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NHS regulators have warned trusts to heed the learnings of an ombudsman report into the deaths of two patients, ahead of their own review into patient safety failings.
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Source: HSJ, 26 September 2019
A no-deal Brexit presents risks to the NHS and care homes despite extensive government planning, a watchdog says. The National Audit Office (NAO) praised the government for the "enormous amount of work" that had been done but said there were still "significant" gaps.
The extra shipping capacity government was buying to bring medicines into ports other than Dover may not be completely ready by 31 October.
And there was no clear evidence the care sector was ready, the NAO said. The government has arranged the stockpiling of supplies for the NHS. But for the care sector, which is fragmented in that it relies on 24,000 companies to provide services, no central arrangement has been made to stockpile equipment and supplies, such as syringes and needles, most of which come from or via the EU.
When it comes to medicines, however, the supply of which has been organised for both the NHS and care sectors, the report acknowledges the work that has been done.
Source: BBC News, 27 September 2019
If ever there were an industry that could reap the benefits of artificial intelligence (AI), it is healthcare. The adoption of this technology to actually make medicine better is obvious. However, with this adoption comes a slew of ethical issues. With AI, there is always a human consequence beyond the tech storyline.
Neil Raden suggests there are two storylines to consider: the usefulness of the application, and the ultimate effect, often unintended, on people.
Source: Diginomica, 19 September 2019
Staff failing to act on abnormal fetal heartbeats during labour was the most common contributing factor in cases where babies were born with brain damage and referred to NHS Resolution’s new early notification scheme, it has emerged.
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Source: HSJ, 26 September 2019
The Royal Pharmaceutical Society (RPS) in Scotland has called on the Scottish Government to give all pharmacists read and write access to patient records.
Chair of the RPS in Scotland, Jonathan Burton, said: “World Pharmacists Day is an opportunity to celebrate the vital role of pharmacists at the forefront of healthcare. Pharmacists across Scotland are already providing high-quality patient care, but the service could be even better if all pharmacists had access to the patient record."
Most community pharmacists do not have access to even basic information, despite performing an increasing role in providing NHS services both in and out of hours. Mr Burton continued: "It’s time the Scottish Government enabled all pharmacists to access patient health records so that, with patient consent and in appropriate circumstances, they have all the information they require to provide the safest and highest quality of care for patients in a timely and accessible manner.’’
Source: Royal Pharmaceutical Society, 25 September 2019
Today millions of pharmacists worldwide will celebrate World Pharmacists Day, this year themed “safe and effective medicines for all.”
The annual day is used to highlight the value of the pharmacy profession to stakeholders and to celebrate pharmacy globally. It was originally adopted in 2009 at the World Congress of Pharmacy and Pharmaceutical Sciences.
The theme for 2019 aims to promote pharmacists’ crucial role in safeguarding patient safety through improving medicines use and reducing medication errors.
“Pharmacists use their broad knowledge and unique expertise to ensure that people get the best from their medicines. We ensure access to medicines and their appropriate use, improve adherence, coordinate care transitions and so much more. Today, more than ever, pharmacists are charged with the responsibility to ensure that when a patient uses a medicine, it will not cause harm”, says International Pharmaceutical Federation (FIP) President Dominique Jordan.
Watch Dominique Jordan's video
Source: FIP, 25 September 2019
Inspectors have found 28 privately run mental health units to be “inadequate” in the past three years, prompting fears that vulnerable patients are receiving poor and unsafe care.
The disclosure of such widespread substandard care in mental health facilities run by non-NHS providers has prompted psychiatrists to call for a public inquiry to investigate.
Source: The Guardian, 25 September 2019
Serious failings have been found at an NHS trust which performed "unacceptably delayed" and unnecessary surgery on a bladder cancer patient.
Denis Harrison, 62, died in August 2017 after waiting six months for surgery at Warrington and Halton Hospitals NHS Foundation Trust. The Parliamentary and Health Service Ombudsman (PHSO) said the trust had "failed to act with any urgency".
Mr Harrison's wife said the couple faced "severe mental anguish" waiting.
The PHSO said it was not possible to know whether earlier surgery would have saved his life, but he "was not given the best possible chance of survival".
Source: BBC News, 25 September 2019
Planned Caesarean delivery can be the safest option for women who have had a Caesarean in the past, according to new research in PLoS Medicine. Attempting a vaginal birth was linked with a small but increased chance of complications for mother and baby compared with repeat Caesareans.
The findings come from more than 74,000 births in Scotland.
Experts say mums-to-be should be offered a choice of how to deliver – natural or Caesarean – when possible.
Source: BBC News, 25 September 2019
The Healthcare Safety Investigation Branch (HSIB) has started a national investigation looking into insulin prescribing and administration in hospitals.
It was launched after a patient was administered an overdose of concentrated insulin while under the care of an acute hospital.
The investigation will focus on factors which compromise safety when health professionals administer concentrated insulin through insulin pen devices.
Source: HSIB, 24 September 2019
"If we truly believe in a just culture for everyone and the benefits that can bring for patient safety, it has to give equal importance to being fair to patients and families as well as to staff, and inform practice and policy at every level," says James Titcombe, Peter Walsh and Cicely Cunningham in a recent commentary in HSJ.
Although there is much to celebrate in the increased focus on 'just culture' – not least that this has become accepted parlance within the NHS mainstream and more widely in the regulatory community – from the perspective of patients and families, the narrative to date can seem somewhat one sided.
From the perspective of those affected, the current system of variable quality local investigations, inquests, litigation, complaints and interactions with a host of other regulatory bodies and organisations can feel designed in such a way that ensures further harm is inevitable.
Source: HSJ, 17 September 2019
The shortage of nursing staff in England is putting patient safety at risk, the Royal College of Nursing (RCN) has warned, as it launched a new campaign to encourage the public to speak out about the impact of England’s 40,000 nurse shortage.
The RCN’s campaign calls for legislation to be brought forward in England to help address the nursing workforce crisis. Earlier this year, nurses and support workers in Scotland secured new legislation on safe staffing levels, and a nurse staffing law was introduced in Wales in 2016.
The 2013 Francis Report on failings of care at Stafford Hospital concluded that the main factor responsible was a significant shortage of nurses at the hospital. Nurse numbers at NHS acute Trusts across England then increased as managers took steps to try to prevent similar scandals in the future. But a new analysis by the RCN shows that for every one extra nurse NHS acute Trusts in England have managed to recruit in the five years since 2013/14, there were 157 extra admissions to hospital as emergencies or for planned treatment.
Commenting on the campaign launch, Dame Donna Kinnair, RCN Chief Executive and General Secretary, said: “Today we’re issuing a stark warning that patient safety is being endangered by nursing shortages. Staffing shortfalls are never simply numbers on a spreadsheet – they affect real patients in real communities."
Source: Ekklesia, 22 September 2019
Health Secretary Jeane Freeman announced the launch of a Joint Learning Fellowship programme between Ireland and Scotland, as the NHS in Scotland reels from one crisis to the next.
Ms Freeman and the Irish Health Minister, Simon Harris, announced the initiative, which will offer two three-month placements for Scottish and Irish senior policymakers or health service workers so they can learn more about what works in each system.
However, the move came on the same day The Times reported that Glasgow's 'super-hospital' was permitted to open despite the ventilation systems failing to meet the necessary safety standards.
Outbreaks of infection which are thought to have spread through the ventilation system at the Queen Elizabeth University Hospital (QEUH) have led to the deaths of two patients.
Source: The Scotsman, 20 September 2019
Teams that face rudeness experience a 12% drop in diagnostic and procedural performance.
University Hospital Southampton NHS Foundation Trust (UHS) has launched the “Reminder to be Kinder” project which was designed to recognise the importance of civility on patient care. The “Reminder to be Kinder” project encourages nurses and allied healthcare professions to be kinder to each other in order to improve patient safety.
Launched to coincide with World Patient Safety Day, the project will see the introduction of a range of action cards which include reminders to celebrate colleagues’ achievements, thank someone for their work and do something to make life easier for a colleague.
Juliet Pearce, Deputy Director of Nursing at UHS, said; “The way we interact with each other can have a surprising effect on patient safety,”
“People who witness rudeness show reduced performance and are 50% less likely to help others. If a patient was to see this happen, you could understand why they would feel anxious dealing with staff and have less trust in the organisation.”
Source: Nursing Notes, 19 September 2019
A 73-year-old woman died after the NHS 111 helpline failed to recognise her symptoms as a sign of sepsis, in the latest death linked to the Pathways system.
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Source: HSJ, 20 September 2019
The Chief Executive of NHS in England has called on all social media firms to crack down on potentially harmful material after two of the biggest sites confirm they plan to act on health service demands for action.
Facebook and Instagram have announced that they will remove posts promoting ‘miracle’ cures and get-slim-quick products, which are known to have limited benefits with possible damaging side-effects.
The move follows a series of requests from health service chiefs, including NHS Chief Executive Simon Stevens, to act responsibly and protect users from content that could cause physical or mental harm.
Source: NHS England, 19 September 2019
Over 6,500 nurses in hospitals around California, Arizona, Florida, and Illinois will strike today. The strike will mark the first ever nurse strike in Arizona, and the first hospital registered nurse strike in Florida's history.
Nurses who are part of the National Nurses United union are asking for better nurse retention and nurse-to-patient ratios.
"The strike is first and foremost about patient care and patient advocacy," Dominique Hamilton, a registered nurse at St. Mary's Hospital in Arizona, said. "We want the hospital to invest in the nursing staff, and we want to have more input into the recruitment and retainment of experienced [registered nurses]."
Source: Business Insider,
Developments in healthcare mean more women and babies are surviving than ever before, a new study has found.
The report, published by the World Health Organisation and the United Nations Children’s Fund (Unicef), found maternal deaths have decreased by more than a third since 2000. Deaths of children were found to have fallen by almost half in the same time period.
There was a 56% decrease in deaths of children younger than 15 since 1990 – from 14.2 million deaths to 6.2 million in 2018.
But the research still found a pregnant woman or a newborn baby dies every 11 seconds from causes that are predominantly preventable and avoidable – with 2.8 million estimated to die every year.
Source: The Independent, 19 September 2019
All safety alerts issued by national bodies are to be standardised under a single template in an effort to eradicate confusion and reduce the burden on NHS organisations.
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Source: HSJ, 19 September 2019
Following Boris Johnson's confrontation by an angry father at Whips Cross University Hospital yesterday, a doctor gives anonymous account of chronic understaffing and lack of resources at Whipps Cross.
"The hospital is held together only by the hard work and dedication of its healthcare workers but it cannot be sustained for much longer under these pressures."
"I’m so glad that Omar Salem said the things he did. He was just telling the truth about what it is like to be on the receiving end of poor staffing levels and under-resourcing."
"I’ve been thinking about it all day and felt I had to say something because NHS hospitals today can be unsafe places. Whipps Cross is particularly understaffed and under-resourced so people don’t get the care that they need as promptly as they need."
Source: The Guardian, 19 September 2019
A woman who died after waiting almost two hours for an ambulance was let down by "systemic" failings with a computer call-handling system, a coroner said.
Daisy Filby, 90, was one of three people who died after delays in receiving care from the South East Coast Ambulance Service (Secamb). Coroner Alan Craze said a human would have "realised what was going on" and prioritised the calls differently.
Mrs Filby, from Seaford, died in June 2017 as a result of an "accident contributed to by neglect," Mr Craze concluded at the Hasting's Coroner's Court inquest. "If an ambulance or anybody with or without medical knowledge had been able to reach this poor lady before her death, the situation would have been different," he added.
Mr Craze said: "The problem is not the actions of any one individual in Secamb Trust. The problem is ultimately systemic and at the heart of the call-taking and decision-making system."
A spokesman for the ambulance service said: "We are very sorry for the service they received. We have listened very closely to the coroner throughout and we are committed to making further improvements where necessary."
Source: BBC News, 18 September 2019
A public inquiry will be held to examine safety and wellbeing issues at the new children's hospital in Edinburgh and the Queen Elizabeth University Hospital in Glasgow. The inquiry will determine how vital issues relating to ventilation and other key building systems occurred. It will also look at how to avoid mistakes in future projects.
In January, it was confirmed two patients had died after contracting a fungal infection caused by pigeon droppings at the Queen Elizabeth University Hospital. Health Secretary Jeane Freeman later ordered a review of the design of the building and said there was an "absolute focus on patient safety".
Meanwhile, the new £150m Royal Hospital for Children and Young People in Edinburgh has been dogged by delays over health concerns. The hospital was supposed to open in 2017 - but will now not be ready until next autumn at the earliest - after problems with the specification of the ventilation system.
Scottish Labour's Monica Lennon said the inquiry was "the only way to get to the bottom of this outrageous series of errors". She added: "Children in Scotland are being let down because the hospitals they were promised are not fit for purpose. We have two hospitals built by the same contractor that are mired in controversy, and all the while patients are suffering. The public need to know the truth of what has gone so badly wrong at these two vital hospitals."
Source: BBC News, 17 September 2019
Prime Minister Boris Johnson has been confronted by an angry father at a hospital who told him his baby daughter had nearly died because the ward on which she was treated was “not safe for children” after years of austerity.
In an encounter caught on camera, Omar Salem said the care given to his seven-day-old daughter at Whipps Cross university hospital, in north-east London, was “not acceptable”. He told the prime minister: “There are not enough people on this ward, there are not enough doctors, there’s not enough nurses, it’s not well organised enough.”
Salem told Boris Johnson: “My daughter nearly died yesterday. And I came here, the A&E guys were great but we then came down to this ward here and it took two hours and that is just not acceptable. This ward is not safe for children."
Source: The Guardian, 18 Setpember 2019
The British Medical A has outlined its vision for an ‘unsafe’ NHS with a culture of bullying.
According to the BMA, doctors are working in hospitals and GP Practices that are hugely understaffed, where bullying and a culture of blame is the norm and where patient care is often unsafe. These are the findings of a year-long study – ‘Caring Supportive Collaborative: Doctors Vision for Change‘ – into the state of the NHS.
The chair of the BMA Council, Dr Chaand Nagpaul said: “Nine in 10 doctors tell us that staffing levels are inadequate and that they work in environments where they fear the toxic combination of ever-increasing demand for services and lack of staff capacity will lead to mistakes."
“They tell us there is a persistent culture of fear across the NHS, where blame stifles learning, contributing to the vicious cycle of low morale so staff leave and then there’s a problem of recruitment."
“This unsafe, underfunded environment is as damaging for patients as it is for doctors. Radical change is clearly needed.”
From the report comes a manifesto, which has today been sent to MPs, as well as the secretary of state for health and social care.
Source: Practice Business, 17 September 2019
NHS governors have called for a police investigation into the urology department of a health service trust following accusations that patients died and were harmed after a string of clinical errors and malpractice.
Morecambe Bay NHS Foundation Trust (UHMBT) has now agreed to an external review after dozens of patients, relatives and staff have came forward following the publication of a book by whistleblower surgeon Peter Duffy, which exposed poor care in the unit.
The call for a police investigation came at a meeting of the council of governors of the trust earlier this month. Governor Dave Welton told the meeting that the council had “very serious concerns about the shocking revelations.”
A former theatre nurse has also come forward claiming to have witnessed countless errors made by surgeons, while another healthcare worker said she was now speaking out to prevent further harm to patients.
Source: BBC News, 16 September 2019