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Trust appoints chair to lead independent suicides review

A trust has appointed a chair to lead an independent review into dozens of suicides that was sparked by allegations of record tampering.

Following questions from HSJ about the review’s chair and terms of reference, Cambridgeshire and Peterborough Foundation Trust said Ellen Wilkinson, a former medical director at Cornwall Partnership FT and its current chief clinical information officer, would chair the review. 

The trust, which is looking for a substantive CEO following Anna Hills’ departure earlier this year, said the review “will not examine individual patient deaths but will take a thematic approach and look at the learnings we can take from these tragic incidents”.

The trust told HSJ the terms of reference for the review of more than 60 cases of patients who died by suicide since 2017 were still being finalised.

The decision not to investigate individual cases has been criticised by the whistleblower whose concerns prompted the review in the first place, as HSJ reported in October.

While an employee of the trust, Des McVey, a consultant nurse and psychotherapist, carried out an investigation in July 2021 into the case of 33-year-old Charles Ndhlovu, who died by suicide in 2017.

Mr McVey told HSJ his review found Mr Ndhlovu’s patient record had been tampered with and “his care plans were created on the day after his death” – a conclusion he stands by.

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Source: HSJ, 3 April 2024

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NHS watchdog to review patient safety at Glasgow A&E department

Patient safety in the Accident & Emergency unit at the Queen Elizabeth University Hospital in Glasgow will be reviewed by an NHS watchdog.

Healthcare Improvement Scotland (HIS) was first contacted by 29 A&E doctors in May 2023 warning that safety was being "seriously compromised".

HIS last month apologised for not fully investigating their concerns.

The review will consider leadership and operational issues and how they may have impacted on safety and care.

In the letter to HIS, the 29 consultants highlighted treatment delays, "inadequate" staffing levels and patients being left unassessed in unsuitable waiting areas.

They claimed this resulted in "preventable patient harm and sub-standard levels of basic patient care".

The doctors also said critical events had occurred including potentially avoidable deaths.

The consultants said repeated efforts to raise the issues with health board bosses "failed to elicit any significant response".

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Source: BBC News, 4 April 2024

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GMC will no longer launch FTP proceedings for ‘minor’ concerns

The General Medical Council (GMC) has relaxed its fitness to practise (FTP) processes for doctors so that ‘minor’ concerns such as ‘pushing a colleague’ are not taken to tribunal. 

In an update to its guidance, the regulator has given FTP decision makers and case examiners ‘more discretion’ to throw out complaints if they represent a lower risk to public protection. 

Concerns which are ‘minor in nature and did not impact patient care’ will fall under this guidance.

This is part of the GMC’s efforts to carry out ‘more efficient and proportionate investigations’ and to ‘minimise’ stress for doctors during the FTP process. 

Two examples of concerns which will no longer need to be investigated, if there are ‘no aggravating factors’,  are:

  • A doctor giving false details to a market research company, in order qualify for free products.
  • A doctor pushing a colleague out the way following a heated argument. 

The regulator has said: "Decision makers will now be able to weigh the full circumstances of a concern earlier in the fitness to practise process to assess the overall risk to public protection including to public confidence in the profession– meaning some concerns may not need to be investigated or referred to a tribunal."

However, the guidance, which covers concerns relating to violence and dishonesty, emphasises that allegations which raise a risk to public protection will continue to be investigated. 

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Source: Pulse, 4 April 2024

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Private ambulance service charging £99 opens to tackle patient delays amid concerns over a ‘two-tier’ system

A new private ambulance service will offer faster travel to A&E for those caught out by half-day waits for NHS ambulances, The Independent can reveal, in a sign of a growing “two-tier” health service.

MET Medical ambulance service will begin by charging £99 for a call-out, and could serve thousands of people a week, its chief executive Dave Hawkins has said.

Mr Hawkins, who is a paramedic himself, said he launched the service after seeing his elderly relatives wait too long for NHS ambulance services following falls.

It comes as waiting times for ambulance service reached a crisis point in the last year, with frail and vulnerable people waiting hours for an ambulance.

Ambulance response times hit record highs over 2022-23, with people who should have an ambulance within 20 minutes waiting an hour and 30 minutes in December 2023.

According to estimates from the Association of Ambulance Chief Executives, 34,000 patients were likely to have suffered harm due to these delays – this hit a high of more than 60,000 in December 2022.

MET Medical will still have to wait to deliver patients if they are seen as a priority, but it said its patients are likely to be lower priority and can be dropped at A&E without waiting for a handover.

Mr Hawkins said vulnerable patients waiting for an ambulance can wait up to 12 hours.

“It’s that moment when you’re out of options, it’s really a horrible place to be, particularly if it’s a loved one … It is a shame, like we’ve seen from the stats and everything, that the health service is failing us."

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Source: The Independent, 3 April 2024

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Almost 10 million people in England could be on NHS waiting list

Almost 10 million people across England could be waiting for an NHS appointment or treatment, 2 million more than previously estimated, according to a survey by the Office for National Statistics (ONS).

The ONS survey of about 90,000 adults found that 21% of patients were waiting for a hospital appointment or to start receiving treatment on the NHS.

When extrapolated, this equates to 9.7 million people. In January, the waiting list stood at 7.6 million, according to official NHS statistics.

The survey found that the delays were most prominent among 16-24-year-olds, one in five of whom said they had experienced waiting times of more than a year.

Conducted in January and February, the survey was part of the annual winter coronavirus infection study of adults aged 16 and over.

The ONS said the survey was the first of its kind to assess the experiences of adults awaiting hospital appointments, tests or medical treatments. It said the data was experimental, based on self-reported data, and may differ from other statistics on waiting lists.

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Source: The Guardian, 3 April 2024

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NHS faces ‘avalanche’ of demand for autism and ADHD services, thinktank warns

The NHS is experiencing an “avalanche of need” over autism and attention deficit hyperactivity disorder (ADHD), but the system in place to cope with surging demand for assessments and treatments is “obsolete”, a health thinktank has warned.

There must be a “radical rethink” of how people with the conditions are cared for in England if the health service is to meet the rapidly expanding need for services, according to the Nuffield Trust.

The thinktank is calling for a “whole-system approach” across education, society and the NHS, amid changing social attitudes and better awareness of the conditions. It comes days after the NHS announced a major review of ADHD services.

Thea Stein, the chief executive of the Nuffield Trust, said: “The extraordinary, unpredicted and unprecedented rise in demand for autism assessments and ADHD treatments have completely overtaken the NHS’s capacity to meet them. It is frankly impossible to imagine how the system can grow fast enough to fulfil this demand.

“We shouldn’t underestimate what this means for children in particular: many schools expect an assessment and formal diagnosis to access support – and children and their families suffer while they wait.”

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Source: The Guardian, 4 April 2024

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NHS gender identity clinics for children are ‘nowhere near ready’

The new NHS gender identity clinics for young people are “understaffed” and “nowhere near ready”, it was claimed on Monday as they officially started taking on patients.

A London hub, alongside a second in the northwest, will begin to see patients this week as they replace the Gender Identity Development Service (Gids) at the Tavistock and Portman NHS Foundation Trust.

The Gids clinic was ordered to close after a review by Dr Hilary Cass found it was “not a safe or viable long-term option”.

However, whistleblowers described as senior staff at Gids have expressed concerns about the preparedness and expertise of the new hubs, just as they open.

One, who spoke to the i newspaper under the condition of anonymity, said: “It’s been shoddy, disorganised, messy and unclear. And at times, it’s felt unsafe.”

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Source: The Times, 1 April 2024

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DrugGPT: new AI tool could help doctors prescribe medicine in England

Drugs are a cornerstone of medicine, but sometimes doctors make mistakes when prescribing them and patients don’t take them properly.

A new AI tool developed at Oxford University aims to tackle both those problems. DrugGPT offers a safety net for clinicians when they prescribe medicines and gives them information that may help their patients better understand why and how to take them.

Doctors and other healthcare professionals who prescribe medicines will be able to get an instant second opinion by entering a patient’s conditions into the chatbot. Prototype versions respond with a list of recommended drugs and flag up possible adverse effects and drug-drug interactions.

“One of the great things is that it then explains why,” said Prof David Clifton, whose team at Oxford’s AI for Healthcare lab led the project.

“It will show you the guidance – the research, flowcharts and references – and why it recommends this particular drug.”

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Source: The Guardian, 31 March 2024

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Trusts face threat of legal action due to new quality standards

Trusts could be exposed to increased negligence claims as a result of new NHS England guidance for a rare spinal condition, a royal college has claimed.

The Royal College of Emergency Medicine (RCEM) has said updated national guidance on treating cauda equina syndrome could also lead to greater “inequity of access” due to issues accessing timely MRI scans at many accident and emergency departments.

An NHS Resolution report in 2022 found delayed MRI scans were a significant factor in high-value clinical negligence claims, particularly those relating to management of spinal conditions. 

The guidance issued by NHSE’s Getting It Right First Time programme national pathway guidance says emergency MRIs for suspected CES should be taken within four hours of requests to radiology, and where this is not possible, “standard operating procedures” involving local spinal and radiology services should be in place for urgent out-of-hours scanning. Local provision for this “must be in place by June 2024,” the guidance says.

NHSE said the GIRFT guidance has been endorsed by 11 clinical and patient bodies, including the Royal College of Radiologists and the Spinal Injuries Association.

But RCEM, understood to be the only clinical body not to endorse the guidance, has issued a position statement last month stating that “few EDs, outside of tertiary centres, have access to 24/7 MRI scanning”.

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Source: HSJ, 3 April 2024

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Catherine died on the operating table. Now police are investigating

Catherine O’Connor was 17 when she died, having lost 14 litres of blood during high-risk surgery on her back.

At her inquest, the surgeon who operated on her, John Bradley Williamson, told the coroner the procedure at Salford Royal Hospital in Greater Manchester had “progressed uneventfully” and “the blood loss was perhaps a little higher than one would usually anticipate but was certainly not extreme”. The coroner recorded a verdict of death by misadventure.

Now Greater Manchester police are examining O’Connor’s death, in February 2007, and whether Williamson misled the coroner during the inquest in September that year.

Catherine's family are now demanding a new inquest into her death in 2007.

This is because in the days after O’Connor’s death, Williamson sent an internal letter to the head of the hospital’s haematology department, Simon Jowitt, describing the surgery as “difficult” and having involved “a catastrophic haemorrhage”. Williamson had also ignored advice to have a second surgeon present during the operation.

Officers led by Detective Inspector Michael Sharples have commissioned two expert reports and sought advice from the Crown Prosecution Service ahead of a meeting with the coroner, who has been asked to consider reopening O’Connor’s inquest.

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Source: The Times, 31 March 2024

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Families must prove trust caused death of babies, despite inquiry’s damning conclusions

Families have been told they will have to prove liability for the harm caused to mothers and children at East Kent Hospitals University Foundation Trust before getting compensation.

This is despite the inquiry having examined each case in detail and concluding 45 babies could have survived, while 12 who sustained brain damage could have had a different outcome. It also determined 23 women who either died or suffered injuries might have had better outcomes had care been given to “nationally recognised” standards. 

However, NHS Resolution – which handles claims for clinical negligence – now says families must prove causation and a breach of duty of care before any compensation can be made. This stipulation has been made even in cases where the inquiry found different treatment would have been reasonably expected to make a difference to the outcome.

The investigation into the trust’s maternity care led by Bill Kirkup reported 18 months ago. Speaking to HSJ, its author said: “I am disappointed that East Kent families are facing these problems after everything that has happened to them. Of course, it is true that the independent investigation panel was not in a position to rule on negligence, but we did provide a robust clinical assessment of each case.

“I would have hoped that this could be taken into account in deciding to offer early settlement instead of a protracted dispute. It seems sad that a more compassionate approach has not been adopted.”

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Source: HSJ, 2 April 2024

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Four-year-old girl left with hearing loss for over a year after being left untreated

Kara Dilliway was just three years old when she came down with a common ear infection in October 2022.

She recovered quickly, as was expected, but just days after the infection cleared her parents found she was struggling to hear and talk.

“We’d noticed she’d just started to say yes and no to things, that’s when we thought something is going on,” says her mother Sam Dilliway, a 41-year-old community care worker from Basildon, Essex. Doctors said she could have glue ear, a common condition in children – fluid build-up had started to cause problems with her hearing, and would need draining.

But what should have been a minor ailment has turned into a never-ending ordeal for the family. What was a simple case of glue ear could now leave her with hearing loss for up to two years as she awaits routine treatment.

It comes after data released in January found that over 10 million people have been left on NHS waiting lists for basic ear care services.

Dr Aymat says that the long-term effects of such conditions being left untreated in children can be severe. While glue ear is unlikely to leave permanent damage, there is always a small risk of permanent hearing loss. However, the developmental effects are far more likely and potentially long-lasting.

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Source: The Independent, 1 April 2024

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NHS told to cut spending on doctors and nurses to save £4.5bn

Hospitals are preparing to cut spending on doctors and nurses by hundreds of millions of pounds after being ordered to plug a £4.5 billion hole in the NHS budget.

Chief executives at hospitals, mental health trusts and community services in England have been ordered to review staffing levels and draw up plans to close some services and merge others. They are also looking at banning or restricting the use of some agency workers.

NHS bosses have been alerted in recent days to the scale of the cuts needed after negotiating financial plans for next year. The health service in England has a budget of £165 billion for the 2024-25 financial year, which starts next week. The budget rose by 3.2% in real terms between 2018-19 and 2023-24.

Spending has been put under additional pressure by the cost of covering strikes by junior doctors which NHS England has said has cost more than £1.5 billion and affected more than 430,000 patients’ appointments.

Saffron Cordery, deputy chief executive of NHS Providers, said services had been stretched by the need to pick up the pieces from a shortage of social care and other community services. She said an ageing population and poor public health meant patients in hospital were sicker and staying longer, needing more care.

She said: “Trust leaders are being pushed to the very limits of what is possible, and there will be a situation where they have to make difficult choices about keeping basic services going versus investing in quality and improvement for the future. We are in a situation where we will be patching something that’s already a bit patched-together.”

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Source: Times, 31 March 2024

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Cost of private Covid jabs risks widening health inequalities, experts warn

Experts and patient groups have warned that the high cost of private Covid vaccinations could exacerbate health inequalities and leave those more at risk from the virus without a vital line of defence.

Both high street chain Boots and pharmacies that partner with the company Pharmadoctor are now offering Covid jabs to those not eligible for a free vaccination through the NHS, with the former charging almost £100 for the Pfizer/BioNTech jab.

While Pharmadoctor says each pharmacy sets its own prices, it suggests the Pfizer/BioNTech jab will set customers back £75-£85, while the latest Novavax jab will cost about £45-£55.

However experts have raised concerns that the high cost of the private jabs will widen inequalities, with the vaccinations unaffordable for many.

“The most disadvantaged in society are most likely to be exposed to respiratory viruses due to things like poverty, intergenerational households and crowded workplaces. While they might be most in need of a seasonal vaccine, they will also be the least likely to afford £100 in the midst of a cost of living crisis,” said Dr Marija Pantelic, of the University of Sussex.

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Source: The Guardian, 28 March 2024

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Vulnerable Britons dying as not being given antibiotics at dentist, doctors say

Patients are dying needlessly every year due to vulnerable Britons with heart problems not being given antibiotics when they visit the dentist, doctors have said.

Almost 400,000 people in the UK are at high risk of developing life-threatening infective endocarditis any time they have dental treatment, the medics say. The condition kills 30% of sufferers within a year.

A refusal to approve antibiotic prophylaxis (AP) in such cases means that up to 261 people a year are getting the disease and up to 78 dying from it, they add. That policy may have caused up to 2,010 deaths over the last 16 years, it is claimed.

That danger has arisen because the National Institute for Health and Care Excellence (NICE) does not follow international good medical practice and tell dentists to give at-risk patients antibiotics before they have a tooth extracted, root canal treatment or even have scale removed, the experts claim.

The doctors – who include a professor of dentistry, two leading cardiologists and a professor of infectious diseases – have outlined their concerns in The Lancet medical journal. In it, they urge NICE to rethink its approach in order to save lives, citing pivotal evidence that has emerged since the regulator last examined the issue in 2015, which shows that antibiotics are “safe, cost-effective and efficacious”.

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Source: The Guardian, 2 April 2024

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Links between primary and secondary care must be ‘streamlined’ says NHSE

All trusts should pick a “designated lead” for improving how they work with primary care, according to new NHS planning guidance. 

The guidance for 2024-25 published by NHS England today states: “Every trust should have a designated lead for the primary–secondary care interface.”

It also asks integrated care boards to “regularly review progress” on how secondary care services are working with primary care.

NHSE recovery plans include trying to cut the number of patients effectively referred back to GP practices by other services, in order to reduce GP workload.

The guidance states: “Streamlining the patient pathway by improving the interface between primary and secondary care is an important part of recovery and efficiency across healthcare systems”.

The planning guidance — published on Wednesday night after months of delays — also said systems should continue to develop integrated neighbourhood teams, including by trying to “improve the alignment of relevant community services” to primary care network footprints. 

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Source: HSJ, 27 March 2024

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Diabetes patients to be offered artificial-pancreas technology

Tens of thousands of people with type 1 diabetes in England are to be offered a new technology, dubbed an artificial pancreas, to help manage the condition.

The system uses a glucose sensor under the skin to automatically calculate how much insulin is delivered via a pump.

Later this month, the NHS will start contacting adults and children who could benefit from the system.

But NHS bosses warned it could take five years before everyone eligible had the opportunity to have one.

This is because of challenges sourcing enough of the devices, plus the need to train more staff in how to use them.

In trials, the technology - known as a hybrid closed loop system - improved quality of life and reduced the risk of long-term health complications.

And at the end of last year, the National Institute of Health and Care Excellence (Nice) said the NHS should start using it.

Prof Partha Kar, NHS national speciality advisor for diabetes, said the move was "great news for everyone with type 1 diabetes".

"This futuristic technology not only improves medical care but also enhances the quality of life for those affected," he added.

Source: BBC News, 2 April 2024

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Long A&E wait times lead to more than 250 needless deaths a week

More than 250 patients a week could be dying unnecessarily, due to long waits in A&E in England, according to analysis of NHS data.

The Royal College of Emergency Medicine analysed the 1.5 million who waited 12 hours or more to be admitted in 2023.

A previous data study had calculated the level of risk of people dying after long waits to start treatment and found it got worse after five hours.

The government says the number seen within a four-hour target is improving. This is despite February seeing the highest number of attendances to A&E on record, it adds.

The Royal College of Emergency Medicine (RCEM) carried out a similar analysis in 2022, which at that time resulted in an estimate of 300-500 excess deaths - more deaths than would be expected - each week.

The analysis uses a statistical model based on a large study of more than five million NHS patients that was published in 2021.

RCEM president Dr Adrian Boyle said long waits were continuing to put patients at risk of serious harm.

"In 2023, more than 1.5 million patients waited 12 hours or more in major emergency departments, with 65% of those awaiting admission," he said.

"Lack of hospital capacity means that patients are staying in longer than necessary and continue to be cared for by emergency department staff, often in clinically inappropriate areas such as corridors or ambulances.

"The direct correlation between delays and mortality rates is clear. Patients are being subjected to avoidable harm."

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Source: BBC News, 1 April 2024

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NHS AI expansion to help tackle missed appointments and improve waiting times

The NHS is set to roll out artificial intelligence (AI) to reduce the number of missed appointments and free up staff time to help bring down the waiting list for elective care.

The expansion to ten more NHS Trusts follows a successful pilot in Mid and South Essex NHS Foundation Trust, which has seen the number of did not attends (DNAs) slashed by almost a third in six months.

Created by Deep Medical and co-designed by a frontline worker and NHS clinical fellow, the software predicts likely missed appointments through algorithms and anonymised data, breaking down the reasons why someone may not attend an appointment using a range of external insights including the weather, traffic, and jobs, and offers back-up bookings.

The appointments are then arranged for the most convenient time for patients – for example, it will give evening and weekend slots to those less able to take time off during the day.

The system also implements intelligent back-up bookings to ensure no clinical time is lost while maximising efficiency.

It has been piloted for six months at Mid and South Essex NHS Foundation Trust, leading to a 30% fall in non-attendances. A total of 377 DNAs were prevented during the pilot period and an additional 1,910 patients were seen. It is estimated the trust, which supports a population of 1.2 million people, could save £27.5 million a year by continuing with the programme.

The AI software is now being rolled out to ten more trusts across England in the coming months.

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Source: NHS England, 14 March 2024

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Global research agenda on knowledge translation and evidence-informed policy-making

While the importance of translating evidence into policies and practices is widely acknowledged by evidence producers, intermediaries, users, and funders, there is much less agreement on suitable mechanisms for promoting effective evidence use. As a response, the World Health Organization (WHO) has initiated an extensive and inclusive research priority-setting exercise in Knowledge Translation (KT) and Evidence-informed Policy-making (EIP) through a series of technical consultations.

This priority-setting initiative, coordinated by the Evidence to Policy and Impact Unit in WHO’s Science Division, involves national and international researchers, practitioners, and organizations across all WHO regions. Collectively, they will assess the evidence base for effective research utilization in decision-making. The overarching goal of this project is to maximize the impact of KT and EIP research to promote the translation of evidence into effective policies that enhance population health and well-being. Key objectives include:

  • Efficiency and Synergy: Streamlining research efforts in KT and EIP.
  • Strategic Funding: Directing research funding toward identified priority areas.
  • Effective Approaches: Enhancing understanding of evidence use for policy-making.
  • Collaboration: Promoting cross-sectoral collaboration in KT and EIP research.
  • Awareness: Championing for evidence-informed policy-making at all levels.

In the first half of the 2024, global experts – selected during an open call – are now actively participating in a series of consultations to identify gaps and opportunities in KT and EIP research. The consultations provide a pivotal opportunity for participants to discuss current research gaps, harmonize terminology and chart a course toward shared priorities.

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Source: WHO, 22 March 2024

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NHS must stop sending eating disorder patients to die, watchdog says

NHS teams are giving up on patients with severe eating disorders, sending them for care reserved for the dying rather than trying to treat them, a watchdog has warned the government.

In a letter to minister Maria Caulfield, the parliamentary health service ombudsman Rob Behrens has hit out at the government and the NHS for failures in care for adults with eating disorders despite warnings first made by his office in 2017.

The letter, seen by The Independent, urged the minister to act after Mr Behrens heard evidence that eating disorder patients deemed “too difficult to treat” are being offered palliative care instead of treatment to help them recover.

The ombudsman first warned the government that “avoidable harm” was occurring and patients were being repeatedly failed by NHS systems in 2017, following an investigation into the death of Averil Hart.

The 19-year-old died while under the care of adult eating disorder services in Norfolk and Cambridge. In 2021, following an inquest into her death and the deaths of four other women, a senior coroner for Cambridge, Sean Horstead, also sent warnings to the government about adult community eating disorder services.

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Source: The Independent, 27 March 2024

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New documents reveal patient safety concerns over strike day cover

An investigation published by The BMJ today reveals new details of requests to recall striking junior doctors from picket lines for patient safety reasons. 

Documents show that while most trusts in England did not make such requests, those that did were rejected by the BMA in most cases. Some of these trusts warned of potential harm to patients from cancelling operations at the last minute and short staffing, reports assistant news editor Gareth Iacobucci.

However, the BMA said it takes concerns about patient safety “incredibly seriously” and provided The BMJ with summaries of why requests were turned down.

The union’s chair of council Phil Banfield said, “Throughout industrial action we have engaged thoroughly and in good faith with the derogation process, considering each request carefully to ensure that granting a derogation is necessary and the last and only option.”

He said that poor planning by some trusts had led to some routine care being inappropriately booked in on strike days. In other instances, he said trusts had failed to make sufficient effort to draft in the necessary cover for strike days.

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Source: BMJ, 28 March 2024

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Hospital caring for Nottingham triple killer left patients worse than when they went in, damning report finds

Patients at the hospital that treated killer Valdo Calocane were discharged too soon and released in a worse state into the community, the NHS safety watchdog has found.

Serious failings by Nottinghamshire Hospital Foundation Trust in keeping patients and the public safe have been identified in a review from the Care Quality Commission (CQC).

More than 1,200 patients are waiting to be seen by community services, the report found. Meanwhile, several hundred who are receiving treatment did not have a clinician overseeing their care,the CQC found.

The review was launched by the government following the conviction of killer Valdo Calocane, who was under the care of the NHS trust’s community services.

The CQC review said patients reported that crisis services are either “useless” or detrimental to their health.

The three broad areas of concern, highlighted in the CQC’s report, were:

  • High demand for services was leading to long waiting times for care and a lack of oversight of those waiting.
  • The trust does not have enough staff to keep patients safe in the community and within some hospital services.
  • Senior leaders at the trust do not have clear oversight of the risks and issues within the service.

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Source: The Independent, 27 March 2024

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Wrong patient fitted with coil after Caesarean

A new mum was confused for another patient and mistakenly fitted with a contraceptive coil after a C-section.

Another patient in north Wales almost had the wrong toe removed during surgery to amputate two others.

A third incident happened when a patient, unable to swallow oral medication, had it crushed, mixed with water and administered with a syringe.

These so-called "never events" happened at hospitals in the Betsi Cadwaladr health board area in February.

In a report into the three incidents in February, Betsi Cadwaladr health board outlined how a patient had a coil - an intrauterine device which prevents pregnancy - inserted after undergoing a Caesarean section.

Described in the report as "wrong procedure", it had been planned for a different patient but a mistake had been made after the "list order was changed due to the increase in category for this patient".

Another incident, described in the report as "wrong site surgery", described a patient who was due to have their second and third toes amputated. However, an incision was made in their fourth toe by accident.

Luckily, the error was spotted and the correct toes were amputated.

In the third never event, described as "wrong route", the report details the case of a patient who was unable to swallow oral medication.

To administer it, a member of staff crushed it, mixed it with water and "inadvertently" gave it intravenously, according to the report.

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Source: BBC News, 28 March 2024

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‘Treated like an animal’: NHS nurse attempted suicide twice while waiting 10 days for hospital bed

A senior mental health nurse suffered “degrading and humiliating” treatment while she languished for 10 days on an unsuitable NHS ward during a mental health crisis, The Independent has been told.

Rachel Luby, 36, was admitted to Basildon Hospital A&E in Essex on 5 January this year after attempting to take an overdose of over-the-counter medicine following a traumatic assault.

This, she claimed, was the start of weeks of horrific care she endured while waiting for a mental health bed. It culminated in her being restrained and forced into a caged van “like an animal”.

She revealed her story after The Independent reported on a warning from top emergency doctors that self-harming and suicidal patients who go to A&E are not being treated with compassion because staff are overwhelmed.

Ms Luby, an award-winning nurse, said she waited more than a week and a half in a general hospital before she was moved to a bed on a mental health ward.

Ms Luby was able to leave the ward and find medication to overdose again, despite staff allegedly assessing her as a risk. In a second incident, she went to the bathroom and attempted to take her own life.

She told The Independent: “I feel that this is something I will not recover from. I will not ever reach out for help in the future.

“If this is the treatment that I’m getting as a nurse, then what the heck is happening to those that don’t have the voice or education that I have? It horrifies me to think what is happening to people that are far more vulnerable than me.”

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Source: The Independent, 27 March 2024

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