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EFORT takes on the demanding implant and patient safety initiative

When orthopaedic surgeons plan a surgical procedure, they demand that safe implants be used. When a patient accepts to undergo surgery, he or she expects the implants used to be safe. When the manufacturer produces and delivers implantsto be used in patients, they take the implants through a meticulous investigation followed by an evaluation of the products by regulators and notified bodies, before the implant is released for free use on the European market by physicians. In this way, all “stakeholders” expect and desire to do their best to bring about safe implants that are used in surgery for patients, which fulfills patients’ expectations of receiving safe treatment.

However, history has shown that, although all participants in this process do their job to treat the patient safely, some implants may still unexpectedly fail. We need to know why this occurs and the trends associated with such failures, such as whether the implant or patient’s characteristics led to the problem or if there is some unforeseen reason that caused the implant to fail.

Incoming EFORT president Prof. Klaus-Peter Günther, of Dresden, Germany, has set up regular meetings to bring all 'stakeholders' in the safety of orthopaedic implants together to regularly discuss relevant issues related to safe implants used to safely treat patients. 

EFORT held the first such meeting, “EFORT Implant & Patient Safety Initiative. Inauguration Workshop,” on 21 January 21 in Brussels. Fifty participants from the EU Commission, notified bodies, regulators, patient organizations, European orthopaedic specialty societies, manufacturers and EFORT board participated in this first initiative. 

The next meeting on this initiative will be held on 10 June during the EFORT Congress in Vienna, Austria.

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Source: Orthopedics Today, 13 February 2020

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NHS Staff Survey 2019

Today the results of the National NHS Staff Survey 2019 are out. This is of the largest workforce surveys in the world with 300 NHS organisations taking part, including 229 trusts. It asks NHS staff in England about their experiences of working for their respective NHS organisations.

The results found that 59.7% of staff think their organisation treats staff who are involved in an error, near miss or incident fairly. While an improvement on recent years (52.2% in 2015) work is needed to move from a blame culture to one that encourages and supports incident reporting.

It also found that 73.8% of staff think their organisation acts on concerns raised by patients/service users. It is vital that patients are engaged for patient safety during their care and there is clear research evidence that active patient engagement helps to reduce unsafe care.

Patient Safety Learning has recently launched a new blog series on the hub to develop our understanding of the needs of patients, families and staff when things go wrong and looking at how these needs may be best met.

 

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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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Infected Blood Enquiry: Timetable and factsheet for expert hearings

This is the independent public statutory inquiry into the use of infected blood. 

The timetable and factsheet to provide information for those attending the hearings in London on 24-28 February have just been published.

Go to this link for more information >> https://www.infectedbloodinquiry.org.uk/news 

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NHS staffing crisis: A critical exception to the immigration rules

Staffing shortages remain a pervasive challenge for the NHS, risking patient safety, care standards and the pursuit of innovation. 

There are now 106,000 vacancies across the NHS in England, with over 44,000 vacancies in nursing. Overseas staff are a crucial way of filling those vacancies, but the message to potential workers is confused to say the least.

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Source: Health Europa, 14 February 2020

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The NHS should act now to avoid a worse crisis next winter

Action must be taken now if the NHS is to avoid an even worse winter crisis next year, the chief inspector of hospitals has warned.

The Care Quality Commission (CQC) said the use of corridors to treat sick patients in A&E was “becoming normalised”, with departments struggling with a lack of staff, poor leadership and long delays leading to crowding and safety risks. Professor Ted Baker said: “Our inspections are showing that this winter is proving as difficult for emergency departments as was predicted. Managing this remains a challenge but if we do not act now, we can predict that next winter will be a greater challenge still. “We cannot continue this trajectory. A scenario where each winter is worse than the one before has real consequences for both patients and staff.”

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Source: The Independent, 18 February 2020

 

 

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Whistleblowing district nurse 'different person' after unfair dismissal

A senior district nurse who was unfairly dismissed after blowing the whistle over valid safety concerns has told how the ordeal has left her life in "chaos" and she feels forced to quit the profession for good. 

Linda Fairhall, who had worked at North Tees and Hartlepool NHS Foundation Trust for 38 years, has spoken to Nursing Times about her experiences after she successfully challenged her employer's decision to sack her. Between December 2015 to October 2016, Ms Fairhall raised 13 concerns to the trust regarding staff and patient safety. At the time, she was managing a team of around 50 district nurses in her role of clinical care co-ordinator.

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Source: Nursing Times, 17 February 2020

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Not enough pharmacists are aware of the yellow card scheme

Every pharmacist must report adverse drug reactions using the yellow card scheme, says chair of the Community Pharmacy Patient Safety Group, Janice Perkins

Polypharmacy, when different medications are used by an individual at the same time, is becoming increasingly common because people are living for longer and with multiple different illnesses. One study, published in 2018 by the Oxford University Press, found that over half (54%) of those aged 65 years and above who took part in the study had two or more long-term conditions, for which they could have been taking a range of medicines.

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Source: Community Pharmacy News, 17 February 2020

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The NHS In England: Patient safety news roundup from Harvard Law

There is always a lot happening with patient safety in the NHS (National Health Service) in England. Sadly, all too often patient safety crises events occur. The NHS is also no sloth when it comes to the production of patient safety policies, reports, and publications. These generally provide excellent information and are very well researched and produced. Unfortunately, some of these can be seen to falter at the NHS local hospital implementation stage and some reports get parked or forgotten. This is evident from the failure of the NHS to develop an ingrained patient safety culture over the years. Some patient safety progress has been made, but not enough when the history of NHS policy making in the area is analysed.

Lessons going unlearnt from previous patient safety event crises is also an acute problem. Patient safety events seem to repeat themselves with the same attendant issues.

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Source: Harvard Law, 17 February 2020

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Senior nurse who tried to whistleblow unfairly dismissed, tribunal rules

A trust unfairly dismissed a senior nurse after she tried to invoke its formal whistleblowing policy, an employment tribunal has ruled.

North Tees and Hartlepool Foundation Trust had suspended Linda Fairhall for 18 months without a “meaningful or adequate” explanation prior to her dismissal, the judgment said. 

Ms Fairhall, who led a team of 50 district nurses in Hartlepool, reported on the trust’s risk register that a “change in policy” by the local authority had directly led to increased workloads for her staff. The change meant staff had to monitor patients who had been prescribed medication “so as to ensure the correct medicines were being taken at the correct time”, the judgment said.

She reported numerous concerns to senior management between December 2015 and October 2016, amounting to 13 protected disclosures according to the tribunal, ranging from work-related stress, sickness, absenteeism and a need to retrain healthcare assistants.

A patient’s death triggered a meeting involving her and senior managers, which she said could have been prevented had her earlier concerns “been properly addressed”.

Ms Fairhall told care group director Julie Parks she wanted to initiate the formal whistleblowing policy on 21 October 2016, before going on annual leave a few days later. When she returned, she was told she had been suspended for 10 days.

The judgment, handed down at Teesside Justice Hearing Centre and published last week, added: “No reasonable employer, in all the circumstances of this case, would have conducted the investigation in this manner.”

The judgment said the tribunal believed the principal reason for her dismissal was because she had made protected disclosures. It upheld her claim that her dismissal was automatically unfair.

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Source: HSJ, 17 February 2020

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‘Plug-and-play’ regtech solution enhances patient safety

With a focus on pharmaceutical supply chain regulation, Bonafi is one of the latest companies to launch within the regtech startup sector.

“Companies operating in the global pharma industry must verify that those they are buying from and selling to are authorised to handle medicinal products for human use in their own countries,” explains its founder, Katarina Antill. “At present, this verification process is manual. Companies are using screenshots as proof and relying on spreadsheets to track verification activities, which increases the risk of errors.”

“Manual processes are very labour intensive not least because companies must deal with multiple registries across multiple countries,” she says. “Most pharma manufacturers and wholesalers don’t have the resources to reverify their trading partners more than once a year, which is the current minimum legal requirement, and this too creates a potential vulnerability that can ultimately have an impact on patient safety and increase corporate risk.

 “I could see that this huge volume of manual work was a threat to patient-safety and extremely inefficient,” she adds. “Our solution gives companies much greater control over their compliance activities because they no longer have to rely on manual processes. It can also retrieve and aggregate data from multiple registers across multiple countries and has a constant monitoring and alert system, quality management dashboards, electronic signatures and workflows and will strengthen the attributes of traceability, transparency and security. It is all designed to help companies to be pro-active in their compliance activities, enabling them to go beyond compliance alone to reduce corporate risk and patient risk.”

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Source: The Irish Times, 13 February 2020

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Health Secretary faces legal challenge for failing patients with learning disabilities and autism

The Equality and Human Rights Commission have launched a legal challenge against the Secretary of State for Health and Social Care over the repeated failure to move people with learning disabilities and autism into appropriate accommodation.

Their concerns are about the rights of more than 2,000 people with learning disabilities and autism being detained in secure hospitals, often far away from home and for many years. These concerns increased significantly following the BBC’s exposure of the shocking violation of patients’ human rights at Whorlton Hall, where patients suffered horrific physical and psychological abuse.

The Equality and Human Rights Commission have sent a pre-action letter to the Secretary of State for Health and Social Care, arguing that the Department of Health and Social Care (DHSC) has breached the European Convention of Human Rights (ECHR) for failing to meet the targets set in the Transforming Care program and Building the Right Support program.

These targets included moving patients from inappropriate inpatient care to community-based settings, and reducing the reliance on inpatient care for people with learning disabilities and autism.

Rebecca Hilsenrath, Chief Executive of the Equality and Human Rights Commission, said: 'We cannot afford to miss more deadlines. We cannot afford any more Winterbourne Views or Whorlton Halls. We cannot afford to risk further abuse being inflicted on even a single more person at the distressing and horrific levels we have seen. We need the DHSC to act now."

"These are people who deserve our support and compassion, not abuse and brutality. Inhumane and degrading treatment in place of adequate healthcare cannot be the hallmark of our society. One scandal should have been one too many."

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Souce: Equality and Human Rights Commission, 12 February 2020

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Review launched into East Kent NHS trust after baby deaths

The government has announced an independent review into maternity services at an NHS trust where a number of babies have died.

“Immediate actions” have also been promised and an independent clinical team has been placed “at the heart” of East Kent Hospitals University NHS Foundation Trust. It comes amid reports that at least seven preventable baby deaths may have occurred at the trust since 2016, including that of Harry Richford.

Harry died seven days after his emergency delivery in a “wholly avoidable” tragedy, contributed to by neglect, in November 2017, an inquest found.

Speaking in the House of Commons, the health minister Nadine Dorries confirmed the independent review would be carried out by Dr Bill Kirkup, who led the investigation into serious maternity failings at Morecambe Bay. It will look at preventable and avoidable deaths of newborns to ensure the trust learns lessons from each case and will put in place appropriate processes to safeguard families.

The review is expected to begin shortly and work in partnership with affected families.

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Source: 13 February 2020

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Hospital's 'gross failings' led to pressure sores death

A double amputee suffered fatal pressure sores caused by "gross and obvious failings" in her hospital treatment.

Janet Prince, from Nottingham, developed the sores after being admitted to Queen's Medical Centre (QMC) in July 2017. The 80-year-old died in January 2019.

Assistant Coroner Gordon Clow issued a prevention of future deaths report to Nottingham University Hospitals NHS Trust (NUH).

Nottingham Coroner's Court had heard Ms Prince was taken to QMC in Nottingham with internal bleeding on 15 July 2017. The patient was left on a trolley in the emergency department for nine hours and even though she and daughter Emma Thirlwall said she needed to be given a specialist mattress, she was not given one.

"No specific measures of any kind were implemented during that period of more than nine hours to reduce the risk of pressure damage, even though it should have been easily apparent to those treating her that [she] needed such measures to be in place," Mr Clow said.

Ms Prince was later transferred to different wards, but a specialist mattress was only provided for her a few days before she was discharged on 9 August, by which time Mr Clow said her wounds "had progressed to the most serious form of pressure ulcer (stage four) including a wound with exposed bone".

Mr Clow said there were "serious failings" over finding an appropriate mattress and other aspects of her care while at the QMC, including "a gross failure" to prevent Ms Prince's open wounds coming into contact with faeces.

Mr Clow said the immediate cause of her death was "severe pressure ulcers", with bronchopneumonia a contributory factor. Recording a death by "natural causes, contributed to by neglect", he said he was "troubled by the lack of evidence" of any changes to wound management at NUH.

NUH medical director Keith Girling apologised for the failings in Ms Prince's care, claiming the trust had "learnt a number of significant lessons from this very tragic case".

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Source: BBC News, 14 February 2020

 

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Harrowing stories of burned out NHS doctors bullied and broken

Dedicated to caring for the sick and vulnerable, junior ­doctors should expect to be ­supported and valued as they carry out their vital work. However, hundreds have revealed they are subjected to bullying and harassment at overstretched hospitals that have been plunged into a staffing crisis by a decade of savage health cuts.

A Mirror investigation uncovered harrowing stories of young medics being denied drinking water during gruelling shifts, working for 15 hours on their feet non-stop and of uncaring managers tearing into them for breaking down in tears over the deaths of patients.

One was even accused of “stealing” surgical scrubs she took to wear after suffering a miscarriage at work. The distraught woman finished her shift wearing blood-soaked trousers, instead of going home to rest.

Doctors are now quitting in their droves, leaving those left ­struggling to cope with a growing ­workload. The Mirror investigation reveals the reality of working for an NHS which has been subject to a record funding squeeze and is 8,000 medics short.

Health chiefs vowed to ­investigate the Mirror’s evidence from 602 ­testimonials submitted to the lobbying group Doctors Association UK.

Chairman Dr Rinesh Parmar said: “These heartbreaking stories from across the country show the extent of bullying and harassment that frontline doctors face whilst working to care for patients".

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Source: The Mirror, 12 February 2020

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Baby with heart condition dies from mould exposure at hospital after open heart surgery

A baby with a serious heart condition has died after she received an infection from mould in a Seattle hospital's operating room, her mother says. 

Elizabeth Hutt was born with a heart condition that she battled for the entirety of her six-month-long life. The young child underwent three open heart surgeries, and after the third one is when it's believed she contracted an Aspergillus mould infection in the hospital's operating room. 

The mould in the hospital's operating rooms was first detected in November, around the same time as the child's third surgery. 

It was later determined the infection was contracted from the mould discovered in three of the 14 operating rooms at the hospital in November. The mould came from the hospital's air-handling units in the operating rooms, and 14 patients have developed infections from the mould since 2001, the hospital revealed. Seven of those 14 children have since died from their infections. 

Elizabeth's parents have joined a class action suit against Seattle Children's Hospital in January, which alleges facility managers knew about the mould since 2005 and failed to fix the problem. 

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Source: The Independent, 14 February 2020

 

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Cancer: Neck lump patient in robot surgery first

Pioneering robotic surgery to remove hard-to-reach head and neck cancers has been performed in Wales for the first time.

More than 20 patients a year from across Wales are expected to benefit from the new service at the University Hospital of Wales in Cardiff.

Surgeons use a precision robot with several arms to remove tumours and improve the chances of recovery. The first patient is recovering well from his operation in December.

A human surgeon's wrist can turn 180 degrees, whereas the robot's four 'hands' can rotate four or five times.

This dexterity reduces the need for more invasive surgery – in some cases this might have involved breaking the jaw open – and patients can recover much more quickly.

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Source: BBC News, 14 February 2020

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East Kent baby deaths: Scale of deaths at trust 'not clear-cut'

The boss of an NHS trust at the centre of concerns about preventable baby deaths has claimed the scale of the failings is not clearly defined.

Susan Acott, Chief Executive of East Kent Hospitals Trust, said there had only been "six or seven" avoidable deaths at the trust since 2011. However, the BBC revealed on Monday that the trust previously accepted responsibility for at least 10.

Ms Acott said some of the baby deaths were "not as clear-cut".

A series of failings came to light during the inquest of Harry Richford who died seven days after his birth at the Queen Elizabeth the Queen Mother Hospital in Margate in November 2017. A coroner ruled Harry's death was "wholly avoidable" and was contributed to by hospital neglect.

Ms Acott added she had not read a key report from 2015 drawing attention to maternity problems at the trust until December 2019.

Ms Acott claims that from 2011 to 2020 there were "about six or seven" baby deaths that were viewed as preventable. She says the other deaths were being investigated adding "these things aren't always black and white".

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Source: BBC News, 12 February 2020

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NHS trust withdraws ‘dangerous’ advice to women on how to achieve a ‘normal birth’

An NHS trust has been criticised for advising pregnant women to stay at home for as long as possible during labour to increase the chances of a “normal birth”. University Hospitals Bristol NHS Trust also suggested mothers should avoid having epidurals or inductions and should try to have a home birth.

The advice has been described as “shocking” by experts, who said the guidance was contrary to evidence and could be “dangerous” for mothers and babies. Others criticised the language used by the trust which suggested women who needed medical help were somehow “abnormal”.

Earlier this month, the Bristol trust paid out £5.8m in compensation to the family of a six-year-old boy after he was left brain damaged at birth following complications during labour.

After being contacted by The Independent, the trust deleted the childbirth advice from its website and accepted it was “outdated”.

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Source: The Independent, 13 February 2020

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Pharmacists are trapped in a system that threatens patient safety

The current pharmacy system in the US needs to to change now, according to Thomas Menighan, APhA Executive Vice President and CEO in a recent blog. 

"The current system sets pharmacists up to fail, and in turn, pharmacists are burning out at high rates", says Thomas. "This is an issue that not only puts patients at risk but deprives pharmacists of the opportunity to provide the kind of patient care we all got into pharmacy to provide". 

"During my time as a community pharmacist, I cherished the relationships I established with patients and understood the great responsibility that came with the trust they placed in me. Pharmacists take an oath to, among other things, “assure optimal outcomes” for patients. I can attest to the emphasis our profession places on patient safety. When it comes to medication-related errors, even one is too many."

Thomas suggests the solution comes from taking a hard look at how pharmacies are reimbursed and who profits from inadequate patient care. Meanwhile, state and local pilot projects that compensate pharmacists for greater involvement in team-based care have proven that when pharmacists are allowed to provide a full range of services, costs go down and patient outcomes improve.

"It’s perverse that we pharmacists are begging for the opportunity to practice the kind of pharmacy we were extensively educated and trained to practice. And who benefits from this warped system? Here’s a hint: it’s not pharmacies or patients."

"We must regulate the pharmacy benefit managers who make obscene sums of money without doing a single thing to serve patients. They say they keep prices and premiums down but simultaneously fight attempts to force them to be transparent about how they supposedly achieve this. If it’s not greedy, let’s see how it works. If it really helps patients, tell us how. But they won’t. It’s indefensible."

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Source: APhA, 11 February 2020

 

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Children with arthritis 'facing delays to diagnosis'

Delays diagnosing and treating children with arthritis are leaving them in pain and at a higher risk of lifelong damage, a national charity has warned.

Arthritis is commonly thought to affect only older people, but 15,000 children have the condition in the UK. 

Versus Arthritis says many children are not getting help soon enough. 

The NHS said: "Arthritis in young people is rare and diagnosing it can be difficult because symptoms are often vague and no specific test exists."

Zoe Chivers, Head of Services at Versus Arthritis, said: "We know that young people often face significant delays getting to diagnosis simply because even their GPs don't recognise that it's a condition that can affect people as young as two. It's often considered that they're just going through growing pains or they've just got a bit of a viral infection and that's not the case."

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Source: BBC News, 12 February 2020

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Nurses to retrain as doctors ‘more quickly’ without EU red tape

Leaving the EU means the UK has greater control over the training of healthcare professionals. The Department of Health and Social Care (DHSC) has announced that nurses and other allied healthcare professionals will be able to retrain as doctors ‘more quickly’ now the UK has left the EU.

Under training standards set by the EU, existing healthcare professionals wishing to move into another area would have to complete a set standard of training, regardless of any existing health background or qualifications. Under the potential new system, a nurse who has been in the job for 10 years could benefit from training standards based upon experience and qualifications, rather than strict time-frames.

Health Secretary Matt Hancock said: “Our incredible NHS is full of highly-qualified and dedicated professionals – and I want to do everything I can to help them fulfil their ambitions and provide the best possible care for patients. Without being bound by EU regulations, we can focus on ensuring our workforce has the necessary training which is best suited to them and their experience, without ever compromising on our high standards of care or on patient safety. The plans we are setting out today mean that we can retrain healthcare workers and get them back to the frontline faster. This is good for patients, and good for our NHS."

Nursing leaders warn that the move needs to come without compromising patient care. Andrea Sutcliffe CBE, Chief Executive and Registrar at the Nursing and Midwifery Council (NMC) said: “Having enough health and care professionals with the right knowledge, skills and values is vital to meet the individual needs of people across all four countries of the UK now and in the future."

“The NMC supports the wish to explore how education and training for registered nurses and midwives may be achieved in more flexible ways while ensuring our high standards are maintained and not compromised. Every nursing and midwifery professional must be safe and competent to provide the best care and support possible."

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Source: Nursing Notes, 9 February 2020

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Coronavirus: Two healthcare workers in UK test positive for deadly virus as GP surgery closed

The number of British cases of coronavirus has doubled to eight – with two healthcare workers among those testing positive – while a GP surgery in Brighton was closed amid fears of the infection spreading.

Brighton’s County Oak medical centre closed on Monday with a warning notice on its door telling patients it was “closed due to operational difficulties”.

According to reports, one of those infected was a GP, who was at work for one day but did not see any patients. Workers wearing protective suits were pictured cleaning the surgery and pharmacy on Monday afternoon.

The government has since classified the virus, which has infected more than 40,000 people in China and led to the death of more than 1,000, as a “serious and imminent threat” to public health while activating emergency powers that can see it force people to remain in quarantine.

“I will do everything in my power to keep people in this country safe,” Matt Hancock, the Health Secretary, said in a statement. “We are taking every possible step to control the outbreak of coronavirus. NHS staff and others will now be supported with additional legal powers to keep people safe across the country.”

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Source: The Independent, 11 February 2020

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Fast response to terror attacks saves lives. UK medics should not be held back

The Streatham terrorist attack has again highlighted one of the most difficult decisions the emergency services face – deciding when it is safe to treat wounded people.

In the aftermath of the stabbings by Sudesh Amman, a passer-by who helped a man lying on the pavement bleeding claimed ambulance crews took 30 minutes to arrive. The London Ambulance Service (LAS) said the first medics arrived in four minutes, but waited at the assigned rendezvous point until the Metropolitan police confirmed it was safe to move in.

Last summer, the inquest into the London Bridge attack heard it took three hours for paramedics to reach some of the wounded. Prompt treatment might have saved the life of French chef Sebastian Belanger, who received CPR from members of the public and police officers for half an hour. A LAS debriefing revealed paramedics’ frustration at not being deployed sooner.

A group of UK and international experts in delivering medical care during terrorist attacks have highlighted alternative approaches in the BMJ. In Paris in 2015, the integration of doctors with specialist police teams enabled about 100 wounded people in the Bataclan concert hall to be triaged and evacuated 30 minutes before the terrorists were killed. The experts writing in the BMJ believe the UK approach would have delayed any medical care reaching these victims for three hours.

These are perilously hard judgment calls. Policymakers and commanders on the scene have to balance the likelihood that long delays in intervening will lead to more victims dying from their injuries against the increased risk to the lives of medical staff who are potentially putting themselves in the line of fire by entering the so-called 'hot zone'.

First responders themselves need to be at the forefront of this debate. As the people who have the experience, face the risks and want more than anyone to save as many lives as possible, their leadership and insights are vital.

In the wake of the Streatham attack the government is looking at everything from sentencing policy to deradicalisation. Deciding how best to save the wounded needs equal priority in the response to terrorism.

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Source: The Guardian, 7 February 2020

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East Kent baby deaths: Four more families come forward

A BBC News investigation has uncovered more preventable baby deaths at an NHS trust that has already been criticised for its maternity services.

Four families said their babies would have survived had East Kent Hospitals NHS Trust provided better care. The NHS's Healthcare Safety Branch is investigating 25 maternity cases at the hospitals in Margate and Ashford.

The trust has apologised for the care provided in two of the cases and said they were investigating a third. It has denied any wrongdoing in the fourth case.

The government is due to receive the Healthcare Safety Branch's report into the 25 cases later, as well as a Care Quality Commission report from an inspection carried out in January.

Last month, the BBC discovered at least seven preventable deaths may have occurred at the trust since 2016. Four further families have now spoken out, saying their babies would not have died if medics had provided better care. In two of the cases, the mothers said the actions of the trust left them feeling they were to blame for their babies' deaths.

In a statement, East Kent Hospitals Trust it had set up a board sub-committee "to ensure we are complying with national safety standards and ensure we are implementing the coroner's recommendations fully and swiftly".

"We are deeply saddened by the stories of families who have suffered the death of a much-loved baby, and we are extremely sorry for their loss," it added.

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Source: BBC News, 10 February 2020

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