and care organisations have united on a single issue in this way - a sign of the desperation many feel about the need for staff to be kept safe.
    The delegation will include representatives of the British Medical Association, the Royal College of Nursing and many other professional organisations and unions.
    On the government side will be about 20 of the most senior officials from all four UK nations, many involved in setting the guidelines on personal protective equipment (PPE).
    Read full story
    Source: BBC News, 3 June 2021
  21. Sam
    The Care Quality Commission may in future be notified when ‘secretive’ external reviews have looked at patient safety issues within trusts.
    Last summer, HSJ revealed guidance for trusts to publish summaries of royal colleges’ reviews was being widely ignored, with some even failing to inform the CQC.
    A recent BBC Panorama programme has again raised the issue, with Academy of Medical Royal Colleges chair Helen Stokes-Lampard saying she was “dismayed” the body’s guidance was not being followed.
    But she has now told HSJ of “advanced discussions” with the CQC about changes which would see the royal colleges routinely inform the regulator when reviews raise patient safety issues.
    Read full story (paywalled)
    Source: HSJ, 3 June 2021
  22. Sam
    A second “mutilated” patient left with life-changing injuries after botched hospital surgery has described how she was left in urine-soaked bed sheets for days by nurses who called her lazy when she was unable to get out of bed.
    Lucy Wilson told The Independent she believes she would have been better looked after at a veterinary practice compared to the level of care she received from nurses at Norfolk and Norwich Hospital Trust in January last year.
    She was one of three patients harmed by surgeon Camilo Valero in the same week and almost died after Dr Valero and other staff failed to recognise her life-threatening injuries following the operation to remove her gall bladder.
    Dr Valero is under investigation by the General Medical Council but is still practising under supervision at the trust, which has refused to say whether the third patient survived their ordeal.
    After requests by The Independent, bosses at the NHS trust have now committed to publishing details of a secret review carried out by the Royal College of Surgeons into Dr Valero’s work and the wider surgical services at the trust.
    Read full story
    Source: The Independent, 31 May 2021
  23. Sam
    A new national service has been established to improve the quality and management of healthcare construction and refurbishment projects across NHS Scotland.
    NHS Scotland Assure brings together experts to improve quality and support the design, construction and maintenance of major healthcare developments. This world first interdisciplinary team will include microbiologists, infection prevention and control nurses, architects, planners, and engineers.
    Commissioned by the Scottish Government and established by NHS National Services Scotland, the service will work with Health Boards to ensure healthcare buildings are designed with infection prevention and control practice in mind, protecting patients and improving safety.
    Cabinet Secretary for Health and Social Care Humza Yousaf said:
    “NHS Scotland Assure will support a culture of collaboration and transparency to provide the reassurance patients and their families deserve to feel safe in our hospitals. This service is unique to Scotland and is leading the way in risk and quality management across healthcare facilities.
    “With services designed with patients in mind, we can make a real, positive difference to people’s lives.”
    Read full story
    Source: Scottish Government, 1 June 2021
  24. Sam
    Thousands of hospital patients were allowed to return to their care homes without a Covid test despite a direct plea to the government from major care providers not to allow the practice, the Observer has been told.
    As the crisis began to unfold in early March 2020, providers held an emergency meeting with department of health officials in which they urged the government not to force them to accept untested residents. However, weeks later, official advice remained that tests were not mandatory and thousands of residents are thought to have returned to their homes without a negative Covid result.
    The revelation will heap further pressure on the health secretary, Matt Hancock, who has admitted some care residents returned from hospital without a test. It comes after Dominic Cummings, the prime minister’s former senior adviser, last week accused Hancock of misleading the prime minister over the policy, during his unprecedented evidence in parliament.
    Some 25,000 people were discharged to care homes between 17 March and 15 April, and there is widespread belief among social care workers and leaders that this allowed the virus to get into the homes.
    Read full story
    Source: The Guardian, 29 May 2021
  25. Sam
    An online trend that involves using tiny magnets as fake tongue piercings has led the NHS to call for them to be banned amid people swallowing them.
    Ingesting more than one of them can be life-threatening and cause significant damage within hours.
    In England, 65 children have required urgent surgery after swallowing magnets in the last three years.
    The NHS issued a patient safety alert earlier this month and is now calling for the small metal balls to be banned.
    It said the "neodymium or 'super strong' rare-earth magnets are sold as toys, decorative items and fake piercings, and are becoming increasingly popular". It added that unlike traditional ones, "these 'super strong' magnets are small in volume but powerful in magnetism and easily swallowed".
    The online trend sees people placing two such magnets on either side of their tongue to create the illusion that the supposed piercing is real.
    But when accidentally swallowed, the small magnetic ball bearings are forced together in the intestines or bowels, squeezing the tissue so that the blood supply is cut off.
    Read full story
    Source: BBC News, 30 May 2021
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