Winners of the Patient Safety Learning Awards 2019
The Patient Safety Learning award winners have been announced today at our annual conference.
You can see the winning entries and read more about their projects here.
The Patient Safety Learning award winners have been announced today at our annual conference.
You can see the winning entries and read more about their projects here.
Becton Dickinson (BD), which manufactures most of the blood tubes used by the NHS, has alerted NHS England and NHS Improvement (NHSE/I) to a global shortage of some of its products, including two types of blood tubes: those with a yellow or purple top.
BD says that the COVID-19 pandemic created the most unpredictable demand it has seen in the past 70 years. The company says that it has also been difficult for customers to predict the types and quantities of blood tubes they will be using from month to month, which affects manufacturers’ abilities to meet demand. “Adding to the issue are global transportation delays that have resulted in more products being tied up in transportation than is normal, creating additional delays in deliveries,” BD said in a statement. “Raw material suppliers are also challenged to keep up with demand for materials and components.”
In the UK, BD has been authorised to import blood tubes that are approved for use in other regions of the world, including the United States. It plans to deliver nine million of these additional blood tubes to the NHS for immediate distribution.
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Source: BMJ, 3 September 2021
Miscarriage may be associated with an increased risk of early death, researchers have said.
The BMJ published a study suggesting that this risk is particularly acute for those who have experienced repeated miscarriages, especially ones that occurred early on in a woman’s life.
US-based researchers said that women who had experienced a miscarriage were 19% more likely to die prematurely. They pointed out that a miscarriage “could be an early marker of future health risk in women.”
The authors of the paper hoped to see if there was any link between miscarriage and a risk of death before the age of 70. Data used was taken from 101,681 women as part of the Nurses’ Health Study in the US. This was made up of female nurses aged between 25 and 42 years.
The researchers followed the women for 24 years and said that 2,936 premature deaths were recorded, this included 1,346 from cancer and 269 from cardiovascular disease.
It appeared that death rates from all causes were comparable both for women with and without a history of miscarriage. However, rates were higher for women who had experienced three or more miscarriages as well as for women who had their first miscarriage under the age of 24.
The study found that the association between miscarriage, or “spontaneous abortion,” and premature death was strongest for deaths from cardiovascular disease.
Source: The Independent, 25 March 2021
An acute trust’s record of eight never events in the last six months has raised concerns that quality standards have slipped since it was taken out of special measures.
The never events occurred at Royal Cornwall Hospitals Trust. They included three wrong site surgeries within the same speciality and an extremely rare incident in which a 30cm (15 inch) wire was left in a cardiology patient.
Kate Shields, chief executive of the trust, said the incidents have led to a “great deal of soul searching”.
Prior to the incidents the trust had gone 13 months without recording a never event, and Ms Shield acknowledged that pressure created by the pandemic was likely to have been a contributing factor behind the cluster of never events.
She stressed that none of the patients affected had suffered physical harm.
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Source: HSJ, 12 November 2020
The number of notified “extreme” and “major” incidents involving serious harm to patients and others in hospital has risen significantly in the Republic of Ireland in recent years, new figures reveal.
Reported “extreme” incidents, which can involve death or permanent incapacity, rose from 373 in 2017 to 579 last year.
The number of cases classified as “major”, where there is long-term disability or incapacity, climbed from 46 to 82 in the same period.
“Moderate” incidents, when there is a patient injury involving medical treatment, also increased from 9,219 in 2017 to 13,563 last year.
Minor incidents, involving injury or illness needing first aid, also increased over the same time from 9,210 to 15,483.
The figures, involving patients, staff, visitors, contractors and the public, were released by the HSE in response to a parliamentary question from Aontú leader Peadar Tóibín.
A spokewoman for the HSE said: “It is HSE policy that all incidents are identified, reported and reviewed so that learning from events can be shared to improve the quality and safety of services.”
“The number of reported incidents has increased year on year since 2004 with a significant increase noted since 2015, with the introduction of the National Incident Management System.”
Source: Independent.ie, 3 May 2022
Patients on weight-loss jabs and diabetes injections should be aware there is a small risk of developing severe acute pancreatitis, the UK medicines regulator has said.
About 1.6 million adults in England, Wales and Scotland used GLP-1 medication, such as semaglutide (Wegovy, Ozempic) and tirzepatide (Mounjaro), between early 2024 and early 2025 to lose weight, according to recent research.
Patient information leaflets for Wegovy, Ozempic and Mounjaro list pancreatitis as an “uncommon” reaction, affecting about one in 100 patients.
Acute pancreatitis occurs when the pancreas, a gland located behind the stomach that aids in digestion, becomes suddenly inflamed. Symptoms include severe pain in the abdomen, nausea and fever, with patients often ending up in hospital.
While acknowledging that pancreatitis is rare, on Thursday the Medicines and Healthcare products Regulatory Agency (MHRA) updated its guidance, after an increase in reports of acute pancreatitis to the agency’s yellow card scheme, which monitors any adverse reactions to medications and medical devices in the UK.
Source: The Guardian, 29 January 2026
Greater NHS support is needed for people chronically ill for months with COVID-19 symptoms, experts have told BBC Radio 4's File on 4.
The Royal College of GPs is calling for a national network of "post-Covid" clinics to help such people. But less than 12% of 86 NHS care commissioning groups asked by the BBC said they were running such services.
NHS England said it was "rapidly expanding new and strengthened rehab centres".
Tim Spector, professor of genetic epidemiology at King's College London and leader of the Covid Symptom Study app, said around 300,000 people in the UK have reported symptoms lasting for more than a month - so called "long Covid".
He added that data from the app showed around 60,000 people have been ill for more than three months. However, many of these people may not have been tested for Covid.
The government moved away from community testing on 12 March, instead only testing those admitted to hospital. That meant people who recovered from suspected coronavirus at home were unable to access tests.
Elly MacDonald, 37, from Surbiton, was training for the London Marathon when she first developed what she believes were Covid symptoms on 21 March. More than five months on, she still suffers from breathlessness and extreme fatigue, but has not received a positive test result - because community testing was re-introduced too late for it to detect her illness.
She changed her GP practice after initially feeling she was not being helped. Elly said: "Just knowing that I actually have people who are taking me seriously - that's been very important for my recovery. I just want my life back."
Source: BBC News, 8 September 2020
One hundred people with learning disabilities and autism in England have been held in specialist hospitals for at least 20 years, the BBC has learned.
The finding was made during an investigation into the case of an autistic man detained since 2001. Tony Hickmott's parents are fighting to get him housed in the community near them.
Mr Hickmott's case is being heard at the Court of Protection - which makes decisions on financial or welfare matters for people who "lack mental capacity".
Senior Judge Carolyn Hilder has described "egregious" delays and "glacial" progress in finding him the right care package which would enable him to live in the community. He lives in a secure Assessment and Treatment Unit (ATU) - designed to be a short-term safe space used in a crisis. It is a two-hours' drive from his family.
This week, Judge Hilder lifted the anonymity order on Mr Hickmott's case - ruling it was in the public interest to let details be reported. She said he had been "detained for so long" partly down to a "lack of resources".
Like many young autistic people with a learning disability, Mr Hickmott struggled as he grew into an adult. In 2001, he was sectioned under the Mental Health Act. He is now 44.
In addition to the 100 patients, including Mr Hickmott, who have been held for more than 20 years - there are currently nearly 2,000 other people with learning difficulties and/or autism detained in specialist hospitals across England.
In 2015, the Government promised "homes not hospitals" when it launched its Transforming Care programme in the wake of the abuse and neglect scandal uncovered by the BBC at Winterbourne View specialist hospital near Bristol. But data shows the programme has had minimal impact.
Source: BBC News, 24 November 2021
The controversial ‘SIM’ mental healthcare model sometimes ‘blurred’ the role of police with healthcare staff, according to results of local reviews seen by HSJ.
Following a whirlwind of concerns last summer, national clinical director Professor Tim Kendall wrote to mental health trust medical directors urging them to review use of the controversial Serenity Integrated Mentoring (SIM) programme.
Pressure to investigate the model, which has been used by at least 22 NHS trusts in recent years, came from patient groups and clinicians alike.
One year on and results of local reviews, obtained under the Freedom of Information Act, have revealed a varying picture of SIM’s use across English mental health trusts.
Professor Kendall’s letters, seen by HSJ, asked trusts to investigate five key areas of concern. These included: a lack of patient reported outcomes; adherence to National Institute for Health and Care Excellence guidelines on self-harm and personality disorders; the principle of police involvement in case management; the legal basis for sharing patient records; and human rights/equalities implications.
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Source: HSJ, 7 July 2022
An ambulance service could be put in special measures after a damning report criticised poor leadership for fostering bullying and not acting decisively on allegations of predatory sexual behaviour towards patients.
East of England Ambulance Service Trust failed to protect patients and staff from sexual abuse, inappropriate behaviour and harassment, the Care Quality Commission said.
It failed to support the mental health and wellbeing of staff, with high levels of bullying and harassment. Staff who raised concerns were not treated with respect and some senior leaders adopted a “combative and defensive approach” which stopped staff speaking out.
“The leadership, governance and culture still did not support delivery of high-quality care,” the CQC said.
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Source: HSJ, 30 September 2020
Expectant mothers are being warned about potentially confusing guidance on consuming caffeine while pregnant, as research suggests energy drinks could have potentially deadly consequences for their babies.
A new report by Tommy’s Maternal and Fetal Health Research Centre claims to have established a 27 per cent rise in the risk of stillbirth for each 100mg of caffeine consumed.
Researchers compared stillbirths to ongoing pregnancies among 1,000 women across 41 hospitals from 2014 to 2016 as well as interviewing women about their consumption of caffeinated drinks. They adjusted for demographic and behavioural factors, such as age and alcohol consumption, to determine whether stillbirth was linked to caffeine.
One in 20 women were found to have increased their caffeine intake while pregnant in spite of evidence some caffeinated drinks put babies lives at risk. However, experts say that calculating precise intake can be difficult, and guidance on limiting caffeine is not consistent
The NHS recommends pregnant women keep their daily caffeine intake below 200mg whereas the World Health Organization stipulates 300mg as the safe amount to consume.
Tommy’s, a leading baby charity, called for both the NHS and the World Health Organisation to rethink such guidelines, but refused to outline a specific limit - saying it was the NHS and World Health Organisation’s responsibility to decide the recommendations in light of their new study.
Professor Alexander Heazell, an author of the study, said: “Caffeine has been in our diets for a long time, and, as with many things we like to eat and drink, large amounts can be harmful – especially during pregnancy. It’s a relatively small risk, so people shouldn’t be worried about the occasional cup of coffee, but it’s a risk this research suggests many aren’t aware of."
Source: The Independent, 18 November 2020
Health officials say they are now investigating unexplained cases of hepatitis in children in four European countries and the US.
Cases of hepatitis, or liver inflammation, have been reported in Denmark, Ireland, the Netherlands, Spain and the US, health officials say.
Last week UK health authorities said they had detected higher than usual cases of the infection among children. The cause of the infections is not yet known.
The European Centre for Disease Control (ECDC) did not specify how many cases have been found in the four European countries in total.
But the World Health Organization (WHO) said less than five had been found in Ireland, and three had been found in Spain. It added that the detection of more cases in the coming days was likely.
Investigations into the cause of the infections are ongoing in all of the European countries where cases have been reported, said the ECDC.
In the US, Alabama's public health department said nine cases have been found in children aged one to six years old, with two needing liver transplants.
Investigations into similar cases in other states are taking place, it added.
Source: BBC News, 20 April 2022
New league tables rating the performance of NHS trusts in England have been published for the first time, external, with specialist hospitals taking the top slots.
Number one is Moorfields Eye Hospital NHS Foundation Trust, followed by the Royal National Orthopaedic Hospital NHS Trust and cancer centre the Christie NHS Foundation Trust.
At the bottom is Queen Elizabeth Hospital in King's Lynn, which has had major problems with its buildings because of structural weaknesses and the need for props to hold up ceilings.
Health Secretary Wes Streeting said the tables would help inform the public and allow them to exercise choice - but trusts have questioned whether they were using the right metrics.
The rankings score NHS trusts on seven different areas including waiting times for operations, cancer treatment, time spent in A&E and ambulance response times.
Their finances are also assessed, and it is possible that a hospital rated highly for clinical care will be marked down if they are running up a larger than expected deficit.
They are then sorted into four categories, the first of which reflecting the best performers and the last listing the worst.
The public will be able to use the league tables check the performance of their local hospital, ambulance service or mental health trust.
Source: BBC News, 9 September 2025
UK plastic surgeons have released new guidelines to try to make Brazilian Butt Lift (BBL) procedures safer for people who desire a bigger bottom.
Some women have died from the operation, which involves sucking out fat from elsewhere - such as the belly - and injecting it into butt cheeks.
The British Association of Plastic Surgeons (BAAPS) says the injections should not go very deep to help avoid complications such as dangerous clots.
According to the NHS, it has the highest death rate of all cosmetic procedures, and the risk of death from BBL surgery is at least 10 times higher than many other procedures.
A major concern is that the injected fat can cause a blockage in a blood vessel in the lungs - called a pulmonary embolism - which can be fatal.
This happened to Leah Cambridge, a beautician and mother of three from Leeds.
She suffered a massive pulmonary embolism during the operation at a private hospital in Turkey in 2018, a coroner found.
BAAPS president Marc Pacifico told the BBC: "Unfortunately we don't know how many people have been going for these risky BBL procedures. We have been recommending against it for a number of years after seeing quite a frightening death rate associated with it. But people have been going abroad to get it done."
"Make sure you ask if the surgeon will be using ultrasound for gluteal fat grafting. We are recommending that surgeons should only perform this with real time ultrasound guidance as the only way to ensure the procedure is performed superficially and safely."
Source: BBC News, 10 October 2022
Trusts must start submitting full data on surgeries which include a high-risk medical device into a new national registry by December as part of a national push to increase accountability and safety around surgery.
NHS England is launching the new mandatory medical device outcome registry this month. The new registry was created in response to Baroness Cumberlege’s “First Do No Harm” review and initial data submissions about surgeries that include a high-risk medical device will begin in June.
Details of the launch arrangements have been set out in a draft letter which HSJ has seen and understands is set to be sent to medical directors and other system leaders imminently.
Relevant procedures include those, for example, involving either a Class III device, like an implant, or a Class IIb therapeutic device, such as drug-eluting balloon catheter.
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Source: HSJ, 16 May 2023
GP practices are being told they must make sure patients can be seen face to face when they need such appointments.
NHS England is writing to all practices to make sure they are communicating the fact doctors can be seen in person if necessary, as well as virtually. It's estimated half of the 102 million appointments from March to July were by video or phone call, NHS Digital said.
However, the Royal College of GPs said any implication GPs had not been doing their job properly was "an insult".
NHS England said research suggested nearly two thirds of the public were happy to have a phone or video call with their doctor - but that, ahead of winter, they wanted to make sure people knew they could see their GP if needed. Nikki Kanani, medical director of primary care for NHS England, said GPs had adapted quickly in recent months to offer remote consultations and "safe face-to-face care when needed".
Prof Martin Marshall, chair of the Royal College of GPs, said general practice was "open and has been throughout the pandemic", with a predominantly remote service to help stop the spread of coronavirus.
He said: "The college does not want to see general practice become a totally, or even mostly, remote service post-pandemic. However, we are still in the middle of a pandemic. We need to consider infection control and limit footfall in GP surgeries - all in line with NHS England's current guidance."
He said most patients had understood the changes and that clinical commissioning groups had been asked to work with GP practices where face-to-face appointments were not possible - for example, if all GPs were at a high risk from coronavirus.
"Any implication that they have not been doing their job properly is an insult to GPs and their teams who have worked throughout the pandemic, continued delivering the vast majority of patient care in the NHS and face an incredibly difficult winter ahead," he said.
Source: BBC News, 14 September 2020
Research from the college indicated that routine GP appointments were back to near-normal levels for this time of year, after decreasing at the height of the pandemic.
"Each and every day last week an estimated third of a million appointments were delivered face to face by general practices across the country," added Prof Marshall.
Fears that their data would be shared with the Home Office following the Windrush scandal left some people from ethnic minorities afraid to access cancer services during the pandemic, an NHS England document has revealed.
The paper from the West Midlands Cancer Alliance said there was a “perception” the government was “accelerating immigration removals” and that, as a result, “individuals (particularly those affected by the Windrush scandal) are then fearful of accessing cancer treatment and may not participate in screening programmes for fear their information will be inappropriately shared with the Home Office”.
The news comes after figures released last week showed the fall-off in referral and treatment of Black-British patients for cancer during the early stages of the pandemic was sharper than for their White-British counterparts.
Referrals and first treatments for cancer dipped across the board in April last year.
However, by July, White patients were receiving 77 per cent of the treatment volumes they had done 12 months before. The figure for Black patients was 67 per cent. This 10 percentage point difference continued in August and September, as treatment volumes for White-British patients recovered to 83 and 91 per cent respectively. Parity was achieved from October to December 2020, the latest period for which data is available.
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Source: HSJ, 22 April 2021
Regulators have raised serious concerns over trainee doctors within the maternity department at one of the largest trusts in the country.
The NHS’ training regulator said it had concerns over the treatment of trainee doctors within the obstetric and gynaecology department at University Hospitals Birmingham Foundation Trust, while some medics report being in ‘meltdown’.
Reviewers raised an incident where a consultant had refused to respond to an obstetric emergency in A&E which had been requested by a junior doctor.
“The panel unanimously agreed that Consultant presence was required without delay,” the report added.
The latest review follows concerns in November 2020 and June 2021 when patient safety issues were also identified.
It warned there was a “real risk” trainees would soon become “hesitant and reluctant” to call for consultant support when need.
Source: The Independent, 5 June 2022
A young woman died following “gross failings” and “neglect” by a mental health hospital in Essex which is also facing a major independent inquiry into patient deaths.
Bethany Lilley, 28, died on 16 January whilst she was an inpatient at Basildon Mental Health unit, run by Essex Partnership University Hospitals.
The inquest examined the circumstances of her death this week and concluded that her death was contributed by neglect due to a “plethora of failings by Essex University Partnership Trust”.
Following the three week inquest, heard before coroner Sean Horstead, a jury found “neglect” contributed to Ms Lilley’s death and identified “gross failures” on behalf of the trust.
The jury identified a number of failings in her care including evidence that cocaine had made its way onto a ward where she was an inpatient.
There was evidence of “very considerable problems in the record-keeping at EPUT psychiatric units.”
It was also concluded staff failed to carry out a risk assessment of Ms Lilley in the days leading up to her death, and failed to carry out observations.
Ms Lilley’s death is one of a series of patients who have died under the care of mental health services in Essex, which have been brought into the light following the campaigning of bereaved families.
Source: The Independent, 19 March 2022
The Joint Commission has unveiled an overhaul to its healthcare accreditation and certification process that will cut hundreds of requirements for hospitals, streamline patient safety practices and give stakeholders as well as the public a clearer look into what’s expected of an accredited facility.
Called “Accreditation 360: The New Standard,” the changes are described by the organization as “the most significant, comprehensive evolution of Joint Commission’s accreditation process since 1965.”
Headlining the effort is the removal of 714 standing requirements from the hospital accreditation programme, which builds upon the 2023 initiative to cut 400 other requirements. And, starting in July, the Joint Commission said it will have its standards available online for public access and search.
“Accreditation 360 directly responds to what this moment demands,” Joint Commission President and CEO Jonathan Perlin, M.D., Ph.D., said in the announcement. “Designed by a team of operationally experienced healthcare leaders, this new model removes standards whose time has passed, and we are introducing a suite of novel tools for benchmarking and performance support. Reducing burden helps busy clinicians and healthcare organizations focus on what matters most: delivering the safest, highest-quality and most compassionate healthcare possible.”
Source: Fierce Healthcare, 30 June 2025
Hundreds of thousands who survived the virus still have side-effects that range from loss of smell to chronic fatigue.
"It started with a mild sore throat. I was in Devon at the beginning of the lockdown, and because I hadn’t been on a cruise ship, gone skiing in Italy or partying with the crowds at Cheltenham races, I didn’t think it could be COVID-19. Then I developed sinusitis. My GP was practical: “This is not a symptom of the virus,” he emailed me. But my sense of smell had disappeared. At first this wasn’t a sign but six months later, I still can’t tell the difference between the smell of an overripe banana or lavender. I can distinguish petrol but not gas, dog mess but not roses, bacon but not freshly cut grass. Everything else smells of burnt condensed milk."
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Source: The Times, 23 September 2020
UK researchers have developed a new risk prediction tool that estimates a person’s chance of hospitalisation and death from COVID-19.
The algorithm, which was constructed using data from more than eight million people across England, uses key factors such as age, ethnicity and body mass index to help identify individuals in the UK at risk of developing severe illness.
It’s hoped that the risk prediction tool, known as QCOVID, will be used to support public health policy throughout the rest of the pandemic, in shaping decisions over shielding, treatment or vaccine prioritisation.
The research, published in The BMJ, was put together by a team of scientists across the UK, and has been praised for the depth and accuracy of its findings.
“This study presents robust risk prediction models that could be used to stratify risk in populations for public health purposes in the event of a ‘second wave’ of the pandemic and support shared management of risk,” the researchers say.
“We anticipate that the algorithms will be updated regularly as understanding of COVID-19 increases, as more data become available, as behaviour in the population changes, or in response to new policy interventions.”
Source: The Independent, 21 October 2020
Nurses in North Carolina, USA, can now be sued for patient harm that results from them following physicians' orders, the state Supreme Court ruled last month.
The 19 August ruling strikes down a 90-year-old precedent set by the 1932 case Byrd v. Marion General Hospital, which protected nurses from culpability for obeying and executing orders from a physician or surgeon, unless the order was obviously negligent.
The North Carolina Supreme Court overturned this ruling in a 3-2 opinion as part of a separate case involving a young child who experienced permanent anoxic brain damage during an ablation procedure at a North Carolina hospital in 2010. The ruling means the certified registered nurse anaesthetist involved in the ablation could be held liable for the patient's harm.
"Due to the evolution of the medical profession's recognition of the increased specialization and independence of nurses in the treatment of patients over the course of the ensuing ninety years since this Court's issuance of the Byrd opinion, we determine that it is timely and appropriate to overrule Byrd as it is applied to the facts of this case," Justice Michael Morgan wrote in the opinion.
Source: Becker's Hospital Review, 6 September 2022
A Scottish Government committee has found that the “profound failings” of IT systems are the biggest problem facing a medicine-prescribing service that does not sufficiently focus on patients.
A report from the members of Scottish Parliament on the Health and Sport Committee describes a medicines system “burdened by market forces, public sector administrative bureaucracy and under resourcing, inconsistent leadership and a lack of comprehensive, strategic thinking and imagination, allied to an almost complete absence of useable data”.
The committee particularly criticised the failure of the NHS to introduce appropriate IT systems.
“We are extremely disappointed that once again all roads lead to the dismal failure of the NHS in Scotland to implement comprehensive IT systems which maximise the use of patient data to provide a better service,” the report says.
Committee members are calling for an overhaul of the system to allow for collection and analysis of data that would ensure the best possible outcomes for patients and cost savings for the NHS.
MSPs found a “lack of care” to understand patients’ experience of taking medicines and a lack of follow up to ensure that medicines were effective or even being used.
Prescribers were “instinctively reaching for the prescription pad” and not taking the time to discuss medicines with patients, nor were the principals of realistic medicine, in which patients and clinicians share decision making about their care, being followed.
Source: Public Technology.net, 1 July 2020
Mental health sick days cost the NHS almost half a million pounds as staff anxiety and stress levels haved skyrocketed.
Costs have almost doubled compared to before the pandemic from £279 million to £468 million.
The sickness data shared with The Independent by GoodShape, an employee well-being and performance analysis company, shows the number of staff sick days increased in 2022 to 12 million from 7.21 million in 2019. That is despite the overall number of people working in the NHS increasing from 1.2 to 1.3 million.
The overall cost to the NHS of absences for the five most common reasons – which includes mental health – increased to a “staggering” £1.85 billion from £1.01 billion between 2019 to 2022, according to figures from GoodShape.
Covid was still the most common reason for staff sickness last year, according to the analysis, accounting for 4.4 million lost days, while mental health was a close second driving 3 million days off due to illness.
Pat Cullen, chief executive and general secretary for the Royal College of Nursing said in response: “These figures are shocking but not surprising. With 47,000 vacant nurse posts in England alone, the pressures on staff are unrelenting.
Source: The Independent, 8 February 2023
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