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Mid Staffs scandal: 10 years on, inquiry chair worries NHS staff too scared to speak up

Ten years on from the Mid Staffordshire NHS trust scandal, the man who led the inquiry into one of the worst care disasters in the service’s history has said he remains worried about the safety of patients and a culture that leaves staff too frightened to speak up.

Sir Robert Francis QC said some safety risks highlighted a decade ago remain unresolved and he threw his weight behind calls for senior managers in the NHS to be regulated.

The barrister said he believed the NHS was safer now than a decade ago but added he worried whether actions taken since the disaster had made a real difference.

“What keeps me awake at night is not so much has anyone implemented recommendation 189 or not, but more whether the collectivity of what has happened since has actually resulted in things being better for patients and staff,” he told The Independent.

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Source: The Independent, 15 January 202

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Lack of transparency on patient complaints risks confidence in the NHS

Public confidence in the health service is being undermined by a lack of transparency from hospitals about patient complaints, the man who led the investigation into one of the NHS’s worst care disasters has warned.

Sir Robert Francis QC, who chaired the public inquiry into the Mid Staffordshire hospital scandal, has called for a new national organisation with powers to set standards on the handling of patient complaints after research found seven in eight hospital trusts do not follow existing rules.

The prominent barrister is now chair of Healthwatch England, a statutory body, which analysed 149 hospitals’ handling of complaints. Under current legislation every hospital is required to collect and report on the number of complaints they receive, what they were about and what action has been taken. Healthwatch England found just 12% of NHS trusts were compliant with all the rules. Only 16% published the required complaints reports while just 38% reported any details about learning or actions taken after a grievance.

Speaking to The Independent, Sir Roberts said better reporting, including the outcome and changes made after a complaint, would create a “collaborative” environment to improving the system with patients and staff alike seeing complaints as a valuable resource.

One persistent problem remained the gap, he said, between hospitals and the national Parliamentary and Health Service Ombudsman. Sir Robert argued commissioners of NHS services should be more involved.

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Source: The Independent, 15 January 2020

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Warning over warring Great Ormond Street surgeons

Warring between two surgeons at Great Ormond Street Hospital could put patients at risk, a review suggests.

A board paper released by the leading children's hospital said a "fractured" relationship between two consultants in the paediatric surgical urology team was affecting the service last year.

The London hospital said steps were being taken to resolve the problems. This has included mediation, mentoring and away days.

The board paper from a meeting in November set out the findings of a two-day inspection by the Royal College of Surgeons last May. The college was invited in by the trust itself after reports of problems. The summary of the report said there were "significant difficulties" between two surgeons in the team. It described a "lack of trust and respect" which meant they did not work collaboratively and led to significant competition for work.

If this continued it would have the "potential to affect patient care and safety" as well as longer waits for surgery, it said. The "dysfunction" between the two senior doctors caused problems for the wider team with evidence support staff had also been treated inappropriately.

Great Ormond Street said it took the issue "extremely seriously" and good progress was being made.

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Source: BBC News, 15 January 2020

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Miscarriage can lead to 'long-term post-traumatic stress'

One in six women who lose a baby in early pregnancy experiences long-term symptoms of post-traumatic stress, a UK study suggests.

Women need more sensitive and specific care after a miscarriage or ectopic pregnancy, researchers say.

In the study of 650 women, by Imperial College London and KU Leuven in Belgium, 29% showed symptoms of post-traumatic stress one month after pregnancy loss, declining to 18% after nine months. The study recommends that women who have miscarried are screened to find out who is most at risk of psychological problems.

"For too long, women have not received the care they need following a miscarriage and this research shows the scale of the problem," says Jane Brewin, Chief Executive of miscarriage and stillbirth charity Tommy's.

"Miscarriage services need to be changed to ensure they are available to everyone and women are followed up to assess their mental wellbeing with support being offered to those who need it, and advice is routinely given to prepare for a subsequent pregnancy."

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Source: BBC News, 15 January 2020

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Urologists support New Zealand MOH report recommendations on surgical mesh

The Urological Society of Australia and New Zealand (USANZ) supports recommendations in the Hearing and Responding to Stories of Survivors of Surgical Mesh report released by the New Zealand Ministry of Health in response to complications resulting from the use of surgical mesh in a range of operations, including for stress incontinence and pelvic organ prolapse.

The Ministry of Health commissioned the review, in which New Zealand urologists participated alongside a wide range of consumer and other health groups, to provide a plan “to minimize future risk to consumers and support those harmed by it”.

“The Urological Society acknowledges that complications from the use of mesh for treating stress urinary incontinence and pelvic organ prolapse has caused considerable physical and psychological harm in some patients, which we feel is unacceptable, said USANZ President, Dr Stephen Mark. "We also acknowledge and accept findings that there were deficiencies in technical and communication skills of some surgeons. We recognise the distress caused to these patients and want to be part of the solution in helping these people, as well as ensuring no patients are harmed in future."

“Further research is necessary to achieve best practice outcomes and help us understand why, when, and in which patient complications may occur. For this reason, USANZ supports participation with Australia in a mesh registry. By collaborating with Australian researchers, we can be part of a substantial database that would underpin ongoing research in the interests of patient safety."

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Source: New Zealand Doctor, 13 January 2020

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Coroner raps trust for not realising woman was in ‘imminent danger’

A coroner has criticised an ambulance trust after it took nearly four hours to reach a woman who had taken an overdose. 

Taking the unusual step of publishing a prevention of future deaths report before an inquest had concluded, coroner for Gateshead and South Tyneside Terence Carney said “the real and imminent danger of [the deceased Maureen Wharton’s] admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way”.

Ms Wharton called North East Ambulance Service Trust to say she was dying of cancer and had taken prescribed drugs, including an opioid-based medication and sleeping pills. She threatened to take more and later called back, appearing drowsier.

North East Ambulance Service graded the 61-year-old’s call as “category three”, which meant she should have received a response within two hours. It took three hours and 45 minutes for the ambulance service to access her flat, by which time she was already dead. 

Mr Carney pointed out no attempts had been made to identify family or other support for her, or to contact other agencies which could have responded. The inquest into her death is expected to conclude later this year. 

In a statement, NEAS said it has already made changes to safeguard patients in mental health cases, including implementing greater oversight in its control rooms, improving call transfers to crisis teams, mapping available local mental health services, introducing more staff training, and telling patients in a crisis but not at risk of physical harm about other, more appropriate, services. 

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Source: HSJ, 14 January 2020

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Care firm's leadership criticised by Care Quality Commission

The Care Quality Commission (CQC) has raised concerns about the treatment of patients at mental health units run by Cygnet. It follows inspections in the wake of a BBC Panorama investigation about alleged abuse at Wharlton Hall in County Durham.

The CQC found that patients under the firm's care were more likely to be restrained. Higher rates of self-harm were also noted by inspectors who quizzed managers and analysed records at the company's headquarters.

The regulator also found a lack of clear lines of accountability between the executive team and its services. It said directors' identity and disclosure and barring service checks had been carried out, butd that required checks had not been made to ensure that directors and board members met the "fit and proper" person test for their roles.

Systems used to manage risk were also criticised, while training for intermediate life support was not provided to all relevant staff across services where physical intervention or rapid tranquilisation was used.

Cygnet runs more than 100 services for vulnerable adults and children, caring for people with mental health problems, learning disabilities and eating disorders.

The CQC says Cygnet must now take immediate action to address the concerns raised.

Cygnet said a number of the services highlighted have since been improved, but "we are not complacent and take on board recommendations where we must improve".

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Source: BBC News, 14 January 2020

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Health NHS patient feedback is not being used to improve services, report warns

The NHS is spending millions of pounds encouraging patients to give feedback but the information gained is not being used effectively to improve services, experts have warned.  

Widespread collection of patient comments is often “disjointed and standalone” from efforts to improve the quality of care, according to a study by the National Institute for Health Research (NIHR).

Nine separate studies of how hospitals collect and use feedback were analysed. They showed that while thousands of patients give hospitals their comments, their reports are often reduced to simple numbers – and in many cases, the NHS lacks the ability to analyse and act on the results.

The research found the NHS had a “managerial focus on bad experiences” meaning positive comments on what went well were “overlooked”.

The NIHR report said: “A lot of resource and energy goes into collecting feedback data but less into analysing it in ways that can lead to change, or into sharing the feedback with staff who see patients on a day-to-day basis.

NHS England's chief nurse, Ruth May, said: "Listening to patient experience is key to understanding our NHS and there is more that that we can hear to improve it. This research gives insight into how data can be analysed and used by frontline staff to make changes that patients tell us are needed."

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Source: 13 January 2020

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India: When a ‘never event’ hits a patient

A young woman was left with a retained foreign object, after surgery in an India hospital. A checklist could have avoided her death. The response from the health officials was: “We have issued a show-cause notice to the staff seeking an explanation. We will initiate departmental action based on their replies and finding of our inquiry.”

In the fields of healthcare quality and patient safety, such punitive measures of “naming and shaming” have not worked.

T.S. Ravikumar, President, AIIMS Mangalagiri, Andhra Pradesh, moved back to India eight years ago with the key motive to improve accountability and safety in healthcare delivery. He believes that we have a long way to go in reducing “preventable harm” in hospitals and the health system in general.  "We need to move away from fixing blame, to creating a 'blame-free culture' in healthcare, yet, with accountability. This requires both systems design for safe care and human factors engineering for slips and violations".

"Providing safe care without harm is a 'team sport', and we need to work as teams and not in silos, with mutual respect and ability to speak up where we observe any deviation or non-compliance with rules, says Ravikumar. Basic quality tools and root-cause analysis for adverse events must become routine. Weekly mortality/morbidity conferences are routine in many countries, but not a routine learning tool in India.

He proposes acceleration of the recent initiative of the DGHS of the Government of India to implement a National Patient Safety Framework, and set up an analytical “never events” or sentinel events reporting structure.

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Source: The Hindu, 12 January 2020

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JAMA editorial blasts FDA's reporting of medical device problems

The US Food and Drug Administration (FDA) needs to do more to quickly and substantially reform its system for reporting adverse events caused by medical devices, two researchers wrote in an Editorial published in JAMA Internal Medicine.

The editorial notes several instances where information on a medical device was withheld from the public or not reported fully. 

The current adverse events reporting system relies on device makers to voluntarily report adverse events, which the authors say does not place patient safety as a priority. 

The editorial specifically highlights a study involving Medtronic's Insync III model 8042 heart failure pacemaker, which the authors said caused a "high burden of serious adverse events (including death)." The authors said it took the FDA 19 months to recall the device after the first instance of the device failing was reported. The FDA also decided to classify the recall as Class II, which signifies a low probability of serious adverse events. 

"This long unexplained delay before the recall and the inappropriate recall classification raise concerns about patient harms that could have been prevented by speedier and stronger regulatory actions," the authors wrote. 

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Source: Becker's Hospital Review, 10 January 2020

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Trust blames behaviour ‘from top of the NHS’ for bullying

Leadership behaviour from the “very top of the NHS” has led to an increase in bullying, according to an official strategy document produced by an acute trust.

East and North Hertfordshire Trust published its new people and organisation strategy in its January board papers. Within it, the report said: “Leadership behaviour from the very top of the NHS, during this time of pressure has led to an increase in accusations of bullying, harassment and discrimination.”

In a separate section, the paper noted the difficulties of being a healthcare professional, saying “many staff leave before they need to and many more cite bullying, over work and stress, as reasons for absence and mistakes”.

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Source: HSJ, 13 January 2020

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Safety fears as hospitals redeploy nurses to care for patients in corridors

Hospitals are having to redeploy nurses from wards to look after queues of patients in corridors, in a growing trend that has raised concerns about patient safety.

Many hospitals have become so overcrowded that they are being forced to tell nurses to spend part of their shift working as “corridor nurses” to look after patients who are waiting for a bed.

The disclosure of the rise in corridor nurses comes days after the NHS in England posted its worst-ever performance figures against the four-hour target for A&E care. They showed that last month almost 100,000 patients waited at least four hours and sometimes up to 12 or more on a trolley while hospital staff found them a bed on the ward appropriate for their condition.

“Corridor nursing is happening across the NHS in England and certainly in scores of hospitals. It’s very worrying to see this,” said Dave Smith, the Chair of the Royal College of Nursing’s Emergency Care Association, which represents nurses in A&E units across the UK. "Having to provide care to patients in corridors and on trolleys in overcrowded emergency departments is not just undignified for patients, it’s also often unsafe.”

A nurse in south-west England told the Guardian newspaper how nurses feared the redeployments were leaving specialist wards too short of staff, and patients without pain relief and other medication. Some wards were “dangerously understaffed” as a result, she claimed.

She said: “Many nurses, including myself, dread going into work in case we’re pulled from our own patients to then care for a number of people in the queue, which is clearly unsafe. We’re being asked to choose between the safety of our patients on the wards and those in the queue."

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Source: The Guardian, 12 January 2020

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Shante Turay-Thomas: Human error factor in allergy death

A teenager with a severe nut allergy died in part because of human error, a coroner has ruled.

Shante Turay-Thomas, 18, had a severe reaction to eating a hazelnut. The inquest heard a series of failures meant that an ambulance took more than 40 minutes to arrive at her home in Wood Green, north London.

Her mother Emma Turay, who said she felt "badly let down" by the NHS, wants an "allergy tsar" to be appointed to help prevent similar deaths.

The inquest heard call staff for the NHS's 111 non-emergency number failed to appreciate the teenager's worsening condition was typical of a severe allergic reaction to nuts.

A telephone recording of the 111 call, made by her mother, at 23:01 BST on Friday 14 September 2018, revealed how the 18-year-old could be heard in the background struggling to breathe.

"My chest hurts, my throat is closing and I feel like I'm going to pass out," she said before asking her mother to check how long the ambulance would be, then adding: "I'm going to die."

The inquest heard Ms Turay-Thomas had tried to use her auto-injector adrenaline pen, however it later emerged she had only injected a 300 microgram dose, rather than the 1,000 micrograms needed to stabilise her condition.

It also emerged she was unaware of the need to use two shots for the most serious allergic reactions and had not received medical training after changing her medication delivery system from the EpiPen to a new Emerade device.

The inquest at St Pancras Coroner's Court was told an ambulance that was on its way to the patient had been rerouted because the call was incorrectly categorised as requiring only a category two response, rather than the more serious category one.

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Source: BBC News, 13 January 2020

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Regulator admits multiple failings in investigation of young woman’s death

Multiple failings have been found in the Parliamentary Health Service Ombudsman's (PHSO)  investigation into the death of a young woman with anorexia.

PHSO has admitted to multiple failings in how it handled a three-and-a-half year investigation into the systemic failings by NHS providers in Cambridgeshire and Norfolk which led to the death of Averil Hart in 2012.

The findings come as a senior coroner in Cambridgeshire investigates whether there are links between the failures in Averil’s care and that of four other women with an eating disorder who were under the care of the same services.

The PHSO’s failings have been revealed in an internal review, published today, which ruled the regulator’s investigation took too long and should’ve been completed in half the time.

It also found “insufficient” resource was allocated to the Averil’s investigation, despite staff requesting it, which led to significant delays.

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Source: HSJ, 10 January 2020

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Quarter of children referred for specialist mental health care on NHS are turned away

A quarter of children referred for specialist mental health care because of self-harm, eating disorders and other conditions are being rejected for treatment, a new report has found. 

The study by the Education Policy Institute warns that young patients are waiting an average of two months for help, and frequently turned away. It follows research showing that one in three mental health trusts are only accepting cases classed as the most severe. 

GPs have warned that children were being forced to wait until their condition deteriorated - in some cases resulting in a suicide attempt - in order to get to see a specialist.

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Source: The Telegraph, 10 January 2020

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New data highlights postcode lottery in ovarian cancer diagnosis

Women in some parts of the country are half as likely to be diagnosed with ovarian cancer as elsewhere, new analysis of NHS data has revealed.

The proportion of women diagnosed at an early stage of the disease, when it is most susceptible to treatment, varied in some areas from 22% to 63%.

UK survival rates for cancer have lagged behind other countries and NHS England has set a target to improve early diagnosis with an ambition to have 75% of all cancers diagnosed early by 2028.

The ovarian cancer audit data shows the UK is far from achieving this with only 33% of cancers diagnosed at stage one or two while 50% of cancers were detected at stage three and four.

Chief Executive of Ovarian Cancer Action, Cary Wakefield, said: “Diagnosing ovarian cancer at the earliest stages is crucial, but sadly as we gather data it is clear that a postcode lottery exists around the country, with some areas diagnosing significantly more patients early than others. We want to see all patients diagnosed early enough to get treatment and survive this disease, no matter where they live.”

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Source: The Independent, 9 January 2020

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GP shortages cause 'unacceptable' patient waits

Family doctors are under intense pressure and general practice is running on empty, warns the Royal College of GPs (RCGP). It says severe staff shortages are causing "unacceptable" delays for patients in England.

In a letter to Health Secretary Matt Hancock, its chairman says ministers must take urgent action to deal with the lack of GPs.

The government said it had recruited a "record number" of GP trainees. Ministers are committed to recruiting 6,000 more GPs in England by 2025.

Prof Martin Marshall, who took over as RCGP chairman in November, says GPs are struggling with an escalating workload, which is causing many to burn out and leave the profession.

Dr Andrew Dharman, who works at the The Avenue surgery in Ealing, said the stress has got worse because of the enormous workload placed on GPs. He said: "Sometimes it feels like you're drowning. You know you're trying to stay afloat and on top of all the workload. And you're trying to make sure you're providing the kind of care that you envisage when you go to medical school."

"You feel frustrated sometimes that you can't necessarily do that because of the amount of work and patients."

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Source: BBC News, 9 January 2020

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Latest HSIB report highlights ‘devastating’ impact of delays and pressure on national glaucoma services

Delays to follow-up appointments for glaucoma patients leaves them at risk of sight loss, the Healthcare Investigation Safety Branch (HSIB) warns in their new report.

The report highlights the case of a 34-year old woman who lost her sight as a result of 13 months of delays to follow-up appointments.

Lack of timely follow-up for glaucoma patients is a recognised national issue across the NHS. Research suggests that around 22 patients a month will suffer severe or permanent sight loss as a result of the delays. In HSIB’s reference case, the patient saw seven different ophthalmologists and the time between her initial referral to hospital eye services (HES) and laser eye surgery was 11 months. By this time her sight had deteriorated so badly, she was registered as severely sight impaired.

The investigation identified that there is inadequate HES capacity to meet demand for glaucoma services, and that better, smarter ways of working should be implemented to maximise the current capacity. The report makes several safety recommendations focused on the management and prioritisation of appointments. 

Helen Lee, RNIB Policy and Campaigns Manager, said: “This report has brought vital attention to a serious and dangerous lack of specialist staff and space in NHS ophthalmology services across the country. We know that thousands of patients in England are experiencing delays in time-critical eye care appointments, which is leading to irreversible sight loss for some."

“Without immediate action, the situation will only continue to deteriorate as the demand for appointments increases. RNIB urges full and immediate implementation of the recommendations set out in this report to improve the capacity, efficiency and effectiveness of ophthalmology services.”

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Source: HSIB, 9 January 2020

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NHS use of puberty blockers legal challenge begins

Legal action is being launched against the NHS over the prescribing of drugs to delay puberty. 

Papers have been lodged at the High Court by a mother and a nurse against the Tavistock and Portman NHS Trust, which runs the UK's only gender-identity development service (Gids). Lawyers will argue it is illegal to prescribe the drugs, as children cannot give informed consent to the treatment.

The Tavistock said it had a "cautious and considered" approach to treatment.

The nurse, Sue Evans, left the Gids more than a decade ago after becoming increasingly concerned teenagers who wanted to transition to a different gender were being given the puberty blockers without adequate assessments and psychological work.

Ms Evans said: "I used to feel concerned it was being given to 16-year-olds. But now, the age limit has been lowered and children as young as perhaps 9 or 10 are being asked to give informed consent to a completely experimental treatment for which the long-term consequences are not known."

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Source: BBC News, 8 January 2020

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Death review backlog still growing despite NHSE commitment

A backlog of thousands of deaths of people with learning disabilities awaiting official review has grown further, despite NHS England committing in spring last year to “address” the buildup. 

Information obtained by HSJ shows the number of incomplete reviews increased slightly between May and November last year – from 3,699 to 3,802.

The “national learning disabilities mortality review” programme – known as LeDeR – was launched in 2016 and is meant to review all deaths of people aged four and over.

Mencap head of policy and public affairs, Dan Scorer, said: “It is unacceptable that thousands of deaths have still not been reviewed despite NHS England announcing further funding to make sure all reviews were carried out quickly and thoroughly. These latest figures show that little progress has been made; the programme is still failing to address outstanding reviews as well as keep pace with incoming referrals."

“Behind these figures are families whose loved ones’ deaths may have been potentially avoidable and they have a right to know that health and care services are learning and acting on LeDeR reviews’ recommendations.”

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Source: HSJ, 8 January 2020

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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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Anger over UK's failure to ban breast implants linked to 61 cancer cases

At least 61 women in the UK have been diagnosed with a potentially fatal cancer linked to breast implants, but the type they received continues to be used, with no plans by the regulator to follow France and Australia in banning them.

Lawyers for more than 40 of the women, who are bringing legal action against the manufacturers as well as the clinics and doctors who carried out the surgery, say the textured implants linked to anaplastic large cell lymphoma (ALCL) should be withdrawn from the market. Smooth implants are available instead, which have no proven connection to the cancer of the white blood cells.

The Medicines and Healthcare Products Regulatory Agency (MHRA) says the disease is very rare, but Sarah Moore, a solicitor at Leigh Day law firm, believes there are more cases than the regulator is aware of. “I think there has been misdiagnosis and under-diagnosis, and I think we have to bear in mind that in the last 18 months there have been 17 more reported cases of ALCL,” she said.

The leading manufacturer of textured implants, Allergan, has withdrawn them from worldwide sale. In December 2018 its European kitemark for the implants expired – the French agency that had granted certification had asked for extra safety data that the company said it could not provide in time. They have not been on sale in Europe since then. The US authorities asked the company to recall its textured implants in July 2019 and Allergan took them off the market.

France and Australia have since banned the sales of all textured implants, although neither has suggested that women should actively seek to have them removed.

In the UK, other brands of textured implants are still in use. Neither NHS England, the NHS Business Services Authority nor the MHRA could say how many had been given to women in the NHS after a mastectomy for breast cancer.

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Source: The Guardian, 7 January 2020

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Health strike: RCN nurses in second day's strike

About 9,000 nurses across Northern Ireland have begun a 12-hour strike today in a second wave of protests over pay and staffing levels.

More than 2,000 appointments and procedures have been cancelled, including a number of elective caesarean operations.

The Health and Social Care Board said it expects "significant disruption"

Royal College of Nursing (RCN) Director Pat Cullen told BBC Radio Ulster's Good Morning Ulster programme that nurses felt "bullied" by health officials. Her comments followed a warning by the heads of Northern Ireland's health trusts on Tuesday that this week's strikes could push the system "beyond tipping point".

Valerie Thompson, a deputy ward sister at Londonderry's Altnagelvin Hospital, said concerns over safe staffing levels and pay parity had brought her to the picket line.

"We need to have the proper amount of staff to care for our patients, give them the respects, dignity, care they deserve," she said. "We are a loyal workforce; we get on with it, and rally around. But it is difficult. We miss breaks, go home late, staff are just exhausted."

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Source: BBC new, 8 January 2020

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Implementation of safety improvements for the placement of nasogastric tubes

The Healthcare Safety Investigation Branch (HSIB) has launched an investigation looking at nasogastric tubes and how previously identified safety improvements for the placement of these tubes are put into practice.

Nasogastric (NG) tubes are used to deliver fluid, food and medication to patients via a tube that passes through the nose and down into the stomach. There is a risk of serious harm and risk to life if NG tubes are incorrectly placed into the lungs, rather than the stomach, and feed is passed through them.

HSIB has started this investigation after they were notified of a patient who inadvertently had a nasogastric tube inserted into his lung.

Further information

Source: HSIB, 7 January 2020

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Improve brand and batch number recording, urge drug safety professionals

New research from the UK’s Drug Safety Research Unit (DSRU) has found that hospital pharmacists, doctors and nurses only recorded batch numbers for biologic medicines between 38% and 58% of the time during routine hospital practice.

Further, an analysis of spontaneous adverse drug reaction (ADR) reports showed that brand names were only included 38% of the time, while batch number traceability was only 15%.

Because of the study results, the DSRU is encouraging health professionals to improve the recording in order to aid patient safety, suggesting that it has “some way to go to encourage health professionals to record this information.”

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Source: PharmaTimes Online, 7 January 2020

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