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A “breakdown in trust” between two of the country’s leading teaching hospitals saw transplant patients referred elsewhere as a result of safety concerns, HSJ reveals.
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Source: HSJ, 28 October 2019
A coroner has criticised an NHS trust for “suboptimal care” and “missed opportunities” in the treatment of 10 patients with cancer at a urology department where relationships were “dysfunctional.”
Coroner Penelope Schofield said that all 10 had died of natural causes but that missed opportunities, suboptimal care, and in three cases “neglect” had contributed to the deaths.
The patients, who died from prostate or bladder cancer from 2006 to 2015, were under the care of Paul Miller, a consultant urologist at East Surrey Hospital in Redhill.
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Source: BMJ, 25 October 2019
Nearly 900 children in a Pakistani city have tested positive for HIV after a rogue paediatrician allegedly reused infected syringes.
About 200 adults have also tested positive for the virus since the epidemic in Ratodero was confirmed in April. But health officials fear the true number affected could be far higher, with less a quarter of city’s 200,000 residents tested so far.
The outbreak was initially blamed on Dr Muzaffar Ghanghro, a paediatrician who at 16p a visit was one of the cheapest in the small central city. He was arrested and charged with negligence and manslaughter after his patients accused him of frequently reusing syringes on their children.
Despite an initial investigation by police and health officials concluding Dr Ganghro’s “negligence and carelessness” as the “prime” reason for the outbreak, officials believe he is unlikely to be the sole cause. Visiting health workers often see doctors in Ratodero reusing syringes, while dentists use unsterilised tools in roadside surgeries and barbers use the same razor on various customers, The New York Times reported.
Source: The Independent, 27 October 2019
The Health Products Regulatory Agency (HPRA) has revealed an increase in the number of adverse reaction reports to medicines as well as a rise in product recalls and quality defects in 2018. With more than 250 Irish patients dying last year while on treatment with medicines where an adverse reaction had been reported, should we be alarmed?
The number of adverse reaction reports received by the authority last year more than doubled. It says the increase is largely accounted for by a new requirement to include non-serious reports of adverse reactions in addition to serious ones. Particular risk factors include age extremes, the prescribing of multiple drug types, co-morbidity and genetics. But in truth reporting of adverse drug reactions (ADRs) in the Republic has never been comprehensive. It is estimated that less than 5% of all ADRs are reported in practice. A 2018 Irish study found that 43% of hospital doctors and 35% of GPs had never reported a suspected ADR.
Medication safety is an important patient safety issue. Working together, and with increased education, healthcare professionals and the public can do more to increase vigilance.
Source: The Irish Times, 28 October 2019
Digital training should be “embedded” into clinical curricula rather than being “bolted on”, the Chief Executive of ORCHA has said. Liz Ashall-Payne said more needed to be done to ensure appropriate digital training for clinicians or risk a “knowledge gap” forming between current and future staff.
Dr Sandeep Bansal, Chief Executive of Medic Creations and mentor on the Royal College of GPs innovation mentorship programme, echoed calls for digital training to be incorporated in the medical school curriculum.
“Your organisation is only as strong as lowest digitally mature staff member. It is all very well educating our tech-savvy junior doctors, but we must make sure those less au fait with digital advancements are not left behind. That is where patient safety could be put at risk. After all the main purpose of digital innovation is to enhance our ability to care for patients, by enabling more effective, efficient and precise clinical practice.”
Clive Flashman, Patient Safety Learning's Chief Digital Officer, agreed with the need for clinicians to receive digital training but with a focus on how to quickly evaluate an apps. “What is essential is that all clinicians, not just GPs, have access to advice, tools and support to enable them to prescribe and monitor the effectiveness of apps and digital therapies,” he told Digital Health News.
Source: Digital Health, 29 October 2019
Paramedics will be able to access the records of mental health service users for the first time as part of a wider scheme that aims to allow clinicians to share care records across the country.
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Source: HSJ, 28 October 2019
A cosmetic surgery was forced to close after the health watchdog raised concerns about the safety of its practices. Smethwick's Bearwood Cosmetic Clinic's registration was cancelled by the Care Quality Commission (CQC) last year.
The health watchdog's report into the practice is yet to be published, but inspectors have written to other practitioners expressing concerns. It found "unsafe practice" and a lack of appropriate training.
The letter from the CQC reveals it has inspected 65 services across the country, about two thirds of independent cosmetic surgery providers and raised concerns about 12. While some were found to be "providing a very good standard of care", there were a number of areas of concern.
Ted Baker, chief inspector of hospitals, wrote to providers raising particular concern regarding the use of anaesthetic during liposuction. Inspectors had seen examples of "unsafe practice", he said, and reminded providers that a trained anaesthetist should be present for procedures. The CQC also warned it had found evidence of staff not having appropriate training, a lack of attention to fundamental safety processes and infection control standards not being followed.
Source: BBC News, 31 October 2019
Half of developers are not seeking ethical approval before they start producing new artificial intelligence systems for healthcare, according to a report by NHSX.
The report, Artificial Intelligence: How to get it right, notes that the “complex governance framework” around AI tech could limit innovation and potentially compromise patient safety.
It also revealed that there is “an almost 50/50 split” between developers who sought ethical approval before they started the development process for a new AI system and those who did not.
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Source: HSJ, 31 October 2019
A shortage of radiologists, pensions issues and rising demand have driven the worst breast cancer wait times for at least nine years, some of the worst performing trusts have told HSJ.
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Source: HSJ, 1 November 2019
England’s top doctor has welcomed new polling showing that patients and the public support NHS proposals focussing on fast treatment for those who need it in A&E.
A national survey commissioned by Healthwatch England found that an overwhelming majority of people placed a high priority on early initial assessment on arrival at A&E for everyone, allowing staff to prioritise those patients with the greatest need, and ensuring that patients with critical conditions get the right standard of care quickly.
These priorities are mirrored in new standards now being trialled across the NHS, as part of a review led by NHS National Medical Director, Professor Stephen Powis, supported by leading staff and patient groups. They include a rapid assessment measure for all patients arriving at A&E, coupled with measuring how quickly life-saving treatment – or Critical Time Standards – is delivered for those with the most serious conditions, such as heart attacks, sepsis, stroke and severe asthma attacks.
Experts believe updating the 15-year old target regime for emergency department teams with these new measures, combined with an average waiting time target to bring down long waits for all patients, may help NHS teams save more lives and prevent long term disability for thousands more people.
Source: NHS England, 31 October 2019
Changes are being made to the NHS 999 and 111 triage software after it was criticised for failing to determine the urgency of overdose cases based on type of drug taken.
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Source: HSJ, 4 November 2019
A 7-year-old boy who has spent most of his life being branded naughty and disruptive has won a settlement of more than £30m after it was discovered that he had sustained a brain injury after negligent delays in his delivery at University College Hospital in London.
The settlement is thought to be one of only a handful of NHS clinical negligence payouts to exceed £30m.
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Source: BMJ, 1 November 2019
The Professional Record Standards Body (PRSB) has published a standard for ambulance handover to ensure that information can be transferred digitally to emergency departments from any ambulance and improve patient care and safety.
Emergency care needs fast, effective sharing of information. Once implemented, the standard for handover will improve continuity of care, as emergency care professionals will have the information they need available to them on a timely basis. It means that emergency care professionals will know what medications have been administered, diagnostic tests performed and whether the patient has any allergies as well as other important information.
The standard is published as a draft while PRSB seeks endorsement from relevant members and other organisations.
Read the Ambulance handover to emergency care standard
Source: PRSB, 1 November 2019
A common hospital bed used by thousands of patients across New South Wales (NSW), Australia, poses a risk to heavier patients and nurses caring for them, healthcare staff have been warned.
A safety alert has been issued throughout the state after NSW Health received five reports of Hill-Rom HR900 model beds tilting dangerously as nurses tried to manoeuvre patients.
The incidents are the latest pressure point for a healthcare system responsible for the rising overweight and obese patient population.
No patients involved were harmed, but “there is a potential risk if the beds tip during an episode of patient care", the alert issued last month by the Clinical Excellence Commission reads.
Source: The Sidney Morning Herald, 4 November 2019
At last week’s meeting in Perth, Australia, the COAG Health Council discussed a number of national health issues, one of which was the Quality Use of Medicines.
The Council’s resulting communique highlights that medicines are the most common intervention in healthcare and can contribute to significant health gains – but can also be associated with harm.
“Half of all medication related harm is preventable and a coordinated national approach that identifies and promotes best practice models and measures progress towards reducing medication related harm has the potential to improve the health of Australians and create savings across the health care system,” it notes.
At the meeting, the Health Ministers agreed to make the Quality Use of Medicines and Medicines Safety the 10th National Health Priority Area
Source: Australian Journal of Pharmacy, 4 November 2019
Every NHS and social care worker in England will have to undergo mandatory training on autism and learning disability following the death of a teenager, the government has said.
Eighteen-year-old Oliver McGowan, who had autism, died in November 2016 after being given anti-psychotic medication against his own and his parents’ wishes by staff at Bristol’s Southmead Hospital, part of the North Bristol NHS Trust. Oliver’s medical records showed he had an intolerance to anti-psychotic drugs and shortly after he was given the dose he developed severe brain swelling and died.
His parents Paula and Tom McGowan have been campaigning for improved training for health and care staff and ministers have now backed their calls with new pilots and £1.4m of funding.
The new training will be named after Oliver and will start next year, with the aim to improve care for people with autism and learning disabilities using case studies and ensuring all staff understand the needs of patients with learning disabilities and autism.
Source: Independent, 5 November 2019
A large mental health provider unfairly dismissed a nurse with a record of whistleblowing because it feared he was seeking to highlight care failures, a tribunal has ruled.
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Source: HSJ, 5 November 2019
More mental health hospital beds are needed in England to end the "distressing" sending of patients far from home, analysis suggests. Patients with conditions such as schizophrenia can be sent to hospitals miles away from their home if their nearby units do not have space.
The Department of Health aims to end inappropriate far-away placements by 2021. But the Royal College of Psychiatrists report suggested the push had stalled. The number of inappropriate out-of-area placements at any one time has been consistently between 700 and 800 patients in recent months, after dipping below 600 towards the end of 2018.
Marjorie Wallace, Chief Executive of the charity Sane, said the drive to cut bed numbers had been "relentless" and caused "widespread distress and neglect".
"Far too many people contacting us are being shunted around the country like unwanted parcels," she said. "We believe this has led to ever more patients left at risk of self-harm and suicide."
Source: BBC News, 6 November 2019
A 48 year old woman with no medical degree who worked as an assistant doctor at a hospital in Germany has been arrested on suspicion of manslaughter over the deaths of four patients, according to prosecutors in Kassel in central Germany.
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Source: BMJ
A hospital trust has declared a "critical incident" because of the "exceptional" pressure on A&E.
Nottingham University Hospitals Trust (NUH) runs the Queen's Medical Centre (QMC) and City Hospital and has been on OPEL 4 – previously known as black alert – since Monday morning. On Wednesday it raised the level further.
Some routine operations have been cancelled as the trust prioritises those who need emergency care. Health bosses do not want to operate on patients who cannot be guaranteed a bed in which to recover.
Lisa Kelly, NUH Chief Operating Officer, said: "This is following a number of days seeing exceptional pressure across the system, with high numbers of very poorly patients arriving at our emergency department."
The trust has been on OPEL 4 at least once this year but this is the first time in 2019 the pressure in the emergency department has been escalated to a critical incident.
Ms Kelly added: "This is not unique to Nottingham, and hospitals across the country are also experiencing similar pressures."
In the East Midlands, University Hospitals of Leicester and Sherwood Forest Hospitals NHS Foundation Trust were both on OPEL 4 – which means patient safety could be compromised – earlier this week. They have since been scaled down to OPEL 3.
Source: BBC News, 6 November 2019
A two-year-old with a twisted bowel died despite her mother telling NHS non-emergency services about "blue lips and breathlessness", a coroner said.
Myla Deviren's mother spoke to a series of NHS 111 and out-of-hours service advisors, but none "appreciated" her symptoms and she later died. A coroner said with earlier hospital transfer and appropriate treatment Myla probably would have survived.
The 111 provider said it had made a number of changes since Myla's death.
In a prevention of future deaths report, Rosamund Rhodes-Kemp, assistant coroner for Cambridgeshire, said after Mylabecame unwell in the early hours of 27 August 2015 her mother rang 111. During the call the health assistant "did not appreciate the significance of key symptoms", Ms Rhodes-Kemp said.
Ms Rhodes-Kemp said that further steps in the 111 and out-of-hours services should be taken, including mandatory annual training for all call staff and having a "suitably-qualified" paediatric specialist clinician available. She added the "default position and precautionary advice should be - if in doubt call an ambulance".
Source: BBC News, 7 November 2019
Troubled teenagers seeking urgent help from NHS mental health services are being denied treatment or facing months of delays, GPs have said. Three in four family doctors do not believe under-18s they refer to child and adolescent mental health services will end up being treated, research shows.
In a survey of 1,008 GPs across the UK, 76% said they did not usually feel confident a young person they referred to Child and Adolescent Mental Health Services (CAMHS) would receive treatment for their illness. Only 10% were confident that treatment would follow.
Emma Thomas, Chief Executive of YoungMinds, said: “As these worrying results show, GPs are on the frontline when it comes to mental health. But too often they don’t believe that there is good enough early support in their community". She added, "This means many young people either receive support from GPs who have the best of intentions but may not feel equipped to provide the right help, or face long waiting times for specialist services, which may then turn them away because of high thresholds for treatment.”
Source: Guardian, 7 November 2019
Tens of thousands of people have have had their operations cancelled because of staff shortages and faulty medical equipment, according to newly revealed NHS figures.
The number of procedures called off by hospitals for non-clinical reasons has increased by 32 per cent in the last two years, the statistics obtained via a freedom of information (FOI) request. Almost 4,000 more were scrapped in 2018 than in 2016.
They also show that of the 79,000 operations to be cancelled last year, 20 per cent were scrapped because of staffing issues and equipment failures.
It comes as the staff vacancies continue to put the health service under strain, with the NHS reporting last year it was short of 100,000 staff including, 10,000 doctors and 35,000 nurses.
Source: The Independent, 5 November 2019
Elderly patients are being “poisoned” with medication because too little is known about how different drugs interact with each other and correct dosages for older people, experts have said.
Speaking at the House of Lords’ science and technology committee hearing on healthier living in old age, Sir Munir Pirmohamed, Professor of Molecular and Clinical Pharmacology at Liverpool University, said most of his patients are on more than 10 and often more than 20 drugs.
“Those drugs are used at conventional doses and those doses have been tested in younger populations who had exclusion criteria for trials – so they have been tested in people who don’t have the multiple diseases,” he said. “So when we use a drug at a dose which is licensed at the moment, we are often ‘poisoning’ the elderly because of the dosing that we are using.”
Source: Guardian, 29 October 2019
The team of healthcare professionals at Doncaster and Bassetlaw Teaching Hospitals (DBTH) discuss their work ‘Sharing How We Care’ after being awarded the Shared Learning Award for their outstanding contributions to improving patient safety.
The Trust ‘Sharing How We Care’ work was selected as the winners of the Shared Learning Award at the Patient Safety Learning Conference in London last month. The award recognised the work involved in setting up an annual conference as a forum to share examples of exemplary healthcare practice and a monthly newsletter which focuses on aspects of patient’s safety, including patient experience and articles about improvements in clinical areas.
As a result of the work through Sharing How We Care, the Trust has seen a 40% decrease in the number of serious incidents reported.
Cindy Storer, Acting Deputy Director of Nursing, Midwifery and Allied Health Professionals at Doncaster and Bassetlaw Teaching Hospitals, said: “We’re so pleased that the work through Sharing How We Care at the Trust has been recognised. We’ve seen real improvements in the quality of the care we provide as a direct result of this shared learning. These results reflect the commitment from all of our staff to support Doncaster and Bassetlaw Teaching Hospitals to become the safest Trust in England.”
Source: Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust website
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