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Sam

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Everything posted by Sam

  1. News Article
    At least 20 patients have suffered harm due to their follow-up appointments not being booked at a hospital department where people ‘continue to come to harm’, according to an internal review. Torbay and South Devon Foundation Trust is reviewing its ophthalmology service after 22 people were harmed following “system failures” with their follow-up appointments. The trust’s initial investigation, obtained by HSJ with the Freedom of Information Act, warned there were “potentially” other patients affected by the failures who had not yet been identified. In response, the trust said its ophthalmology department had already “undertaken a significant amount of work to address a large proportion of the actions arising from the review”, including building another operating theatre and recruiting more staff. Read full story (paywalled) Source: HSJ, 21 August 2023
  2. News Article
    In September last year, Ebrima Sajnia watched helplessly as his young son slowly died in front of his eyes. Mr Sajnia says three-year-old Lamin was set to start attending nursery school in a few weeks when he got a fever. A doctor at a local clinic prescribed medicines, including a cough syrup. Over the next few days, Lamin's condition deteriorated as he struggled to eat and even urinate. He was admitted to a hospital, where doctors detected kidney issues. Within seven days, Lamin was dead. He was among around 70 children - younger than five - who died in The Gambia of acute kidney injuries between July and October last year after consuming one of four cough syrups made by an Indian company called Maiden Pharmaceuticals. In October, the World Health Organization (WHO) linked the deaths to the syrups, saying it had found "unacceptable" levels of toxins in the medicines. A Gambian parliamentary panel also concluded after investigations that the deaths were the result of the children ingesting the syrups. Both Maiden Pharmaceuticals and the Indian government have denied this - India said in December that the syrups complied with quality standards when tested domestically. It's an assessment that Amadou Camara, chairperson of the Gambian panel that investigated the deaths, strongly disagrees with. "We have evidence. We tested these drugs. [They] contained unacceptable amounts of ethylene glycol and diethylene glycol, and these were directly imported from India, manufactured by Maiden," he says. Ethylene glycol and diethylene glycol are toxic to humans and could be fatal if consumed". Read full story Source: BBC News, 21 August 2023
  3. News Article
    More than 3,000 patients have died following incidents in the Irish health service since 2018, new data shows. New HSE data shows more than 480,000 incidents potentially causing harm were recorded across hospitals and community healthcare groups since 2018. These include falls, attacks on patients or staff, problems with medication, treating the wrong limb, or reactions to medical devices, among other issues. Last year’s total of 106,967 was the highest of five years recorded, up from 94,422 in 2018. While around half the incidents annually led to no injury, last year 0.65% or 556 led to a death. That stood at 0.59% or 557 deaths in 2018. A spokesperson for the Irish Nurses and Midwives Organisation (INMO) said the figures are very high, but not surprising. “Hospitals are not supposed to be dangerous places," she said. "No matter how highly skilled your staff are, patient safety issues and the risk of missed care incidents are inevitable in a situation where patients are lining corridors on trolleys and there aren’t enough staff to care for them." Read full story Source: Irish Examiner, 18 August 2023
  4. News Article
    Nurse Lucy Letby has been found guilty of murdering seven babies on a neonatal unit, making her the UK's most prolific child serial killer in modern times. The 33-year-old has also been convicted of trying to kill six other infants at the Countess of Chester Hospital between June 2015 and June 2016. Letby deliberately injected babies with air, force fed others milk and poisoned two of the infants with insulin. Commenting on the verdict, Parliamentary and Health Service Ombudsman Rob Behrens said: “We know that, in general, people work in the health service because they want to help and that when things go wrong it is not intentional. At the same time, and too often we see the commitment to public safety in the NHS undone by a defensive leadership culture across the NHS. “The Lucy Letby story is different and almost without parallel, because it reveals an intent to harm by one individual. As such, it is one of the darkest crimes ever committed in our health service. Our first thoughts are with the families of the children who died. “However, we also heard throughout the trial, evidence from clinicians that they repeatedly raised concerns and called for action. It seems that nobody listened and nothing happened. More babies were harmed and more babies were killed. Those who lost their children deserve to know whether Letby could have been stopped and how it was that doctors were not listened to and their concerns not addressed for so long. Patients and staff alike deserve an NHS that values accountability, transparency, and a willingness to learn. “Good leadership always listens, especially when it’s about patient safety. Poor leadership makes it difficult for people to raise concerns when things go wrong, even though complaints are vital for patient safety and to stop mistakes being repeated. We need to see significant improvements to culture and leadership across the NHS so that the voices of staff and patients can be heard, both with regard to everyday pressures and mistakes and, very exceptionally, when there are warnings of real evil.”
  5. News Article
    Older patients should walk around hospital wards and along corridors to prevent their muscles weakening, research suggests. Lying in a hospital bed for several days can cause a sharp deterioration in strength, leaving some elderly patients struggling to walk or live independently when they are discharged. New research shows this decline can be prevented if patients are helped to walk for at least 25 minutes a day while in hospital. The best effect was observed when patients walked around the hospital for at least 50 minutes a day. The study suggested that a mixture of physical activity, such as 20 minutes working with resistance bands while seated and 20 minutes of walking, also helped. The authors said patients who remained active during their stay in hospital were less likely to suffer “adverse events” after they were discharged. Read full story (paywalled) Source: The Times, 4 August 2023
  6. Event
    Virtual wards have the potential to improve patient experience by enabling them to receive care at home, and to alleviate workforce pressures by freeing up staff time. However, there is still a lot of work to be done to improve capacity and use of virtual wards if patients and staff are to feel the benefits. Additionally, there are still extensive variations progress and use of virtual wards - operationally, digitally and financially - across the NHS and integrated care systems (ICS). With central funding coming to an end, all parts of the health and care system face practical challenges in making virtual wards a positive option for the future. Against this backdrop, this panel discussion will bring together experts to discuss: how to build a model for sustainable virtual wards that meets the immediate challenges of the health and care system, but also aligns with the NHS vision and aspirations for the future what patients and communities want from virtual wards and how their voices can shape future services what opportunities there are for virtual services to enable better integration between partners across the health and care system, as well as providing better working options and flexibility for staff. Register
  7. News Article
    A man died after A&E doctors sent him home from hospital and “told him to drink Lucozade” despite him vomiting 100 times in 24 hours. Nick Rousseau died from an undiagnosed blocked bowel in 2019 after doctors at Milton Keynes Hospital failed to spot that he had the life-threatening condition. The 47-year-old was sent home twice in three days and reassured he “would be alright” as doctors believed he had gastroenteritis, his “devastated” wife Kimberly White said. But Mr Rousseau was actually suffering from an ischaemic bowel, a condition which blocks the arteries to the bowel. He had been to see his doctors several times and had lost three stones in weight over two years due to vomiting and diarrhoea but was never diagnosed. His family, represented by Osbornes Law, received a six-figure payout in June from Milton Keynes University Hospital NHS Foundation Trust. While it did not admit negligence, it accepted that there were features of Mr Rousseau’s illness which could have justified admission, inpatient observation, and further tests, which could have given a definitive diagnosis. Read full story Source: The Independent, 4 August 2023
  8. News Article
    The prospect of waiting at least six weeks for a biopsy was too much for Neil Perkin. In February, the 56-year-old was told that he had suspected prostate cancer which needed to be confirmed by examining a sample of his tissue. “After the initial appointment with the consultant, there were no letters, texts or anything,” Perkin said. Instead, he decided to pay for it himself: £5,000 – a substantial sum for the part-time ferry operator. The results from a private hospital in Guildford confirmed the cancer. “I’d lost faith in the NHS by this point and I went private,” he said. “The cancer was spreading and my surgeon made it clear that if I’d waited for the NHS for my prognosis, [the] chances of cancer recurrence would be far worse.” In May he paid another £22,500 for the prostate to be removed at a private hospital in London, with financial help from his family. “I feel let down. It turned out from the pathology that this was urgent and a delay would have made a huge difference to my outcome, my prognosis and quality of life. They got there in the nick of time.” Portsmouth Hospitals University Trust said it was sorry to have been unable to meet Perkin’s expectations and strived to provide quality and timely care. “But we recognise that across the NHS there is an increased demand on services and this can impact patient waiting times.” Read full story Source: The Guardian, 30 July 2023
  9. Event
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    Overview: The Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. This workshop will focus on applying PSIRF within Infection Prevention and Control (IPC). Audience: All PSIRF webinars are open to everyone to attend, including both NHS and arm’s length bodies. This webinar will focus on PSIRF in IPC. It is recommended for Directors of Infection Prevention and Control, IPC practitioners, IPC Doctors, Microbiologist, pharmacists and patient safety leads. Presenters: Tracey Herlihey – Head of Patient Safety Incident Response Policy, NHS England Rosie Dixon – Regional Head of IPC North West , NHS England Ruth Henein – Head of IPC and Aimee Joyce –Data and Information Co-ordinator, Northumbria-healthcare NHS Foundation Trust Sharon Edgell – ICB System Lead for IPC, NHS Surrey Heartlands ICB Register
  10. News Article
    A director at a major acute trust said it needs to stop “caving in” to demand pressures by opening extra escalation beds. Board members at Mid and South Essex were discussing a recent report from the Care Quality Commission (CQC), which rated medical services as “inadequate”. The CQC flagged significant staffing shortages and repeated failures to maintain patient records, among other issues. Deputy chair Alan Tobias told yesterday’s public board meeting: “We have just got to hold the line on these [escalation] beds. We never do. Every year we cave in… “We have just got to hold the line with this… Do what some other hospitals do, they shut the doors then. We have never had the bottle to do that.” Barbara Stuttle, another non-executive director, said: “Our staff are exhausted… We don’t have the staff to give the appropriate care to our patients when we have got extra beds. To have extra beds on wards, I know we have had to do it and I know why, [but] you are expecting an already stretched workforce to stretch even further. “And when that happens, something gives. Record keeping, that’s usually the last thing that gets done because they’d much rather give the care to patients.” Read full story (paywalled) Source: HSJ, 28 July 2023
  11. Event
    The health and care system are in crisis with staff trying to address backlogs of care and the aftermath of the Covid-19 pandemic, amid workforce shortages, financial constraints and a wider cost-of-living crisis. But how can the system move away from this new normal to a new way of working? Population health approaches offer the opportunity to move from a reactive system that treats patients when they are ill to one that proactively addresses the impact of wider social determinants on people’s heath and tackles the effects of health inequalities. Now is the time to start thinking differently about the health and care system. At this King's Fund event you will hear from local experts and international speakers about how the health and care system can begin to make this shift. It will discuss why population health offers a way to not only tackle health inequalities and improve the health of individuals and communities but can also provide solutions for a system under constant stress. New ideas will be discussed that are inspiring professionals across the sector and explore practical examples of how to address the inequalities social determinants create using a population health lens. Sharing of good-practice examples of how population health works within integrated care systems, how communities come together to promote better health outcomes for residents, and how leaders make a difference from local to national level to solve many of the problems facing the health and care system through the population health model. Register
  12. Event
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    Employee investigations refers to the investigation of allegations made by and against staff. Aneurin Bevan University Health Board (ABUHB) is responsible for the planning, delivery, and commissioning of NHS Wales services for a population of over 660,000 citizens. It employs over 15,000 staff. ABUHB started a programme of work to improve its employee investigations because its HR team identified that during a 15-month period, over 50% of investigations had led to no sanctions for individuals who had been taken through them. Their Employee Wellbeing Service had been concerned about the number of clients who had experienced significant stress and trauma as a result of going through the employee investigation process. The focus of the intervention was to reduce ‘avoidable employee harm’ by reducing the number of employees subjected to investigations, and to reduce the duration of investigations that take place. Andrew Cooper and Liz Rogers from ABUHB will present the case study and report back on the intervention outcomes, key learning points and progress made to date. The webinar will last one hour with time for questions to the presenters. Register
  13. News Article
    An award-winning hospital consultant says he has been “hunted” out of the NHS after 43 years for flagging patient safety failings. Peter Duffy, 61, performed his final surgical procedure, supervising a bladder cancer removal, earlier this month at Noble’s Hospital on the Isle of Man. He said he had “been looking forward to a good few more years of full-time work — another five, at least”. But the cumulative toll of a long-running whistleblowing dispute with his former employer, Morecambe Bay NHS Trust (UHMBT), instead pushed him into “an abrupt, even savage termination of my calling”. The General Medical Council watchdog recently dropped a 30-month probe into Duffy prompted by emails that he alleges were falsified. The emails, which were apparently sent by Duffy in December 2014 but did not surface until 2020, appeared to implicate him in the string of clinical errors that led to the death of Peter Read, a 76-year-old man from Morecambe. The GMC concluded that it could not attach weight to the emails as evidence. However, Duffy says the ordeal of “having the responsibility for an avoidable death I’d reported being flipped and of having the finger pointed back at me” drove him to contemplate suicide. Read full story (paywalled) Source: The Times, 24 July 2023
  14. Event
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    Save the date for THIS Space 2023, THIS Institute’s annual event bringing together people interested in evidence-based healthcare improvement. It’s free to join and will take place entirely online 29 and 30 November. You can expect: the latest evidence on what works in healthcare improvement, what doesn’t, and why imaginative ways of understanding problems and evaluating solutions fresh thinking on how we can improve healthcare. Register your interest
  15. News Article
    A nurse-led trial has found that a new electronic tool could reduce the number of preventable injuries and deaths caused by wrongly inserting nasogastric tubes. The study, led by Tracy Earley, a consultant nutrition nurse at Royal Preston Hospital, tested a new fibre-optic device which can tell clinicians definitively if a nasogastric tube – which is inserted through the nose and delivers food, hydration and medicine into the stomach – has been placed correctly. Currently, to check if nasogastric tubes – also referred to as NG tubes – are in the right place, nurses have to extract bodily fluid from the patient through the tube. Clinicians then test this fluid on a pH strip to judge whether the placement is correct. Studies show that interpreting the pH level results in mistakes 12-30% of the time, and that in 46% of cases nurses are unable to draw aspirate at all. This means patients have to undergo x-rays, leaving them without nutrition or treatment for longer. The study tested a device called NGPod, which uses a fibre-optic sensor to retrieve the pH reading from the tip of the NG tube leading to a definitive 'yes' or 'no' result in terms of whether it has been placed correctly – removing the need for aspirate or interpretation from the health professional. It found that the device was as accurate as pH strip testing, and removed all of the risks associated with making subjective pH strip judgements. Read full story Source: Nursing Times, 18 July 2023
  16. Event
    This conference is for staff involved in managing concerns in NHS Scotland, including the promotion, delivery, and use of the Whistleblowing Standards. The Independent National Whistleblowing Office are supporting the event. It will explore the legislative requirements around whistleblowing and the benefits of effective management of concerns. The programme concludes with a focus on what a healthy speak up culture looks like and how that can be delivered. The day will be chaired by John Sturrock, KC, and include a keynote presentation from Rosemary Agnew, the Independent National Whistleblowing Officer. It also brings together expert speakers from NHS Scotland, Scottish Government, trade union and academia with expertise in speaking up, culture change, quality, safety and candour. The programme will consider the Whistleblowing Standards since their launch in April 2021, as they approach their anticipated 3-year review. It offers an opportunity to share good practice, support ongoing improvements and promote an effective Speak Up culture that works from the bedside to the boardroom. Programme Register
  17. News Article
    NHS mental health services are stuck in a “vicious cycle” of short staffing and overwhelming pressures, a government committee has warned. Rising demand for mental health services has “outstripped” the number of staff working within NHS organisations, according to the public accounts committee. A report from the committee warned that ministers must act to get services out of a “doom loop” in which staff shortages is hitting morale and leading people to quit the already-stretched services. It found staffing across mental health services has increased by 22% between 2016 and 17 and 2021 and 22 while referrals for care have increased by 44% over the same period. Healthcare leaders warned there are 1.8 million people on the waiting list for NHS mental health care with hospital bosses “deeply concerned”. Read full story Source: The Independent, 21 July 2023
  18. News Article
    The government has admitted that many ‘vulnerable’ hospitals ‘suffer with a lack of permanence of leadership’, but said that chiefs are only sacked by NHS England ‘in extreme and exceptional circumstances’. The comments were included in the government’s response to the independent investigation into major maternity care failures at East Kent Hospitals University Foundation Trust, which highlighted how the practice of repeatedly hiring and firing leaders had contributed to its problems. The investigation said successive chairs and CEOs at the FT were “wrong” to believe it provided adequate care, and urged that they be held accountable. But it said senior management churn had been “wholly counterproductive”, and that it had “found at chief executive, chair and other levels a pattern of hiring and firing, initiated by NHS England” which would “never have been an explicit policy, but [had] become institutionalised”. Read full story (paywalled) Source: HSJ, 21 July 2023
  19. News Article
    More than 250,000 dementia patients could miss out on new treatments for the disease because they do not have a formal diagnosis, according to government figures. NHS data published for the first time shows the prevalence of different types of dementia with which people in England have been diagnosed. Dementia is an umbrella term for many different conditions, affecting more than 55 million people worldwide. This week, health regulators were urged to approve two new game-changing dementia drugs, after a landmark study confirmed that donanemab slowed cognitive decline in Alzheimer’s patients by 35%, while last year, a second drug, lecanemab, was found to reduce the rate by 27%. The NHS primary care dementia figures estimate that there are about 708,000 people over 65 with dementia in England, but only about 450,000 have a recorded diagnosis. That means that more than 250,000 are missing out on these potential new treatments. Read full story Source: The Guardian, 20 July 2023
  20. News Article
    The adoption of artificial intelligence (AI) by the NHS should be faster, and more frameworks should be in place to get emerging technologies to as many patients as possible, experts have told MPs. A number of senior figures from medicine and biotechnology gave evidence to the Health and Social Care Committee as part of its inquiry into cancer technology. Stephen Duffy, a professor of cancer screening at the Wolfson Institute of Population Health at Queen Mary University of London, told MPs there is “strong potential” for AI, particularly in areas such as reading mammograms for the breast screening programme. However, he warned that there will be “staff issues in terms of the number of staff needed to double-read mammograms”. He added: “Those issues aren’t going away. It seems to me that AI systems have already been shown to be very good in terms of detection of cancer on from mammograms, so they’re safe in that respect. Read full story Source: The Independent, 19 July 2023
  21. News Article
    A trust has been accused of presiding over the deterioration of a key service amid communication problems between senior leaders and a ‘worrying series of resignations’ which has left the department with ‘no doctors’. The British Association of Dermatologists wrote to Worcestershire Acute Hospitals Trust on 13 July to request an urgent meeting with the provider’s management to discuss the matter. The letter, seen by HSJ, outlines fundamental patient safety and staffing concerns about the trust’s dermatology service and accuses the trust of putting “continued communication barriers” between clinicians and management. The letter, signed by BAD president Mabs Chowdhury, says there are now “no doctors in the department” after two consultants and a locum consultant resigned “due to apparent unhappiness with the running of services [and in] a continuation of a worrying series of resignations”. Read full story (paywalled) Source: HSJ, 19 July 2023
  22. News Article
    The majority of trust leaders have reported an increase in the ‘burden’ put on them by regulators, citing more demanding ‘ad hoc’ requests during heightened operational pressure. In NHS Providers’ latest survey of NHS trust leaders’ experiences of regulation, a little over half of respondents – 52% – said the burden from NHS England and the Care Quality Commission had increased in the past year. The percentage was higher among acute/community and community trusts, and all ambulance and specialist trust respondents said the burden had increased. An even higher overall share of trusts – 59% – said “ad hoc requests” from regulators had increased during the same time period. This includes requests for information or meetings at short notice, diverting staff from day-to-day operational duties. Read full story (paywalled) Source: HSJ, 20 July 2023
  23. News Article
    The trust at the centre of a maternity scandal insists it has been providing immediate anaesthetic cover for obstetric emergencies, contrary to an NHS England report suggesting it had not and had been potentially breaching safety standards. Health Education England – now part of NHSE – visited William Harvey Hospital in March and was told senior doctors in training who were covering obstetrics could also be covering the cath lab – which deals with patients who have had a heart attack, and could receive trauma, paediatric emergency and cardiac arrest calls. This suggested the trust was in conflict with Royal College guidelines which state an anaesthetist should always be “immediately available” for obstetrics. East Kent Hospitals University Foundation Trust, which runs the hospital, originally told HSJ its rota had very recently been changed and that an anaesthetist with primary responsibility for maternity could leave any other work to attend to a maternity emergency immediately. However, it has since said it has been the case for a long time that an anaesthetist is available to return to maternity in case of an emergency. Read full story (paywalled) Source: HSJ, 17 June 2023
  24. Event
    This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. You’ll also be directed to specific activities designed to extend and consolidate your knowledge. Register
  25. Event
    This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. You’ll also be directed to specific activities designed to extend and consolidate your knowledge. Register
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