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A trust and the NHS’ staffing agency have launched an investigation after a coroner found two nurses and a healthcare assistant may have lied about carrying out patient observations.
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Source: HSJ, 4 October 2019
Mental health patients are at risk of suicide because so many of the units they are treated in are dangerously decrepit, say NHS chiefs.
Crumbling old buildings are unsafe as they offer opportunities for mentally vulnerable people with conditions such as depression and schizophrenia to try to hang themselves or fall from a height, according to mental health trusts in England.
New figures show that patient safety incidents in mental health units caused by problems with staffing, facilities or the enviroment in which people are treated have risen by 8%. In all, 19,088 such incidents occurred in 2018-19 compared with 17,693 the year before.
In a stark warning, NHS Providers, which represents health trusts, categorises the risk to patient safety from “infrastructure failures in mental health trusts” as severe. “Continued under-prioritisation of the mental health estate is having a real impact on patients,” it says. “Mental health trusts continue to be neglected despite clear evidence that critical improvements are required. Mental health trust leaders are increasingly concerned that the lack of investment places their patients at increased risk.”
Source: The Guardian, 6 October 2019
Last week two nurses lost their lives while driving home from work.
Kerrie Browne, a 26-year-old nurse working at University Hospital Kerry in Tralee, died in a road traffic collision Wednesday morning. It is understood she was on her way home after finishing her night shift when the accident occurred on the N21 at Meenleitrim, Castleisland.
The news comes only hours after the death of another young nurse, Laurie Jones, from Wales.
Tributes to both the young nurses have filled social media alongside calls for health services to take urgent action to ensure there are no more deaths. One registered nurse said; “Sometimes I am so tired I don’t remember how I get home”.
Source: Nursing Notes, 3 October 2019
A Scottish mum has made an emotional plea to other parents to push for blood tests for their children if they feel ‘something isn’t right’ after her son’s leukaemia symptoms were dismissed numerous times by doctors.
Jayke Steel, aged 5 years, was diagnosed with acute lymphoblastic leukaemia (cancer of the blood) in February after months of being ill.
His mum Cara took him to the doctor on various occasions but time and time again she was told he was fine and it was “probably just a virus”.
When he started getting night sweats, instead of the doctor Cara him to Forth Valley Hospital where they ran tests and said they believed he was suffering from leukaemia.
“He was then transferred to Glasgow’s Queen Elizabeth Hospital where they immediately took a bone marrow test which showed he definitely had leuklaemia."
Source: The Scotsman, 15 September 2019
Dozens of residents and staff at a care home have been diagnosed with the latent form of tuberculosis (TB) after a nurse was found to have the disease.
Tests are being carried out at The Grange in Gloucestershire to see if any of the people diagnosed have developed the active form of the infection.
Public Health England (PHE) said the nurse had since been treated and was no longer infectious.
Source: BBC news, 3 October 2019
An NHS cancer hospital has such crumbling buildings, out-of-date equipment and staffing problems that patients’ safety and quality of care are at risk, a report for health service bosses has warned.
Patients at the Mount Vernon Cancer Centre who are acutely unwell or dying are receiving substandard care because it lacks the medical expertise and facilities needed to manage them properly, and its services need to be moved, an inquiry has found.
The group of experts who undertook the urgent review on behalf of NHS bosses have concluded that Mount Vernon has been neglected for so long that it can no longer operate safely as an important regional centre of cancer care, is unviable and as a result its services need to be moved and rebuilt from scratch elsewhere.
“Maintaining safety of patients cannot be guaranteed in the near future. Status quo is not an option. There is a need for urgent action. Current estate is not fit for purpose, particularly ward buildings for acutely unwell and end of life inpatients,” the report says.
Source: The Guardian, 3 October 2019
The leader of the emergency medicine profession has issued a fresh warning about its doctors cutting their hours due to new pension tax rules as demand surges through winter.
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Source: HSJ, 4 October 2019
“Little progress” has been made improving patient safety in the NHS over the past 20 years, said the Chief Inspector of Hospitals at the Care Quality Commission (CQC).
Professor Ted Baker yesterday revealed he receives between 500 and 600 reports of “never events” a year, incidents that are wholly preventable whatever the circumstances.
This includes an occasion where surgeons operated on the wrong eye of a patient.
Speaking at Patient Safety Learning's annual conference, he said that hospital managers routinely hide evidence from the CQC, because they regard the organisation as out to blame them.
The chief inspector called for a fundamental change in culture whereby NHS bosses drove safety improvements for their own sake, rather than in order to pass an inspection.
Source: The Telegraph, 2 October 2019
New rules will mandate trusts to supply references when NHS directors are given a new job, in a bid to stop the so-called “revolving door” for those who have failed.
Officials at the Department of Health and Social Care are working on the proposal, originally made by Tom Kark QC in his report to the department, published in February, on the fit and proper person test regulations.
Speaking at Patient Safety Learning's Annual Conference in London yesterday, Mr Kark, said he had been informed earlier this week that government had now accepted his recommendation for mandatory references.
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Source: HSJ 2 September 2019
Mental health charity, Mind, have found in their annual survey that people are being prescribed medication for mental health issues without being told of the side effects.
In response, the charity is calling for more mental health training to be made available for GPs.
Mind’s Big Mental Health Survey, asks people currently battling with mental health issues to disclose experiences of care and services they have received. More than 12,000 participants found that, when prescribed new medication, only 21% said that they were definitely given an explanation about the potential side effects. It showed that 50% of people didn’t receive enough information about the purpose of any new medication.
More than 40% of all doctors’ appointments are related to mental health, yet GPs receive no mandatory, practise-based training.
Mind wants GPS to have a wide range of training available to them, ensuring they have the confidence to provide quality support for those struggling with mental health.
Source: National Health Executive, 2 October 2019
The Healthcare Safety Investigation Branch (HSIB) have started a new national investigation looking into medication omission in mental health hospitals.
It was launched after they were notified by the parent of a young adult service user with a learning disability that he was regularly not offered prescribed medication whilst on a long-stay mental health ward.
The investigation will focus on information transfer within the prescribing and administration of medication in mental health hospitals to reduce omissions.
Follow the progress on the medication omission in mental health hospitals investigation page.
Source: HSIB, 30 September 2019
The Royal College of Psychiatrists has called for a full public inquiry to uncover what is "repeatedly going wrong" in mental health facilities in the North East of England. It follows a BBC Panorama documentary which appeared to show patients at Whorlton Hall being abused.
A worker at Darlington's Newbus Grange, which is also run by Cygnet Health Care, was also jailed for abuse.
The college said it had written to the secretary of state.
The Care Quality Commission (CQC) has been reviewing six facilities run by Cygnet in the North East.
Source: BBC News, 2 October 2019
Patients' lives are being put at risk at a short-staffed A&E department where a man died amid a series of failings, coroner has said.
John Shrosbree, 72, died a week after arriving "clearly unwell" at Milton Keynes Hospital, a report found. The seriousness of his illness was not recognised and he went into cardiac arrest, suffering brain damage, coroner Tom Osborne said.
Hospital bosses said they had made changes to increase staffing levels.
Mr Osborne, who oversaw the inquest into Mr Shrosbree's death, said it became clear during evidence that problems in the department were mainly the result of a lack of staff.
"I was told that staff shortages occur on a daily basis," he said. "I believe that as a result lives of the citizens of Milton Keynes are being put at risk and the problem should be addressed as a matter of urgency."
Source: BBC News, 3 October 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.
Today, we are proud to announce the official launch of the hub, our shared learning platform for patient safety.
We have been hard at work since launching the hub in beta in July, continuing to develop and improve the platform. Now, the hub is officially ready to be used by everyone committed to improving safety – patients and their families, clinicians, patient safety experts, and health and social care organisations.
the hub has been designed with clinicians, patient safety experts and patients following research by Carl Macrae, Professor of Organisational Behaviour and Psychology at Nottingham University Business School and a renowned specialist on patient safety.
the hub will be a crucial online repository for sharing different experiences and perspectives of what has worked well, as well as case studies, research papers, blogs, investigation reports, policy guidance and toolkits. It will provide a platform where people can ask questions, seek advice and share ideas to improve patient safety.
Registration and use of the hub are free.
Help us work towards the patient-safe future by joining the hub, sharing your learning and hearing valuable insight from others in health and social care.
Latest National Medical Examiner update on national and regional infrastructure, funding the medical examiner system, medical examiners and referrals to coroners, working with registrars, and face to face training.
Every year, mental health trusts spend millions of pounds employing lawyers to represent them at inquests, where they could be found to be at fault. The relatives of those who have died, however, often get no legal aid and have to stand up and face those lawyers alone. Becky Montacute describes her bid to ensure that the lessons from her mother's death were learned.
Source: BBC News, 1 October 2019
The NHS Long Term Plan included suggested changes to the law to help implement the Plan. In Spring, NHS staff, partner organisations and interested members of the public were invited to give their views on the proposals.
The NHS has published its response to the views it received during engagement and set out its recommendations to Government and Parliament for an NHS Bill. This Bill could help deliver improved patient care by removing barriers and promoting collaboration between NHS organisations and their partners.
Read the NHS’s recommendations to Government and Parliament for an NHS Bill
Source: NHS, 26 September 2019
The Healthcare Safety Investigation Branch (HSIB) latest report highlights that mislabelling of blood samples could pose a deadly risk to patients.
National data indicates there were 792 ‘wrong blood in tube’ near misses (where the error was spotted in time and no patient suffered harm) relating to blood transfusion samples, in 2018 across England.
The reference event in the report is a case where patient details became mixed up on blood samples sent from a maternity unit. In the case of mislabelling on blood transfusion samples, the impact could be devastating. There’s the potential for serious injuries and even death.
Dr Stephen Drage, HSIB Director of Investigations and ICU consultant, said: “Millions of blood tests are carried out across the NHS each year, from GP surgeries to large teaching hospitals. Most happen without incident but when it does go wrong it could represent a catastrophic outcome for patients, families and staff."
Source: HSIB, 26 September 2019
New laws will come into effect tomorrow requiring doctors to report deaths to a coroner for the first time in a bid to modernise the death reporting process in England and Wales.
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Source: HSJ, 30 September 2019
Dr Julia Patterson of campaign group EveryDoctor tells why she quit health service "cut back to its very bones".
“Doctors love their jobs, and most wouldn’t do anything else,” she said. “It’s our vocation to care for our patients. However, the level of stress endured by frontline NHS staff is unbelievable. Understaffing leaves doctors feeling isolated and stretched. There is often pressure to take on more patients, to work extra shifts, to stretch themselves thinner and thinner.”
New findings shared exclusively with the Observer by legal support service the Medical Protection Society (MPS) confirm the deep discontent in Britain’s medical profession. It has found that 52% of doctors working in the UK are dissatisfied with their work-life balance, 46% feel guilty about taking time off, and almost 40% believe their employer does not give them the support they need to do their job well.
Source: The Guardian, 29 September 2019
NHS Highland has revealed that it will have “clear milestones” prepared for its November board meeting as part of its action plan to deal with bullying within the organisation. That is according to Human Resources Director Fiona Hogg, on the long-awaited plan that was called for in an independent report by John Sturrock QC into bullying allegations.
The human resources department will soon share details of how the board will deal with the issue. Ms Hogg said: “Our plan from the November board meeting onwards is that it will contain an update on progress, but it will also include the revised action plan.
The move is likely to be welcomed by whistle-blowers and victims of bullying who have been calling for it for more than a year.
Source: Strathspey & Badenoch Herald, 26 September 2019
Plummeting learning disability student nurse numbers are leaving the specialty on the “verge of collapse”, it was warned today. Fears about the future of learning disability nursing were raised during the second annual Nursing Times Workforce Summit last week.
Professor Mark Radford, Deputy Chief Nursing Officer for England and soon-to-be Chief Nurse at Health Education England, revealed that only around 260 learning disability nurses were expected to graduate this year – almost half the figure from previous years.
NHS Employers Chief Executive Danny Mortimer also outlined his fears about the learning disability nurse workforce during the panel discussion. He said: “The biggest areas of risk in nursing right now are mental health and learning disability nursing. Learning disability nursing in particular is on the verge of collapse educationally and we have do some urgent things to redress that balance.”
Source: Nursing Times, 25 September 2019
NHS hospitals are going back to the future to help patients with dementia by decorating their wards, rooms and corridors in 1940s and 1950s style – creating a calming, familiar environment which can help jog memories, reduce anxiety and distress.
With ageing well and caring for people with dementia both key priorities in the NHS Long Term Plan, hospitals across the country have revamped their dementia ward decor, with innovations ranging from a ‘memories pub’ to 1950s style ‘reminiscence rooms’ and even a cinema booth where patients can watch old films.
Welcoming the innovations, Alistair Burns, National Clinical Director for Dementia and Older People’s Mental Health for NHS England and NHS Improvement said: “Hospital can be a frightening place for many people but can prove a bigger challenge for people with dementia who might feel more confused and agitated in an unfamiliar environment. Having a dementia-friendly place to stay may help these patients adjust better to their surroundings, lessen the likelihood of falls and reduce their reliance on medicine."
Source: NHS England, 24 September 2019
An independent review has been ordered into a hospital trust’s urology unit after patient safety concerns were put to an employment tribunal.
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Source: HSJ, 27 September 2019