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Nurse's conviction should be wake-up call for health system leaders, IHI says

RaDonda Vaught's conviction for a fatal medical error has already damaged patient safety and should serve as a wake-up call for health system leaders to improve harm prevention efforts, the Institute for Healthcare Improvement has said.

Ms. Vaught was convicted 25 March of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 while working as a nurse at Vanderbilt University Medical Center in Nashville, Tenn. 

"We know from decades of work in hospitals and other care settings that most medical errors result from flawed systems, not reckless practitioners," IHI said. "We also know that systems can learn from errors and improve, but only when those systems encourage reporting, transparently acknowledge their mistakes and are held accountable for those errors."

The organization said criminal prosecution of errors over-focuses on the individual and diverts attention from necessary system-level issues and improvements. 

"Were this practice to be repeated in future cases of a serious or fatal error, there will be more damage, less transparency, less accountability and more lives lost," IHI said. "Instead, this case should be a wake-up call to health system leaders who need to proactively identify system faults and risks and prevent harm to patients and those who care for them."

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NHSE warned of ‘inaccurate’ and ‘unethical’ investigation into man’s death

An independent investigation into the death of a man with autism and learning difficulties in NHS care may never be published in full as his sister has rejected several drafts as inaccurate, telling NHS England they were ‘totally unethical’.

Anthony Dawson died from a burst gastric ulcer in Ashmount, a residential care home run by Surrey and Borders Partnership Foundation Trust, in May 2015. The jury at an inquest into his death found there were gross failings in his care and his death was contributed to by neglect.

NHS England commissioned an independent investigation into the incident from Sancus Solutions in June 2017. But seven years after Mr Dawson’s death the investigation’s report has yet to be published, despite several reports being submitted.

His sister, Julia Dawson, has written to NHS chief executive Amanda Pritchard in recent weeks saying: “The investigation has not had my brother at its heart which we were assured would be the case” and that its reports had been “totally unethical”.

Ms Dawson has asked that only the executive summary of the latest draft of the investigation be published, alongside a statement saying that she feels it has inaccuracies and misses out important points.

She says that successive drafts have misrepresented her brother’s situation and failed to address what she believes was the real cause of his death – the frequent use of NSAIDs (ibuprofen) without any measures taken to protect his stomach. This ultimately led to the undiagnosed gastric ulcer bursting. An expert witness told the inquest into his death that treatment with proton pump inhibitors and stopping NSAIDs would have eradicated the ulcer.

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Source: HSJ, 4 April 2022

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‘She died in excruciating pain, instead of being properly treated,’ says sailor’s father

Seaman Danyelle Luckey “didn’t die in combat or any military operation. She died from gross negligence of the medical providers on the ship she served, the USS Ronald Reagan,” said her father, Derrick Luckey.

Danyelle Luckey died from sepsis on 10 October 2016. The 23-year-old had been on the ship for two weeks, and had been going back and forth to medical from 3 to 9 October with worsening symptoms. “Her death was very preventable. She died in excruciating pain, instead of being properly treated,” Derrick Luckey told lawmakers during a hearing about patient safety and the quality of care in the military medical system.

“If the medical providers had given her a simple treatment of antibiotics instead of turning her away, she would be alive today,” he said.

Luckey and Army veteran Dez Del Barba, who said he lost part of his left leg and suffered 70% muscle and tissue damage after his strep infection went untreated, urged lawmakers to make changes so others in the military community don’t have to suffer.Both contend this could have been avoided if proper medical care, such as antibiotics, had been provided. And both said they haven’t been able to get any information on investigations, or any actions to hold anyone accountable.Read full story

Source: Yahoo News, 31 March 2022

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Clinically vulnerable Covid patients denied access to life-saving antivirals

Clinically vulnerable people infected with Covid are being denied access to potentially life-saving antiviral medicine, patients, health officials and charities say.

Around 1.3 million people with underlying health conditions in England have been identified by the NHS as at-risk and sent letters explaining they will be assessed for antiviral treatment if infected with Covid.

The NHS said “tens of thousands of the most vulnerable patients” have received the medication to date, but told The Independent it was “aware of some local issues” in which clinically vulnerable people have struggled to access the antivirals. It comes at a time of record-breaking infection levels.

Patients seeking the treatment, which suppresses an infection to prevent disease escalation and hospitalisation, have reported being turned away by GPs and hospital doctors, while others say they’ve been “pushed from pillar to post” in an attempt to access the medication.

An NHS manager told The Independent that only 15% of eligible patients cared for by Kent and Medway Clinical Commissioning Group received antiviral medication in February.

Anthony Nolan, the blood cancer charity, and Kidney Care UK both said they had received reports that Covid Medicine Delivery Units (CMDUs), which are responsible for ensuring antiviral medication reaches patients, were overwhelmed and struggling to provide treatment.

“Weekends are a particular problem and it causes a lot of stress,” said Fiona Loud, a policy director a Kidney Care UK. “We have had reports from people in different parts of the country.”

Paxlovid, molnupiravir and remdesivir are available via the NHS as antiviral medicine. All three have been shown to be effective in reducing the risk of hospitalisation among infected vulnerable patients. Antibody treatment, administered intravenously, is also available.

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Source: The Independent, 4 April 2022

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Swamped NHS mental health services turning away children, say GPs

Children and young people who are anxious, depressed or are self-harming are being denied help from swamped NHS child and adolescent mental health services, GPs have revealed.

Even under-18s with an eating disorder or psychosis are being refused care by overstretched CAMHS services, which insist that they are not sick enough to warrant treatment.

In one case, a crisis CAMHS team in Wales would not immediately assess the mental health of an actively suicidal child who had been stopped from jumping off a building earlier the same day unless the GP made a written referral. In another, a CAMHS service in eastern England declined to take on a 12-year-old boy found with a ligature in his room because the lack of any marks on his neck meant its referral criteria had not been met.

The shocking state of CAMHS care is laid bare in a survey for the youth mental health charity stem4 of 1,001 GPs across the UK who have sought urgent help for under-18s who are struggling mentally. CAMHS teams, already unable to cope with the rising need for treatment before Covid struck, have become even more overloaded because of the pandemic’s impact on youth mental health.

Mental health experts say young people’s widespread inability to access CAMHS care is leading to their already fragile mental health deteriorating even further and then self-harming, dropping out of school, feeling uncared for and having to seek help at A&E.

“As a clinician it is particularly worrying that children and young people with psychosis, eating disorders and even those who have just tried to take their own life are condemned to such long waits”, said Dr Nihara Krause, a consultant clinical psychologist who specialises in treating children and young people and who is the founder of stem4.

“It is truly shocking to learn from this survey of GPs’ experiences of dealing with CAMHS services that so many vulnerable young people in desperate need of urgent help with their mental health are being forced to wait for so long – up to two years – for care they need immediately.

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Source: The Guardian, 3 April 2022

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Gynaecology waits soar by 60% during pandemic

Gynaecology waiting lists in England have risen by 60% during the pandemic - more sharply than any other specialty.

Across the UK, more than 570,000 women are waiting for help.

The Royal College of Obstetricians and Gynaecologists (RCOG) said patients were "consistently deprioritised and overlooked".

NHS England says hospitals are making progress on dealing with the Covid backlog and average waiting times for elective treatment are coming down.

The RCOG is calling for much greater attention to women's views, and for care to be designed around their needs.

Chetna Mistry says she is a "prisoner" to endometriosis, a painful condition in which tissue similar to the lining of the womb grows in other places, like the ovaries.

She described it as "a whole-body disease which affects you physically and mentally". It has left her infertile, and, at 42, she needs a hysterectomy.

Chetna said she was referred to a specialist in June 2020, but 21 months later still does not have a date for surgery.

RCOG president Dr Edward Morris said he felt helpless not being able to speed up access to care for women and people on his waiting lists.

"There is an element of gender bias in the system. I don't think believe that we are listening to voices of women as well as we should be. The priority they urgently need is not being given to them."

The Royal College asked 830 women on waiting lists about the other impacts on their lives.

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Source: BBC News, 4 April 2022

 

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Patient care and safety put at risk in A&E at brand new £350m hospital

Patients visiting Wales' newest emergency department were likely to have been put at risk of harm due to the lack of processes and systems in place, inspectors found. Healthcare Inspectorate Wales (HIW) carried out an unannounced inspection of The Grange University Hospital in Cwmbran between 1 and 3 November last year and published its findings on 29 March.

On the day of their arrival inspectors said The Grange was at full capacity with no empty beds in A&E or in the hospital in general. Despite the best efforts of staff who were "working hard under pressure" the report stated the emergency department had several issues which could have compromised the privacy and dignity of patients. This included problems with the physical environment of the waiting room, which was described as a "major cause of anxiety" for visitors, as well as with the flow of patients through the hospital in general.

It found that patients were not triaged and medically managed in A&E in a timely fashion with many being placed on uncomfortable chairs or in corridors for hours on end. Between 1 April 2021 and 1 November 2021, the average waiting time in the department was six hours and seven minutes.

The report said some issues required immediate action including the fact patients in the waiting area were often left to "deteriorate without being overseen". There were also infection control failures which could have led to the cross-contamination of Covid-19. "We were not assured that all the processes and systems in place were sufficient to ensure that patients consistently received an acceptable standard of safe and effective care," the report stated.

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Source: Wales Online, 1 April 2022

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Bullying among top surgeons sparks two national investigations

‘Horrifying and upsetting’ reports of bullying in prestigious heart units are being probed by national officials and professional leaders, HSJ can reveal.

Health Education England told HSJ it was “undertaking a national thematic review of training in cardiothoracic surgery”, while the Society for Cardiothoracic Surgery separately revealed it was investigating concerns about “bullying, harassment and undermining behaviour” in the specialty following high-profile recent cases in Newcastle and Wales.

Society president consultant surgeon Simon Kendall, who is based at James Cook University Hospital in Middlesbrough, told HSJ he has been made aware of wider problems beyond those identified in the North East and Wales.

Mr Kendall revealed allegations reported to the society have included people being shouted at in public, problems resulting from a “legacy culture of sarcasm and public humiliation”, and more personal disputes between individuals.

The consultant surgeon told HSJ: “The job is hard enough for all of us, without picking on each other and making it worse."

He added: “It’s the extended team that is affected by these behaviours and it will have an impact on patient safety and patient care.

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Source: HSJ, 1 April 2022

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RCM response to Ockenden review into maternity services at Shrewsbury and Telford

Poor culture and leadership must be addressed if we are to make our maternity services the safest place to give birth. This statement from the Royal College of Midwives (RCM) came as the final report of the largest ever review of NHS maternity services was published. The RCM acknowledged that the pain and suffering of the families had been worsened by having to fight for answers and vowed to work with NHS bodies and other professional organisations to ensure lessons are learned from these tragic failings.

Today the RCM has pledged to continue its work to be part of the solution to safety improvements and support its members to do the same not only at Shrewsbury and Telford NHS Trust, but throughout all maternity services across the UK.

Commenting, the Royal College of Midwives’ (RCM) Chief Executive, Gill Walton said:

“It is heartbreaking that this report only came about because of the determination of the families. We owe them a debt that I fear can never be repaid. What we can do - all of us who are involved in maternity services – is work together to ensure we listen, and we learn from this and ensure that women and families have trust in their care."

“This review must be a turning point for all those working in maternity services. The actions recommended are measured and sensible and reflect much of what the RCM has been calling for. We hope that those in a position to enact them – NHS England and the Department for Health & Social Care – will do so in partnership with organisations like ours and with haste.”

"A poor working culture, where staff were afraid to raise concerns, has been cited by the report as a key factor in many of the cases. Earlier this year the RCM called for a seismic NHS cultural shift to improve maternity safety as it published guidance for its members to raise concerns about maternity care which outlined steps staff can take and what to do if they feel they are not being listened to or their concerns are ignored."

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Source: Royal College of Midwives, 30 March 2022

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Experts warn of racial disparities in the diagnosis and treatment of Long Covid

It has long been clear that Black Americans have experienced high rates of coronavirus infection, hospitalisation and death throughout the pandemic.

But those factors are now leading experts to sound the alarm about what will may come next: a prevalence of Long Covid in the Black community and a lack of access to treatment.

Long Covid — with chronic symptoms like fatigue, cognitive problems and others that linger for months after an acute coronavirus infection has cleared up — has perplexed researchers, and many are working hard to find a treatment for people experiencing it. But health experts warn that crucial data is missing: Black Americans have not been sufficiently included in Long-Covid trials, treatment programmes and registries, according to the authors of a new report released on Tuesday.

“We expect there are going to be greater barriers to access the resources and services available for Long Covid,” said one of the authors, Dr. Marcella Nunez-Smith, who is the director of Yale University’s health equity office and a former chair of President Biden’s health equity task force.

“The pandemic isn’t over, it isn’t over for anyone,” Dr. Nunez-Smith said. “But the reality is, it’s certainly not over in Black America.”

In the first three months of the pandemic, the average weekly case rate per 100,000 Black Americans was 36.2, compared with 12.5 for white Americans, the authors write. The Black hospitalisation rate was 12.6 per 100,000 people, compared with 4 per 100,000 for white people, and the death rate was also higher: 3.6 per 100,000 compared with 1.8 per 100,000.

“The severity of Covid-19 among Black Americans was the predictable result of structural and societal realities, not differences in genetic predisposition.” 

"Many Black Americans who contracted the coronavirus experienced serious illness because of pre-existing conditions like obesity, hypertension and chronic kidney disease, which themselves were often the result of “differential access to high-quality care and health promoting resources,” the report says.

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Source: New York Times, 29 March 2022

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Guilty verdict for nurse RaDonda Vaught’s dosing mistake could cost lives

Patient safety and nursing groups around the country are lamenting the guilty verdict in the trial of a former nurse in Tennessee, USA.

The moment nurse RaDonda Vaught realised she had given a patient the wrong medication, she rushed to the doctors working to revive 75-year-old Charlene Murphey and told them what she had done. Within hours, she made a full report of her mistake to the Vanderbilt University Medical Center.

Murphey died the next day, on 27 December 2017. On Friday, a jury found Vaught guilty of criminally negligent homicide and gross neglect.

That verdict — and the fact that Vaught was charged at all — worries patient safety and nursing groups that have worked for years to move hospital culture away from cover-ups, blame and punishment, and toward the honest reporting of mistakes.

The move to a “Just Culture" seeks to improve safety by analyzing human errors and making systemic changes to prevent their recurrence. And that can't happen if providers think they could go to prison, they say.

“The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent,” the American Nurses Association said. “Health care delivery is highly complex. It is inevitable that mistakes will happen. ... It is completely unrealistic to think otherwise.”

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Source: The Independent, 31 March 2022

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Sajid Javid: Doctors too often ‘ignore’ women’s pain

Doctors too often "ignore" women's pain, Sajid Javid said as he called for change in the wake of the Shrewsbury maternity scandal.

Writing for The Telegraph, the Health Secretary said the wider NHS needed to do much more to listen to women, adding that too many are left in pain and ignored by clinicians.

On Wednesday, the Ockenden report revealed that the deaths of 201 babies and nine mothers at Shrewsbury and Telford NHS Trust could have been avoided, citing a failure to listen to women.

Mr Javid wrote: "This week we have seen the tragic reality of what can happen when women's voices are not listened to when it comes to their care. 

"Donna Ockenden's report into maternity failings at Shrewsbury and Telford Hospitals raises specific concerns for maternity services, but more widely we must address issues across the whole of the health and care system when it comes to listening to women's concerns and recognising their pain."

In the joint piece with Maria Caulfield, the minister for women’s health, Mr Javid welcomed a "shift in the way we talk about women's health", with more open discussions about areas once seen as taboo.

But the pair said more needed to be done – specifically to improve the treatment of endometriosis, an extremely painful gynaecological condition.

"We must ensure all women feel confident in going to their GP when they experience symptoms of endometriosis and, when they do, that they are listened to," they said. Too many were "spending too long in pain waiting for a diagnosis, often feeling ignored by clinicians", they warned.

Later this year the Government will publish a women's health strategy, which will examine issues including fertility, menopause, and prevention and treatment of diseases.

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Source: The Telegraph, 31 March 2022

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Stroke and heart patients routinely waiting over an hour for ambulance

Stroke and heart attack victims are now routinely waiting more than an hour for an ambulance, after a further fall in performance in recent weeks, and with hospital handover delays hitting a new high point, HSJ reveals.

Figures for ambulance performance this week, seen by HSJ, showed average response times for category two calls at more than 70 minutes for successive days. 

3,000 patients may have suffered “severe harm” from delays in February, ambulance chief executives say.

Several well-placed sources in the sector said response times had deteriorated further this month, and that more than half of ambulance trusts were this week seeing average category two responses of longer than an hour. 

Some cited an average category two response last week of around 70 minutes, with the services under huge pressure from a combination of demand, long handover delays, and covid-related sickness.

Category two calls include patients with suspected heart attacks and strokes, and the national target for reaching them is 18 minutes.

The figures seen by HSJ for this week showed average response times for category one calls — the most serious, including cardiac arrests and other immediately life threatening emergencies — of more than 10 minutes on Wednesday, against a target of just 7 minutes. Monthly average performance for category one has never reached 10 minutes.

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Source: HSJ, 1 April 2022

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Artificial pancreas to revolutionise diabetes care in England

Nearly 900 patients with type 1 diabetes in England are testing a potentially life-changing artificial pancreas.

It can eliminate the need for finger prick tests and prevent life-threatening hypoglycaemic attacks, where blood sugar levels fall too low.

The technology uses a sensor under the skin. It continually monitors the levels, and a pump automatically adjusts the amount of insulin required.

Six-year-old Charlotte, from Lancashire, is one of more than 200 children using the hybrid closed loop system.

Her mother, Ange Abbott, told us it has made a massive impact on the whole family.

"Prior to having the loop, everything was manual," she said. "At night we'd have to set the alarm every two hours to do finger pricks and corrections of insulin in order to deal with the ups and downs of Charlotte's blood sugars."

Prof Partha Kar, NHS national speciality adviser for diabetes, said: "Having machines monitor and deliver medication for diabetes patients sounds quite sci-fi like, but technology and machines are part and parcel of how we live our lives every day.

"It is not very far away from the holy grail of a fully automated system, where people with type 1 diabetes can get on with their lives without worrying about glucose levels or medication."

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Source: BBC News, 1 April 2022

Further reading on the hub

How safe are closed loop artificial pancreas systems?

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GP practices training receptionists to do blood tests

A number of London GP practices are training their receptionists to do blood tests, Pulse has learned.

Professor Sir Sam Everington, a GP and chair of Tower Hamlets CCG, told Pulse that ‘lots of practices’ in the area have taken the step, including his own.

Training a receptionist to carry out blood tests – which can be done in just six weeks – provides much-needed support to pressured practices, he said.

Dr Everington told Pulse: ‘A lot of our receptionists have signed up to be phlebotomists and they love it because actually, phlebotomy is not just about taking blood. 

"You get to know all the patients with long-term conditions and so our phlebotomists know all these patients."

He added that reception teams are a ‘fertile recruitment ground’ for a phlebotomist. They can ‘manage even the most terrified patients’ and have ‘amazing’ clinical skills.

Dr Everington suggested that training receptionists as phlebotomists can help build trust with patients who are suspicious about having to describe their symptoms for triage by reception staff.

But he said that the extra role just ‘acknowledges’ that all members of practice staff are ‘part of the clinical team’.

He told Pulse: "In our practice, we all train together. We have meetings together, the whole team, and it’s acknowledging in this modern world that actually every member of your staff is a clinician – part of the clinical team – because there are always things they will do or can do that will have an impact clinically."

"There isn’t a hidden supply of GPs out there in the next few years. It takes 10 years to train GPs so actually help is going to come from a wider team base."

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Source: Pulse, 31 March 2022

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Less than half of staff at maternity scandal trust feel able to speak out

Less than half of staff at scandal-hit Shrewsbury and Telford Hospital NHS Trust feel they can speak up about concerns, according to a staff survey, as a damning report warned serious problems persist in maternity care.

Shrewsbury and Telford Hospital Trust is one of the worst-performing trusts on the latest national survey of staff for the NHS.

It comes after Donna Ockenden, who chaired a review into maternity failures at the trust, said her “biggest concern” was that staff had been told not to share concerns with her inquiry.

Ms Ockenden told The Independent her biggest concern was “that ordinary staff on the ground are telling me they were advised not to cooperate with the Ockenden review”.

The NHS staff survey, published on Wednesday, showed just 49% of staff at the trust reported they would feel safe enough speaking up about concerns in 2021 – down from 53% in 2020.

Meanwhile, just 34% of staff said they feel their concerns would be addressed if there were to speak up.

The trust is one of the worst three hospital trusts in the country when it comes to rising care concerns, the figures show. Only United Lincolnshire Hospitals NHS Trust and Barking, Havering and Redbridge University Hospitals NHS Trust performed worse.

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Source: The Independent, 31 March 2022

 

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Every ICS expected to break even in ‘harsh’ new regime

Every health and care system — including those carrying huge deficits going into the pandemic — will be told to deliver financial balance in 2022-23, according to draft guidance seen by HSJ.

For the last two years, local NHS organisations have effectively seen all their spending covered by the government under temporary Covid measures.

But a more typical financial regime is now due to begin in April, with systems expected to deliver services from within funding envelopes set at the start of the year, and to be held to account on this.

Some integrated care systems went into the pandemic with deficits of more than £100m, and will likely struggle to reach a balanced position.

But draft guidance circulated to local leaders in recent months by NHS England says: “NHS England and NHS Improvement intend to use additional powers in the legislation to set a financial objective for each integrated care board [the local commissioning body] and its partner trusts to deliver a financially balanced system, namely a duty on break even.”

However, it is unclear what the consequences will be for an ICS that fails to meet what is described as a “new joint legal duty”.

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Source: HSJ, 31 March 2022

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Shrewsbury maternity scandal: Sajid Javid’s statement to the Commons

Sajid Javid has issued an apology for the maternity service failings reported at Shrewsbury and Telford Hospital NHS Trust.

The health secretary spoke in the Commons on Wednesday after an independent inquiry into the UK’s biggest maternity scandal found that 201 babies and nine mothers could have - or would have - survived if the NHS trust had provided better care.

Speaking in the Commons, the health secretary said Donna Ockenden - a maternity expert who led the report - told him about “basic oversights” at “every level of patient care” at the trust.

He said the report “has given a voice at last to those families who were ignored and so grievously wronged”.

Javid said the report painted a tragic and harrowing picture of repeated failures in care over two decades which led to unimaginable trauma for so many people.

Rather than moments of joy and happiness for these families their experience of maternity care was one of tragedy and distress and the effects of these failures were felt across families, communities and generations.

The cases in this report are stark and deeply upsetting.

Mr Javid offered reassurances that the individuals who are responsible for the “serious and repeated failures” will be held to account.

Read full story and Sajid Javid's statement

Source: The Independent, 30 March 2022

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‘Ideologically driven’ NHSE maternity model causing national tension

A policy ‘at the heart’ of NHS England’s efforts to improve maternity care is under question after being sharply criticised by an independent inquiry, and is the subject of major tensions within NHSE and midwifery, HSJ understands.

The Ockenden report into major care failings at Shrewsbury and Telford Hospital Trust included 15 “immediate actions” for all maternity services in England, which government has accepted and said it would begin implementation.

However, one of these relates to the “continuity of carer” model, which NHS England has championed since 2017, when it was described as “at the heart of” its national plans for improving maternity care and outcomes.

The model intends to give women “dedicated support” from the same midwifery team throughout their pregnancy, with claimed benefits including improved outcomes, with a particular focus on some minority groups.

However, Ms Ockenden indicated its implementation in recent years had stretched staffing, and therefore harmed quality and safety overall, and also appeared to question whether the model was evidenced.

Some midwifery leaders are advocates for the model, but others have described how it can result in awful working patterns, with concerns it is causing some staff to leave the profession.

Royal College of Midwives director for professional midwifery Mary Ross-Davie told HSJ: “With the right resources and the right number of midwives, CoC can have a positive impact on maternity care – but in too many trusts and boards this is simply not the situation. We are really pleased, therefore, to see that the review team has echoed the RCM’s recommendations around the suspension of continuity of carer where too few staff puts safe deployment at risk.”

She said the model was “something to which many maternity services aspire, particularly for women who need enhanced monitoring throughout their pregnancy to deliver better outcomes for them and their baby”.

Helen Hughes, chief executive of Patient Safety Learning charity, said that although it had heard positive feedback that the model can improve outcomes, there must also be a “robust assessment of the safety impact of implementing such changes and the sources and staffing in place to deliver this”.

“Otherwise the core intentions and benefits will be lost,” Ms Hughes said.

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Source: HSJ, 31 March 2022

Further reading

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The NHS’s multimillion-pound blunders laid bare in new report

The reasons behind the most catastrophic blunders in emergency departments have been laid bare in a NHS Resolution report highlighting some of the biggest pay outs for NHS A&E errors.

NHS Resolution conducted a deep dive into compensation claims concerning emergency departments in England, including 16 cases which saw more than £1 million handed out after life-changing or deadly errors.

The average “high-value claim” was £2,069,029, with many of them related to spinal cord injuries which, left undetected, can have a life-long impact on patients.

The report detailed the case of a woman who suffered permanent neurological damage and now has bladder, bowel and sexual dysfunction symptoms, as well as loss of mobility, after a spinal condition was misdiagnosed as sciatica.

The report also looked at 86 deaths which resulted in average pay outs of more than £45,000.

After reviewing 220 claims between 2014 and 2018, the authors highlighted a number of “common themes”, including:

  • diagnostic errors, including missing signs a patient was deteriorating
  • a failure to recognise the significance of repeat attendance at A&E
  • delays in care
  • problems with communication, including problems with different hospital departments talking to each other.

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Source: In Your Area News, 29 March 2022

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All patients with type 1 diabetes in England should be offered continuous glucose monitoring, says NICE

Everyone with type 1 diabetes in England should be offered some form of continuous glucose monitoring (CGM) technology to support their care, the National Institute for Health and Care Excellence (NICE) has recommended.

Updated draft guidelines published on 31 March recommend that all adults with type 1 diabetes should be offered a choice of either real time or intermittent (flash) CGM through a sensor attached to the skin as part of their ongoing NHS care.

NICE also recommends that all young people aged 4 years and over with type 1 diabetes should be offered real time CGM and that some people with type 2 diabetes who use insulin intensive therapy (4 or more injections a day) should have access to Flash.

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Source: BMJ, 31 March 2022

Read NICE guidelines here.

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Women and babies remain at risk of unsafe NHS care, experts warn

A shortage of more than 2,000 midwives means women and babies will remain at risk of unsafe care in the NHS despite an inquiry into the biggest maternity scandal in its history, health leaders have warned.

A landmark review of Shrewsbury and Telford hospital NHS trust, led by the maternity expert Donna Ockenden, will publish its final findings on Wednesday with significant implications for maternity care across the UK.

The inquiry, which has examined more than 1,800 cases over two decades, is expected to conclude that hundreds of babies died or were seriously disabled because of mistakes at the NHS trust, and call for changes.

But NHS and midwifery officials said they fear a growing shortage of NHS maternity staff means trusts may be unable to meet new standards set out in the report.

“I am deeply worried when senior staff are saying they cannot meet the recommendations in the Ockenden review which are vital to ensuring women and babies get the safest possible maternity care,” said Gill Walton, chief executive of the Royal College of Midwives (RCM).

The number of midwives has fallen to 26,901, according to NHS England figures published last month, from 27,272 a year ago. The RCM says the fall in numbers adds to an existing shortage of more than 2,000 staff.

Experts said the shortage was caused by the NHS struggling to attract new midwives while losing existing staff, who felt overworked and fed up at being spread too thinly across maternity wards.

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Source: The Guardian, 29 March 2022

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Two out of five NHS staff would not recommend their organisation as a place to work

NHS staff are significantly less likely to recommend their organisations as places to work or believe they employ enough people to deliver effective care, the service’s annual staff survey has revealed.

The 2021 survey results, published today, showed regression across a broad range of questions, including in areas such as motivation, morale, workload pressures and staff health.

One of the biggest drop-offs in survey scores related to the question asking whether there were enough staff in their organisation for respondents to do their job properly.

Only 27.2% of those surveyed said staffing was adequate, a fall of 11% points from the previous year (38.4%).

Only 59.4%nof staff said they would recommend their organisation as a place to work. This represented a 7% point decline from the previous year (66.8%). The rating had steadily improved since 2017 when it was at 59.7%.

While a decline was seen across all sectors, the steepest drop was found among ambulance trusts.

Ambulance trusts performing worse compared to other sectors appeared to be a recurring theme across the survey. 

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Source: 30 March 2022

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Baby deaths inquiry: Shrewsbury NHS trust condemned for ‘repeated failures’

A damning report into hundreds of baby deaths has condemned the trust at the centre of the biggest maternity scandal in the history of the NHS for blaming mothers while repeatedly ignoring its own catastrophic blunders for decades.

The independent inquiry into maternity practices at Shrewsbury and Telford hospital NHS trust uncovered hundreds of cases in which health officials failed to undertake serious incident investigations, while deaths were dismissed or not investigated appropriately. Instead, grieving families were denied access to reviews of their care and mothers were blamed when their babies died or suffered horrific injuries.

A combination of an obsession with natural births over caesarean sections coupled with a shocking lack of staff, training and oversight of maternity wards resulted in a toxic culture in which mothers and babies died needlessly for 20 years while “repeated failures” were ignored again and again.

Tragically, it meant some babies were stillborn, dying shortly after birth or being left severely brain damaged, while others suffered horrendous skull fractures or avoidable broken bones. Some babies developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries.

The report, led by the maternity expert Donna Ockenden, examined cases involving 1,486 families between 2000 and 2019, and reviewed 1,592 clinical incidents.

“Throughout our final report we have highlighted how failures in care were repeated from one incident to the next,” she said. “For example, ineffective monitoring of foetal growth and a culture of reluctance to perform caesarean sections resulted in many babies dying during birth or shortly after their birth.

“In many cases, mother and babies were left with lifelong conditions as a result of their care and treatment. The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the trust and a culture of not listening to the families involved.

“There was a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths. What is astounding is that for more than two decades these issues have not been challenged internally and the trust was not held to account by external bodies.

“This highlights that systemic change is needed locally, and nationally, to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding. Going forward, there can be no excuses.”

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Source: The Guardian, 30 March 2022

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Children’s services rated ‘inadequate’ as trust remains ‘outstanding’

The children’s inpatient unit at an ‘outstanding’ mental health trust has been downgraded to ‘inadequate’ by the Care Quality Commission (CQC), amid a surge in demand for its services.

The CQC previously rated child and adolescent mental health wards at Hertfordshire Partnership University Foundation Trust as “outstanding” in May 2019.

But after an inspection in November and December 2021, these services were downgraded to “inadequate” overall and for the key categories of safety and leadership.

Although inspecting a core service, the CQC said its visit was “not wide-ranging enough” to update overall trust ratings, so HPFT remains “outstanding” overall.

Teenagers aged from 13 to 18 and admitted to Forest House, a 16-bed unit in Radlett providing HPFT’s only inpatient service for children and adolescents, told CQC inspectors they felt “unsafe”, dissatisfied with their care, and had experienced bullying by fellow patients.

Leadership in the service had “significantly deteriorated” since previous inspections, CQC chiefs wrote in a report published today, and this was having a “knock-on effect in all areas of care being provided”.

Staff morale was low and access to clinical psychologists limited, with a reduced ability to provide therapeutic interventions, inspectors added.

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Source: HSJ, 30 March 2022

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