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Sam

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  1. Content Article
    The theme for the 4th Learning from Excellence Community Event was “Being better, together”, reflecting LfE's aspiration to grow as individuals, and as part of a community, through focussing on what works. For this event, LfE partnered with the Civility Saves Lives (CSL) team, who promote the importance of kindness and civility at work and seek to help us to address the times this is lacking in a thoughtful and compassionate way, through their Calling it out with Compassion programme.
  2. News Article
    Lessons learnt in relation to increasing uptake of the COVID-19 vaccine among ethnic minority groups should now be applied to the booster programme, a government progress report recommends. This includes continuing to use respected local voices to build trust and to help tackle misinformation, the report from the government’s Race Disparity Unit says. Such approaches should also be carried over to the winter flu and childhood immunisation programmes and be applied to the work to tackle longer standing health disparities. In June 2020 the minister for equalities was asked to look at why COVID-19 was having a disproportionate impact on ethnic minority groups and to consider how the government response to this could be improved. This latest report is the final one of four. Taken together the reports identified that the main factors behind the higher risk of COVIDd-19 infection for ethnic minority groups include occupation, living in multigenerational households, and living in densely populated urban areas with poor air quality and high levels of deprivations. Read full story Source: BMJ, 3 December 2021
  3. Content Article
    The Royal College of Anaesthetists recently received a coroners report where an oesophageal intubation took place and was not recognised in time to save the life of the patient. Unrecognised oesophageal intubation is preventable through adherence to published recommendations on the monitoring of exhaled carbon dioxide (capnography) and its correct interpretation. All clinicians involved in airway management should watch the College and DAS video on capnography. Always remember 'No Trace = Wrong Place' and actively seek to exclude oesophageal intubation when a flat capnograph trace is encountered.
  4. News Article
    A hospital trust has been told to "immediately improve" its maternity and surgical services. The Care Quality Commission (CQC) made unannounced inspections in September and October at four of the hospitals run by University Hospitals Sussex NHS Foundation Trust. Inspectors raised concerns about staff shortages, skills training and risk management. At the trust's four maternity services, inspectors found departments "did not have enough staff to keep women and babies safe" and staff were "not up to date" with training. Infection prevention measures in surgical services at the Royal Sussex County Hospital were "not consistently applied" and managers were not running services well, inspectors noted. The report also said morale was low and often staff "did not have time to report incidents". The trust said it has taken "urgent action" to make improvements. Read full story Source: BBC News, 10 December 2021
  5. News Article
    NHS bosses have warned the high prevalence of long Covid among staff is adding to rising healthcare pressures, amid growing concern that the new omicron variant could further drive infections and absences in the workforce. Some 40,000 (3.26%) of healthcare workers in the UK are estimated to have long Covid, according to the Office for National Statistics. This figure has risen by 5,000 since July. Many will be unable to work, though others are continuing to work despite their debilitating symptoms, experts say. “Trust leaders have told us they are concerned about the prevalence of long Covid amongst health and care staff,” said Chris Hopson, chief executive of NHS Providers. “Staff who are unwell need time to recover with support. But this may worsen unavoidable absences and sickness levels in the NHS at a time when pressures on the health service are mounting.” Read full story Source: The Independent, 9 December 2021
  6. News Article
    A trust will not face a second prosecution over the death of a baby seven days after a chaotic birth at one of its hospitals, unless new evidence emerges. Kent police had been looking into incidents at the maternity services department of East Kent Hospitals University Foundation Trust. These incidents include the death of Harry Richford, who was born at Queen Elizabeth, the Queen Mother, Hospital in November 2017. A coroner found a string of failures in his care amounted to neglect. The trust pleaded guilty to failing to meet fundamental standards of care and was fined £733,000 in a case brought by the Care Quality Commission earlier this year. But detective chief superintendent Paul Fotheringham, head of major crime at Kent Police, said: “After careful consideration and following consultation with the Crown Prosecution Service, we took the decision that a criminal investigation would not be undertaken at this time as there is no realistic prospect of conviction against any individual or organisation based on the evidence currently available." In a statement, Harry’s family said: “We are disappointed that Kent Police, in collaboration with the CPS special crime unit in London, have not been able to take forward a charge of corporate manslaughter for Harry at this time. They have assured us that they will keep an open mind on this matter, and any other appropriate charges as and when new evidence is brought before them. “We believe that the Kirkup inquiry and investigation may allow them to revisit a raft of charges on behalf of harmed babies in east Kent in due course. Only when senior leaders are properly held to account, will there be lasting change.” Read full story (paywalled) Source: HSJ, 9 December 2021
  7. News Article
    Vacancies for nurses and midwives in Scotland have increased by almost 20% in just three months, new figures show. Official figures revealed that at the end of September the whole time equivalent (WTE) of 5,761.2 posts were unfilled across the NHS – a rise of 18.9% from the WTE total of 4,845.4 that was recorded at the end of June. The rise in vacancies comes at the same time as health service staffing reached a record high, with the NHS employing the equivalent of 154,307.8 full-time workers as of September 30 – 5.2% higher than a year ago. However, opposition leaders warned the health service, which is coming under ongoing pressure as a result of the coronavirus pandemic, is facing a “staffing crisis” this winter. Scottish Labour health spokeswoman and deputy leader Jackie Baillie said: “Across our NHS services are on the brink of collapse, and things will only get worse as the cold weather bites. “This staffing crisis at the heart of this catastrophe has unfolded entirely on Nicola Sturgeon’s watch and will jeopardise the ability of services to remobilise and cope with demand. “Looking at the state of services in Scotland, we can all only hope we don’t get sick this winter.” Read full story Source: The Independent, 8 December 2021
  8. News Article
    "You hear his heartbeat and the next thing you know, you've got nothing." A woman whose son was stillborn has said she wants to change the law to enable an inquest to investigate the circumstances surrounding his death. Katie Wood's son Oscar was stillborn on 29 March 2015, but under law in England and Wales, inquests for stillborn babies cannot take place. A consultation was put out by the UK government in March 2019, but the findings have yet to be published. The UK government said it would set out its response in due course, but this delay was criticised by the House of Commons justice committee in September. Katie and her family said they have never received satisfactory answers about why Oscar died. Her pregnancy, while challenging, had not given any serious cause for concern. An investigation by the Aneurin Bevan health board found a number of failings in Katie's care. A post-mortem examination suggested a condition known as shoulder dystocia, where the baby's shoulder becomes stuck during birth, may have contributed, but this is rarely fatal. The health board said it conducted a serious incident investigation into Oscar's death and added: "Whilst we seek to find answers during any investigation, in some cases, a full understanding around the cause of death may not always be achieved and we accept the unavoidable distress this may pose for families." Clinical negligence and medical law specialist, Mari Rosser, says allowing coroners to look into the reasons for a baby's death is long overdue. "Currently parents who suffer a still birth can have the circumstances investigated, but the circumstances are investigated by the health board and of course that's less independent," she said. Read full story Source: BBC News, 9 December 2021
  9. News Article
    Health experts have expressed fears over the impact tighter Covid restrictions in England could have on cancer patients as alarming new figures reveal that the number taking part in clinical trials plummeted by almost 60% during the pandemic. Almost 40,000 cancer patients in England were “robbed” of the chance to take part in life-saving trials during the first year of the coronavirus crisis, according to a report by the Institute of Cancer Research (ICR), which said COVID-19 had compounded longstanding issues of trial funding, regulation and access. Figures obtained from the National Institute for Health Research by the ICR show that the number of patients recruited on to clinical trials for cancer in England fell to 27,734 in 2020-21, down 59% from an average of 67,057 over the three years previously. The number of patients recruited for trials fell for almost every type of cancer analysed. Health experts said the relentless impact of Covid on the ability of doctors and scientists to run clinical trials was denying many thousands of cancer patients access to the latest treatment options and delaying the development of cutting-edge drugs. Read full story Source: The Guardian, 9 December 2021
  10. News Article
    Incidents including a cardiac arrest where an ambulance took more than an hour to arrive and the patient died have prompted trust chiefs to suggest they cannot prevent patient harm under their current funding levels. A report to the North East Ambulance Service (NEAS) said patients suffering harm due to delayed ambulance response times “is a continuing theme due to the unprecedented demand the service is currently experiencing”. The report said the trust is trying to secure additional funding from commissioners, which would “reduce the likelihood of a similar incident for other patients in future”. NEAS has upheld several recent complaints made by families or patients about the harm being caused by delayed response times, but suggested the levels of demand on the service meant there was nothing it could have done differently. In one example, a woman in her 50s died from a cardiac arrest shortly after arrival to hospital after NEAS took 62 minutes to respond to a 999 call. NEAS had designated the woman, who had a history of heart attacks, a category two response – which should aim to arrive within 18 minutes on average. "All ambulance trusts have been seeing significant patient harm and the mainstream press have been strangely silent about this." "That it has got the stage where patients are routinely dying and being harmed while the resources are available, but tied up waiting outside hospitals, is truly maladministration on a grand scale." Read full story (paywalled) Source: HSJ, 9 December 2021
  11. News Article
    A vulnerable man detained for 10 years was failed by a system meant to care for him, an independent NHS investigation has found. Clive Treacey, a man who lived his life in the care of NHS and social care authorities, experienced an “unacceptably poor quality of life”, and was not kept safe from harm before his death at just 47. The findings of the independent review, The Independent and Sky News can reveal, have concluded Mr Treacey’s death was “potentially avoidable” and comes after years of his family “fought” for answers. His family are now pursuing a second inquest into his death after the review found a pathologist report and post-mortem used by coroners did not follow guidelines, along with new CCTV footage from the night he died. NHS England commissioned the review, under the Learning Disability Mortality Review Programme, in January 2020 – three years after Mr Treacey’s death and after his family was initially denied a review. In an exclusive interview with The Independent, Mr Treacey’s sister, Elaine Clark said: “We have fought on because Clive deserved nothing less. He spent his entire life being incarcerated and so did we, his entire family. He didn’t matter. His voice didn’t matter. His human rights didn’t matter. His life choices didn’t matter. The system and its people believed he did not matter and nobody in it had enough ambition to do anything differently." “Well Clive did matter. It matters what happened to him. It matters that it’s still happening to other people. And it matters that nothing seems to be changing we are one family but there are many others like us.” Read full story Source: The Independent, 9 December 2021
  12. News Article
    Around 80% of adolescents who died by suicide or who had self-harmed had consulted with their GP or a practice nurse in the preceding year, shows new research. The large study of 10 to 19-year-olds between 2003 and 2018, published in the Journal of Child Psychology and Psychiatry, also puts forward a series of proposals to deal with the problem. The study, funded by the NIHR Greater Manchester Patient Safety Translational Research Centre (NIHR GM PSTRC), a partnership between The University of Manchester and The Northern Care Alliance NHS Foundation Trust (NCA). It showed that 85% who later took their own lives consulted with their GP or a practice nurse at least once in the preceding year; the equivalent figure was 75% for those youngsters who harmed themselves non-fatally. Lower than expected rates of diagnosis of psychiatric illness, around a third in both groups, were probably down to a lack of contact with mental health services, rather than an absence of psychiatric illness, argue the research team. Depression was by far the commonest of the examined conditions among both groups, accounting for over 54% of all recorded diagnoses. Also, while suicide was more common in boys, non-fatal self-harm was more common in girls. Two-thirds of adolescents who died by suicide had a history of non-fatal self-harm. And while self-harm risk rose incrementally with increasing levels of deprivation, suicide risk did not. Read full story Source: The University of Manchester, 7 December 2021
  13. Content Article
    The launch of Barts Health quality strategy in November 2019 was an important moment for the trust. The 24 page document set out how they would use quality improvement (QI) methodology to become a good and outstanding group of hospitals. Within weeks of the strategy however, the world had changed with COVID-19. How they worked, where they worked and the things they were working on were flipped on their head. Despite this, colleagues across Barts Health have continued to apply the QI skills they had learnt since the WeImprove programme began three years ago. Examples include setting up family liaison hubs for patients in critical care and establishing a network of blood test locations across the boroughs to reduce visits to the hospitals.
  14. News Article
    Three pharmacy and medication safety organisations are warning clinicians about a reported increase in age-related COVID-19 vaccine mix-ups. The Institute for Safe Medication Practice's National Vaccine Errors Reporting Program said it's seen a "steady stream" of mix-ups involving the Pfizer vaccine intended for kids ages 5-11 and formulations for people 12 and older. ISMP said the reports involved hundreds of children and included young children receiving formulations meant for those 12 and up or vice versa. The safety organisation said some errors were linked to vial or syringe mix-ups. In other situations, healthcare providers gave young children a smaller or diluted dose of the formulation meant for people 12 and up. "Vaccine vials formulated for individuals 12 and up (purple cap) should never be used to prepare doses for the younger age group," the organisation said. Read full story Source: Becker's Hospital Review, 7 December 2021
  15. Content Article
    While ‘human error’ is often blamed when things go wrong, the ‘technical’ part of ‘sociotechnical systems’ often escapes the spotlight. In this article, Harold Thimbleby outlines how hidden risks with digitalisation have far-reaching consequences, and how we can start to fix them.
  16. Content Article
    The Nursing Times has carried out an investigation into nurses’ experiences of speaking out in light of the Covid-19 pandemic, revealing disturbing findings about the current state of openness in the NHS.
  17. Content Article
    Northumbria Healthcare NHS Foundation Trust were awarded the Freedom to Speak Up Organisation of the Year Award at the 2021 HSJ Awards with their demonstration of an integrated approach to speaking up. Kirsty Dickson was appointed as the first Freedom to Speak Up Guardian at Northumbria, following recommendations in the Francis Report. Since then, she has been working proactively to make sure that Freedom to Speak Up is woven into the fabric of the organisation.
  18. Event
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    Hosted by the WHO Athens Quality of Care Office, the conference will feature the participation of WHO/Europe’s leadership, as well as health ministers, high-level officials, scientists and technical experts from across the Region. It will provide an opportunity to evaluate lessons learned from the pandemic and to build on shared experiences in health-care services. The event will be held in a hybrid format, with a livestream on this page, with English, Greek and Russian interpretation. A key outcome of the conference will be a compendium of applied good practices based on Member States’ experiences related to quality of care and patient safety. The compendium will inform the development of a roadmap/framework for action to implement essential activities, raise awareness and increase stakeholders’ involvement in the areas of quality of care and patient safety. Over the 2 days, participants will: establish supportive collaboration and mutual learning networks in the area of quality of care; share Member States’ experiences with health-care service responses during the COVID-19 pandemic, specifically on quality of care and patient safety; highlight patients’ perspectives and promote patient-informed involvement and shared decision-making in health care; galvanize a new era in the development, implementation and evaluation of evidence-based national quality of care plans. Register
  19. Event
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    Ahead of the UN General Assembly’s debate on global health and foreign policy, join a distinguished line-up of speakers for a discussion about the progress - and lack thereof - on the international response to COVID-19, as well as recommendations for ensuring that this pandemic is the last one we face. With speakers: H.E. Ellen Johnson Sirleaf (Co-Chair, Independent Panel for Pandemic Preparedness and Response, member of The Elders, and former President of Liberia) H.E. Ms. María Fernanda Espinosa Garcés (Member of the Lancet Commission on COVID-19, former Ecuadorian Minister of Foreign Affairs and Defence, and former President of UN General Assembly) David Nabarro CBE (Special Envoy on Covid-19 for the World Health Organization) Register
  20. Event
    A team of educators from the Investigation Education, Learning & Standards department at the Healthcare Safety Investigation Branch (HSIB) will discuss why they believe investigation is emerging as science in its own right. It’s described by Dawn Benson at the HSIB as “the adoption of a scientific approach to the development to all aspects of investigation practice, education, policy and research”. When in post as a national investigator at HSIB, Dawn noticed that the mix of expertise, knowledge and experience of her colleagues was heterogeneous and included psychology, sociology, systems engineering, human factors, medicine and the sciences of safety, management, improvement, implementation and education. All of which are needed for safety investigations which seek to enable organisations to learn from past experience in order to improve their safety performance. The team from HSIB, Dawn Benson, Rich McMaster, Laura Pickup and Deinniol Owens will also explain why they’ve stopped talking about human factors despite it forming much of what they do. Join us to debate and explore these areas. Helen Vosper will be your chair. Register
  21. Event
    This conference will discuss the next steps for rare diseases policy in the UK, looking at priorities going forward for the Rare Diseases Framework, the role of genomics in improving diagnosis and care, and the future for research, treatment access, and system preparedness. Taking place following the publication of the Rare Diseases Framework earlier this year, delegates will discuss the first year of its delivery, the impact of the pandemic, and the key priorities for delivering ambitions within the framework over the next year. It will also be an opportunity to look at the impact of policy developments within the life sciences and health research landscape, as well as the opportunities these developments present for improving rare disease outcomes, including the Genome UK Implementation Plan, the Life Sciences Vision, the Future of UK Clinical Research Delivery, and the new Innovative Medicines Fund. Key areas for discussion include: taking forward the UK Rare Diseases Framework and priorities for improving diagnosis and care the implementation of Genome UK and harnessing genomics to improve the understanding, detection, and treatment of rare genetic conditions developing the UK’s research ecosystem, improving access to new and innovative medicine and treatment, and the potential for global leadership in this field raising awareness of rare diseases across the health system, meeting new workforce needs, and developing expertise to support high-quality care. Register
  22. News Article
    Dying patients are going without care in their own homes because of a collapse in community nursing services, new data shared with The Independent reveals. Across England a third of district nurses say they are now being forced to delay visits to end of life care patients because of surging demand and a lack of staff. This is up from just 2% in 2015. The situation means some patients may have to wait for essential care and pain medication to keep them comfortable. Other care being delayed includes patients with pressure ulcers, wounds which need treating and patients needing blocked catheters replaced. More than half of district nurses said they no longer have the capacity to do patient assessments and psychological care, in an investigation into the service. Professor Alison Leary, director of the International Community Nursing Observatory, said her study showed the country was “sleepwalking into a disaster,” with patients at real risk of harm. She said the situation was now so bad that nurses were being driven out of their jobs by what she called the “moral distress” they were suffering at not being able to provide the care they knew they should. “People are at the end of their tether. District nurses are reporting having to defer work much more often than they did two years ago. What they are telling us is that the workload is too high. This is care that people don’t have time to do.” Read full story Source: The Independent, 29 November 2021
  23. News Article
    Plans to scrap tens of millions of “unnecessary” hospital follow-up appointments could put patients at risk and add to the overload at GP surgeries, NHS leaders and doctors are warning. Health service leaders in England are finalising a radical plan under which hospital consultants will undertake far fewer outpatient appointments and instead perform more surgery to help cut the NHS backlog and long waits for care that many patients experience. The move is contained in the “elective recovery plan” which Sajid Javid, the health secretary, will unveil next week. It will contain what one NHS boss called “transformative ideas” to tackle the backlog. Thanks to Covid the waiting list has spiralled to a record 5.8 million people and Javid has warned that it could hit as many as 13 million. Under the plan patients who have spent time in hospital would be offered only one follow-up consultation in the year after their treatment rather than the two, three or four many get now. “While it is important that immediate action is taken to tackle the largest ever backlog of care these short-term proposals by the health secretary have the potential to present significant challenges for patients and seek to worsen health disparities across the country,” said Dr David Wrigley, the deputy chair of council at the British Medical Association. Read full story Source: The Guardian, 25 November 2021
  24. News Article
    One hundred people with learning disabilities and autism in England have been held in specialist hospitals for at least 20 years, the BBC has learned. The finding was made during an investigation into the case of an autistic man detained since 2001. Tony Hickmott's parents are fighting to get him housed in the community near them. Mr Hickmott's case is being heard at the Court of Protection - which makes decisions on financial or welfare matters for people who "lack mental capacity". Senior Judge Carolyn Hilder has described "egregious" delays and "glacial" progress in finding him the right care package which would enable him to live in the community. He lives in a secure Assessment and Treatment Unit (ATU) - designed to be a short-term safe space used in a crisis. It is a two-hours' drive from his family. This week, Judge Hilder lifted the anonymity order on Mr Hickmott's case - ruling it was in the public interest to let details be reported. She said he had been "detained for so long" partly down to a "lack of resources". Like many young autistic people with a learning disability, Mr Hickmott struggled as he grew into an adult. In 2001, he was sectioned under the Mental Health Act. He is now 44. In addition to the 100 patients, including Mr Hickmott, who have been held for more than 20 years - there are currently nearly 2,000 other people with learning difficulties and/or autism detained in specialist hospitals across England. In 2015, the Government promised "homes not hospitals" when it launched its Transforming Care programme in the wake of the abuse and neglect scandal uncovered by the BBC at Winterbourne View specialist hospital near Bristol. But data shows the programme has had minimal impact. Read full story Source: BBC News, 24 November 2021
  25. News Article
    Wales' Health Minister has rejected a suggestion that the NHS is “harming patients” due to the severe levels of pressure on its services. Eluned Morgan MS acknowledged that the speed at which patients were receiving treatment was being impacted but said she would “not accept for a moment” that the NHS was harming its patients. ITV Cymru Wales has spoken to a number of NHS staff and health sector bodies and heard concerns over the sustainability of the health service in its present form. Ms Morgan said: “I don’t think the NHS is harming patients, no. “I think our ability to get to patients quickly, that is perhaps compromised by the pressures that we’re under at the moment but no, I would not accept for a moment that the NHS is harming patients. “I think the situation is that maybe people have to wait a bit longer for care because of the pressures that have grown as a result of the pandemic and let’s be clear about that, that we’re seeing about 20% more people going to their GPs, we’ve got hugely long waiting lists because, of course, we had to be very careful about who was able to go into hospitals during the height of the pandemic. “We’re trying to reign all that back at the same time as dealing with Covid, because that hasn’t finished yet.” Speaking to ITV Cymru Wales for Wales This Week, looking at the challenges facing the NHS, Dr Pete Williams, a consultant in emergency medicine and paediatric medicine at Ysbyty Gwynedd in Bangor, said he felt the current pressures on services were causing harm to patients. He said: “This is not sustainable. We, this department, other departments around the country and the wider NHS, are harming patients because they’re not getting timely care." Read full story Source: ITV News, 22 November 2021
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