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Baby boy died from sepsis after doctors’ delay giving antibiotics

A three-month-old boy died from sepsis after ‘gross failures’ by medics to give him antibiotics until it was too late, an inquest ruled. Lewys Crawford died a day after he was admitted to the University Hospital of Wales in Cardiff with a high temperature last March. Jurors at Pontypridd Coroner’s Court said the failure of doctors to treat his illness with antibiotics until seven hours after his arrival had ‘significantly contributed’ to his death. They found the little boy died from natural causes contributed to by neglect in his care.

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Source: The Metro, 15 February 2020

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More than 75% of NHS midwives think staffing levels unsafe, says RCM

More than three-quarters of midwives think staffing levels in their NHS trust or board are unsafe, according to a survey by the Royal College of Midwives (RCM).

The RCM said services were at breaking point, with 42% of midwives reporting that shifts were understaffed and a third saying there were “very significant gaps” in most shifts.

Midwives were under enormous pressure and had been “pushed to the edge” by the failure of successive governments to invest in maternity services, said Gill Walton, the chief executive of the RCM.

“Maternity staff are exhausted, they’re demoralised and some of them are looking for the door. For the safety of every pregnant woman and every baby, this cannot be allowed to continue,” she said.

“Midwives and maternity support workers come into the profession to provide safe, high-quality care. The legacy of underfunding and underinvestment is robbing them of that – and worse still, it’s putting those women and families at risk.”

RCM press release

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Source: The Guardian, 16 November 2020

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Safety watchdog says NHS ‘never event’ mistakes are not yet truly preventable

At least seven so-called NHS “never events” should be reclassified because the health service has failed to put in place effective measures to stop them from repeatedly happening, safety experts have said.

The independent Healthcare Safety Investigation Branch (HSIB) said NHS England should remove the never event incidents from the list of 15 it requires hospitals to report, because they are not “wholly preventable” and the NHS has not adequately recognised the systemic risks that mean they keep happening.

The errors include examples such as a 62-year-old man having the wrong hip replaced during surgery and a nine-year-old girl who was given a drug by injection that should have been given by mouth.

Other incidents included a woman who had a vaginal swab left inside her following the birth of her first child and a 26-year-old man who had a feeding tube accidentally inserted into his lung rather than his stomach.

In a new report, investigators from HSIB carried out a detailed analysis of seven incidents it has investigated which account for the majority of never events recorded by NHS hospitals in 2018-19.

NHS England claims there are steps hospitals can take that mean the errors should never happen but HSIB says many of the steps are administrative, such as a checklist, and do not fully take into account the environment staff work in, the nature of the errors or how they happen.

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Source: The Independent, 21 January 2021

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Hospital wrong to ban woman visiting partner on his deathbed

The partner of a dying man was denied the chance to be at his bedside during his final moments after a hospital wrongly banned her from daily visits, an ombudsman report has found.

Brian Boulton, 70, was admitted to Royal Gwent Hospital in Newport, South Wales, after suffering from a chest infection, which was later diagnosed as aspiration pneumonia caused by oesophageal cancer.

Celia Jones, his “long term life partner” of twenty years, was accused by hospital staff of giving the retired tailor a larger dose of the prescribed furosemide medication than was allowed. Ms Jones, 65, was restricted to one-hour visits twice a week, meaning she was unable to be with him when he died a day after her last authorised visit on Wednesday 27 September 2017.

The Public Services Ombudsman for Wales has upheld her complaints about her “appalling” treatment, ruling that the visiting restrictions were imposed “without warning” and resulted in a “significant injustice”.

It found no record of Ms Jones, a retired nurse, admitting to a senior ward manager that she gave the large dose of medicine to her partner.

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Source: The Telegraph, 6 January 2020

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Hernia mesh implants used 'with no clinical evidence'

"Too many" types of hernia mesh implants are being used on NHS patients with little or no clinical evidence, the BBC has been told.

New data shows more than 100 different types of mesh were purchased by NHS Trusts from 2012 to 2018 in England and Scotland, leading to fears over safety. The meshes can cut into tissue and nerves, leaving some people unable to walk, work or care for children.

Currently, hernia mesh devices can be approved if they are similar to older products, which themselves may not have been required to undergo any rigorous testing or clinical trials in order to assess their safety or efficacy.

In England, around 100,000 such operations are performed each year, the majority using mesh. Many go well. But the Victoria Derbyshire programme has heard from nearly 300 people who have experienced complications - including chronic pain, infections and organ perforations. International guidelines estimate one in 10 patients will experience "significant chronic pain" following a mesh repair.

The director of devices at the Medicines and Healthcare products Regulatory Agency (MHRA), Graeme Tunbridge, told the BBC: "The benefits and risks of using mesh for hernia repair have been considered in detail by clinicians and the professional bodies who represent them. We continue to monitor and review evidence as it becomes available and will take any appropriate action on that basis."

Mr Tunbridge said he recognised the system "does need strengthening" and said new legislation on medical devices would take effect from May 2020.

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Source: BBC News, 15 January 2020

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Abuse became ‘normal’ at Birmingham care home, finds watchdog

A care home in Birmingham has been heavily criticised by the care watchdog after it found physical and verbal abuse of residents with learning disabilities and autism had become “normal”.

The Care Quality Commission (CQC) said it had put urgent restrictions on Summerfield House, in Birmingham, to stop any more people being admitted there.

The home was looking after four residents with disabilities in August when CQC inspectors found a string of concerns. Records revealed episodes of physical, verbal and emotional abuse of the residents with staff making threats to cancel activities or threatening to call the police.

The CQC found staff were not able to recognise abuse, citing an example where inspectors saw a person being hit on the head by another person with no action being taken.

The watchdog’s report said abuse was happening between residents and staff.

Debbie Ivanova, CQC deputy chief inspector for people with a learning disability and autistic people, said: “Our latest inspection of Summerfield House found a truly unacceptable service with a poor culture where abuse and people being placed at harm had become normal, with no action taken to prevent incidents from happening or reoccurring."

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Source: The Independent, 28 September 2021

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‘Life threatening’ risk to clinically vulnerable after firms disconnect energy supply, warns NHS chief

A senior NHS leader has warned of a “life-threatening” situation in which clinically vulnerable people are being admitted to hospital after having their energy supplies disconnected.

Sam Allen, chief executive of North East and North Cumbria Integrated Care Board (ICB), has written to Ofgem today to raise “serious concerns” that vulnerable people have seen their electricity or gas services disconnected as a result of non-payment.

In the letter, which the ICB has published on its website, Ms Allen said the impact of energy supplies being cut off “will be life threatening for some people” and place additional demand on already stretched health and social care services.

She wrote: “It has come to light that we are starting to see examples where clinically vulnerable people have been disconnected from their home energy supply which has then led to a hospital admission.

“This is impacting on people who live independently at home, with the support from our community health services team and are reliant on using electric devices for survival.

“An example of this is oxygen; and there will be many other examples. There is also a similar concern for clinically vulnerable people with mental health needs who may find themselves without energy supply.

“Put simply, the impact of having their energy supply terminated will be life threatening for some people as well as placing additional demands on already stretched health and social care services.”

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Source: HSJ, 5 September 2022

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Experts warn against DIY Botox-like injections available illegally online

People seeking cheap Botox-like injections have been warned by experts against doing it themselves due to the risk of “eyelid droops”, infection and even botulism.

There are growing concerns over the availability of medication called Innotox that is being sold illegally online in the UK. Unlike Botox, which comes as a powder that must be reconstituted for use in an injection, Innotox is a ready-to-use liquid – making it easier to self-administer.

Wes Streeting, the health secretary, announced plans this week to introduce legislation cracking down on England’s cosmetic “wild west”, where there is scant regulation of who can deliver treatments such as dermatological filler and Botox.

Experts say Innotox is not licensed for use in the UK, unlike some other liquid Botox-like injections, meaning its quality and safety has not been assessed.

Aenone Harper-Machin, a consultant plastic surgeon and spokesperson for the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), said the online availability of Innotox was frightening and appalling, and she cautioned against DIY jabs.

“People could be giving themselves eyelid droops and all sorts of weird asymmetries by injecting it in the wrong place, too deeply, too superficially. You can inject it into your blood vessel and give yourself botulism,” she said.

Health officials have said 41 recent cases of botulism poisoning in England have been linked to unlicensed jabs.

Harper-Machin has had Botox-like injections but said she would not self-administer them. “I wouldn’t have it done by anybody other than a consultant plastic surgeon who has intimate knowledge of facial anatomy,” she said.

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Source: The Guardian, 10 August 2025

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BMA calls for legislation to stop doctors being blamed when under “unmanageable pressure”

The BMA has written to the government to call for new legislation to ensure accountability for safe staffing levels and that “individual clinicians are not blamed when the system places them under unmanageable pressure.”

The call came as the BMA published a year long study looking at the changes needed to improve care of patients and the working lives of doctors in the NHS, alongside a “manifesto for change” outlining all the recommendations.

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Source: BMJ, 13 September 2019

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Hospital deploys new £700,000 computer system to improve patient safety in intensive care unit

A new £700,000 computer system has been deployed in an intensive care unit at Aberdeen Royal Infirmary. The new Philips system will replace bedside charts, freeing up clinical time and improving patient safety at the NHS Grampian hospital.

ICU clinical director Dr Iain MacLeod said: “At the heart of this change is patient safety. The system records physical measurements like blood pressure and heart rate as well as blood results and parameters from the various machines used in ICU, such as dialysis machines and ventilators."

“It will also save on staff time. Currently medical staff members waste lots of time transcribing blood results from a computer onto sheets of paper. The new system allows this to happen automatically. That’s great from a timesaving point of view but more importantly there will be a reduction of errors that can happen when writing something down.”

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Source: FutureScot, 11 November 2019

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CQC reveals some patients have spent a decade in seclusion

The Care Quality Commission (CQC) has called for ‘ministerial ownership’ to end the ‘inhumane’ care of patients with learning difficulties and autism in hospital – after finding some cases where people had been held in long-term segregation for more than 10 years.

Following its second review into the uses of restraint and segregation on people with a learning difficulty, autism and mental health problems, the CQC has warned it “cannot be confident that their human rights are upheld, let alone be confident that they are supported to live fulfilling lives”.

The review was ordered by health and social care secretary Matt Hancock in late 2018 in response to mounting concerns about the quality of care in these areas.

According to the report, published today, inspectors found examples people being in long-term segregation for at least 13 years, and in hospital for up to 25 years. It also found evidence showing the proportion of children from a black or black British background subjected to prolonged seclusion on child and adolescent mental health wards was almost four times that of other ethnicities.

Looking at care received in hospital the CQC found many care plans were “generic” and “meaningless” and patients did not have access to any therapeutic care.

Reviewers also found people’s physical healthcare needs were overlooked. One women was left in pain for several months due to her provider failing to get medical treatment.

The regulator also reviewed the use of restrictive practices within community settings. While it found higher quality care, and the use of restrictive practices was less common, it said there was no national reporting system for this sector.

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Source: HSJ, 22 October 2020

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Thousands still being denied PPE for procedures with ‘high covid risk’

Thousands of frontline workers delivering treatments where the risk of transmitting coronavirus is heightened are still being denied personal protective equipment (PPE), according to multiple unions and professional bodies.

Eleven organisations, including Unison and the British Association of Stroke Physicians, believe numerous procedures have been “wrongly excluded” from the list of 13 “aerosol generating procedures” that require PPE, despite the NHS now having adequate supplies.

They say their members are “facing illness and even death” while performing procedures such as chest physiotherapy, introducing feeding tubes, and assessing whether a patient can swallow safely.

The unions have formed an alliance to lobby on the issue, and its chair Dr Barry Jones told HSJ: “We’ve asked ministers and the Department of Health and Social Care again and again to take action and provide PPE to frontline NHS staff carrying out procedures which are not currently listed as AGPs but which the scientific evidence shows should be.

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Source: HSJ, 13 November 2020

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Private sector ‘pushing back’ on NHS request to take more patients, says top trust

Private hospitals are ‘pushing back’ on requests from NHS trusts to send them more NHS patients, following a change to the national contract with the independent sector, and amid high pressure from COVID-19.

Manchester University Foundation Trust, one of the largest NHS providers, has reported difficulties in accessing capacity at its local Spire, BMI and Ramsay hospitals this month.

It comes as the NHS is facing “unthinkable” pressures from coronavirus patients, with dozens of hospitals on the brink of being overwhelmed.

Throughout most of 2020, the bulk of private providers in England were on a national block contract whereby the NHS could use as much capacity as it needed.

But a new contract, agreed with oversight from the Treasury last month, is now in place between January and April, and only offers trusts a minimum volume of activity which equates to activity provided in October and November.

Pressures on the NHS have since intensified to unprecedented levels, with many areas now in far greater need of the private capacity than they were two months ago.

And there appears to be a misunderstanding or lack of clarity in some areas about the extent to which they can now call on private capacity.

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Source: HSJ, 13 January 2021

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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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‘Big personalities’ accused of bullying thought to be ‘bullet proof’, finds review

Doctors at an acute trust believe their clinical leaders have failed to tackle the ‘big personalities’ accused of being aggressive bullies, a review has found.

The probe at University Hospitals of North Midlands Trust was prompted by a survey carried out last year by the British Associations of Physicians of Indian Origin, after concerns were raised by its members.

The review was undertaken by Birmingham-based equalities charity Brap, and Roger Kline, a research fellow at Middlesex University Business School. It found the trust was not an outlier in statistical measures of bullying and harassment, but suggested the situation was still worse than leaders would wish.

They said: “The most common reason people cited for bullying/harassment they experienced was the personality, attitude, and disposition of their managers and colleagues… it is felt senior clinical leaders have, in the past, failed to tackle these ‘big personalities’.

“It is worth noting feedback from interviews suggesting many doctors feel they have endured poor behaviour – talking over people during meetings, criticising work in public, aggressive questioning – for years, and have simply become inured to it.

The reviewers found that as a consequence, certain people within the organisation were perceived to be “bullet proof”, and added: “We would suggest the trust needs a big, long-term plan to ‘rehumanise’ the organisation.

“The trust’s existing culture has permitted, and continues to permit infringements in behaviour… While this is not condoned by senior leaders in the trust, the lack of a plan to proactively tackle a legacy of overlooking poor behaviours has allowed them to persist.”

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Source: HSJ, 6 April 2022

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Staff falsified records night man died, inquest hears

Staff at a mental health trust, run by Norfolk and Suffolk NHS Foundation Trust, falsified records that they had checked on a vulnerable patient the night he died, an inquest has heard.

Eliot Harris was found dead in his room at Northgate Hospital in Great Yarmouth, Norfolk, in April 2020. A police witness statement detailed how CCTV footage contradicted 19 log entries.

Mr Harris, 48, was admitted to hospital after the care home where he was a resident requested an urgent mental health assessment, an inquest into his death at Norfolk Coroner's Court heard.

He had been diagnosed with paranoid schizophrenia, had a history of epileptic seizures and had not been taking his medication.

Mr Harris was deemed to be high risk and was supposed to be on regular checks four times an hour.

In a witness statement read out in court, Det Sgt Nick Appleton described how police had cross referenced logs of his observations with CCTV recordings.

Det Sgt Appleton listed 19 instances in which the observation record was signed by a staff member that night, indicating Mr Harris had been checked, but was not backed up by the CCTV record.

He identified a number of "points of concern" in his evidence in which falsifying logs was "normal" and "standard practice" on wards.

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Source: BBC News, 1 August 2022

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Radar that checks people living with Parkinson’s in their own home

A miniature radar system that tracks a person as they walk around their home could be used to measure the effectiveness of treatments for Parkinson’s.

The disease, which affects about 145,000 people in the UK, is linked to the death of nerve cells in the brain that help to control movement.

With no quick diagnostic test available at present, doctors must usually review a patient’s medical history and look for symptoms that often develop only very slowly, such as muscle stiffness and tremors.

The device, about the size of a wi-fi router, is designed to give a more precise picture of how the severity of symptoms changes, both over the long term and hourly.

It sits in one room and emits radio signals that bounce off the body of a patient. Using artificial intelligence it is able to recognise and lock on to one individual. Over several months it will notice if their walking speed is becoming slower in a way that indicates that the disease is becoming worse. During a single day it can also recognise periods where a person’s strides quicken, which means that it could be used to monitor the effectiveness of new and existing drugs, even where the effects last a relatively short time.

“This really gives us the possibility to objectively measure how your mobility responds to your medication. Previously, this was nearly impossible to do because this medication effect could only be measured by having the patient keep a journal,” said Yingcheng Liu, a graduate student at the Massachusetts Institute of Technology (MIT) who is part of the team behind the device. 

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Source: The Times, 22 September 2022

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The Shrewsbury scandal proves what women tell me every day – NHS maternity care is in crisis

As many as one in three women in the UK are traumatised by their birth experiences, and one in 25 of those will go on to develop full-blown PTSD. 

Following the most recent scandal at Shrewsbury, Milli Hill, the founder of the Positive Birth Movement, talks to The Independent about why we need to bring human connection back into maternity services, as well as continuing to invest in the research and technology that can save the lives of those most at risk and, why, above all, we need to start listening to women. If we don’t do these things, history will only repeat itself.

Milli says: "We cannot continue to see scandals like Shrewsbury and Morecambe Bay as isolated, instead we must be brave enough to view them as symptomatic of a wider problem of a maternity system that has become completely dehumanised and unable to listen to women."

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Source: The Independent, 20 November 2019

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Full picture of how covid is hitting hospitals in the north

The most comprehensive picture so far of how covid’s second wave has hit the NHS in the north of England is revealed in new figures obtained by HSJ.

The latest data confirms that parts of the North West region now have more coronavirus patients in hospital beds than they did in the spring. It comes amid intense public debate about the best way to fight covid, and whether or not it is close to swamping the NHS.

Collected from local NHS sources in a joint HSJ and Independent investigation, the information shows for example that:

  • Lancashire and South Cumbria had 544 confirmed covid hospital patients yesterday (around 15-18% of the bed base), about 20 more than during the April peak.
  • Liverpool University Hospitals – which remains the most severely affected trust – had 408 confirmed covid patients yesterday (20-25% of bed base), whereas it never topped 400 in the spring.

The data is sent routinely by trusts to NHS England but most of it is not published – something some politicians are now calling for.

As of yesterday, there were nearly 6,100 confirmed-covid patients across England, about 650 of whom were in critical care, and 560 receiving mechanical ventilation, according to information shared with HSJ.

The number of “unoccupied” hospital beds is much lower now than in the spring, when they were cleared out in anticipation of a major hit. In the North West, up to 5,500 acute beds were reported as “unoccupied” in the spring, whereas the figure now is about 2,500 (around 14-18% of the bed base).

However, critical care is the major pinch point in the most affected areas, with nearly half of the mechanical ventilation beds open at Liverpool’s hospitals (29 of 62) occupied by confirmed covid patients; and a third of those across the North West (178 of 556).

However, hospitals in the area have opened very few extra critical care “surge” beds so far. The total numbers of mechanical ventilation (a subset of critical care) beds open in LUH and the rest of the region has not increased much in recent weeks, and falls well short of what they have declared they could open as potential surge capacity, if they cancelled large amounts of non-urgent care and reorganised staffing and wards.

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Source: HSJ, 23 October 2020

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NHS fears ‘mass exodus’ of staff as mental health absences soar in 2021

NHS leaders and experts have warned healthcare staff will leave their roles in a "mass exodus" unless exhausted doctors and nurses are given better support. This comes as reports earlier this year showed many healthcare staff are suffering from burnout. 

“From April onwards we’ve seen a significant rise in mental health cases, and it shows no sign of stopping,” Steve Carter, director of consulting services at FirstCare, told a panel of MPs and peers on Tuesday. “We need to address the mental health issue quickly if we are to get through the winter.”

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Source: The Independent, 25 August 2021

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COVID-19: Pfizer’s paxlovid is 89% effective in patients at risk of serious illness, company reports

Pfizer’s oral antiviral drug paxlovid significantly reduces hospital admissions and deaths among people with COVID-19 who are at high risk of severe illness, when compared with placebo, the company has reported.

The interim analysis of the phase II-III data, outlined in a press release, included 1219 adults who were enrolled by 29 September 2021. It found that, among participants who received treatments within three days of COVID-19 symptoms starting, the risk of covid related hospital admission or death from any cause was 89% lower in the paxlovid group than the placebo group.

Commenting on the announcement, England’s health and social care secretary, Sajid Javid, said, “If approved, this could be another significant weapon in our armoury to fight the virus alongside our vaccines and other treatments, including molnupiravir, which the UK was the first country in the world to approve this week.”

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Source: BMJ, 8 November 2021

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Patient safety issues with VA Cerner EHR caused harm to veterans, federal watchdog says

A new patient medical records system at a Spokane Veterans Affairs hospital in the US has caused nearly 150 cases of patient harm, according to a federal watchdog agency.

An inspection by the VA Office of the Inspector General (OIG) found that a new Cerner electronic health record (EHR) system, now owned by Oracle, failed to deliver more than 11,000 orders for specialty care, lab work and other services at Mann-Grandstaff VA Medical Center, the first VA facility to roll out the new technology.

The OIG review found that the new EHR sent thousands of orders for medical care to an undetectable location, or unknown queue, instead of the intended care or service location, effectively causing the orders to disappear without letting clinicians know they weren't delivered.

The intent of the unknown queue is to capture orders entered by providers that the new EHR cannot deliver to the intended location because the orders were not recognized as a “match” by the system, according to the VA watchdog.

From facility go-live in October 2020 through June 2021, the new EHR failed to deliver more than 11,000 orders for requested clinical services.

Those lost orders, often called referrals, resulted in delayed care and what a VA patient safety team classified as dozens of cases of "moderate harm" and one case of "major harm."

The clinical reviewers conducted 1,286 facility event assessments and identified and classified 149 adverse events for patients.

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Source: Fierce Healthcare, 20 July 2022

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Cardiologist who fitted wrong pacemaker and destroyed patient notes is struck off

A cardiologist has been struck off the UK medical register after he failed to check a patient’s medical notes before surgery, implanted the wrong type of pacemaker, and then destroyed the notes specifying the correct type.

Amer Chit, a locum consultant cardiologist at Royal Cornwall Hospitals NHS Trust, admitted to a trust investigation that, before implanting the pacemaker, he had looked at the operating list but not at the patient’s medical notes.

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Source: BMJ, 23 August 2019

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Earlier recognition of aortic dissection needed to prevent deaths

Up to half of all patients who suffer an acute aortic dissection may die before reaching crucial specialist care, according to a new Healthcare Safety Investigation Branch (HSIB) report.

The report highlights the difficulty which can face hospital staff in recognising acute aortic dissection. The investigation was triggered by the case of Richard, a fit and healthy 54-year old man, who arrived at his local emergency department by ambulance after experiencing chest pain and nausea during exercise. It took four hours before the diagnosis of an acute aortic dissection was made, and he spent a further hour waiting for the results of a CT scan. Although Richard was then transferred urgently by ambulance to the nearest specialist care centre, he sadly died during the journey.

The report has identified a number of risks in the diagnostic process which might result in the condition being missed. These include aortic dissection not being suspected because patients can initially appear quite well or because symptoms might be attributed to a heart or lung condition.

It also highlighted that, once the diagnosis is suspected, an urgent CT scan is required to confirm that an acute aortic dissection is present. 

Gareth Owens, Chair of the national patient association Aortic Dissection Awareness UK & Ireland, welcomed the publication of HSIB’s report, saying: “HSIB’s investigation and report have highlighted that timely, accurate recognition of acute Aortic Dissection is a national patient safety issue. This is exactly what patients and bereaved relatives having been telling the NHS, Government and the Royal College of Emergency Medicine for several years."

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Source: HSIB, 23 January 2020

 

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Plymouth maternity staff missed chances to save baby’s life, report finds

A baby died after maternity staff repeatedly missed chances to intervene to save his life, an official investigation has found.

Giles Cooper-Hall was just 16 hours old when he died after a catalogue of errors in the maternity care of his mother, Ruth Cooper-Hall, at Derriford hospital in Plymouth.

A Healthcare Safety Investigation Branch (HSIB) report into the incident has exposed how inexperienced and overstretched staff failed to carry out proper checks, recognise there was an emergency or seek help from senior doctors until it was too late.

It comes just weeks after the independent Ockenden report into more than 1,800 cases revealed serious failings in the maternity care provided at Shrewsbury and Telford hospital NHS Trust.

It revealed how Ruth Cooper-Hall, then aged 37, was not personally seen by a consultant when she went into labour in October last year, despite recommendations made in the interim Ockenden report published in December 2020.

The HSIB report also suggested Giles’ death could have been avoided if staff had known about the care plan for his mother’s labour. Instead, vital messages were not passed on, with the investigation finding this was likely to be because the staff responsible were “distracted” by other tasks.

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Source: The Guardian, 10 May 2022

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