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Keep up to date with the latest news, research and activity in patient safety.

USA: Judge orders CDC, FDA, HHS webpages to be restored

A judge has granted Public Citizen’s motion for a temporary restraining order (TRO) in a lawsuit brought on behalf of Doctors for America against the Office of Personnel Management (OPM), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA) and the Department of Health & Human Services (HHS). The lawsuit challenges the agencies’ removal from publicly accessible government websites of vital health-related data and other information used by physicians, researchers, and other health professionals.
The TRO orders the agencies to restore the webpages and datasets.
Dr. Christine Petrin, president of the board of directors for Doctors for America, “In the short time that important web pages were removed from the websites of major public health agencies, our members have seen firsthand how dangerous it can be to practice medicine without critical clinical information. For the safety of our patients, we applaud the decision to restore this information, placing it back in the hands of providers around the country to keep their patients and communities safe and healthy.”
Dr. Reshma Ramachandran, a member of the board of directors for Doctors for America, added: “Today’s victory recognizes just how important these webpages are for us as physicians and researchers as we work to care for patients and improve public health. When these pages went dark, leaving us without access to crucial clinical information and public health data, many of my colleagues and I faced challenges in providing evidence-based care to patients, sometimes even leading to delays in doing so. We will continue to fight to reinstate these pages permanently so that no other patients face any harm.”
Read full story
Source: Doctors for America, 11 February 2025
Patient Safety Learning

Scandal of the women harmed by medical implants who are banned from seeking compensation

Last September Emma-Louise Lucas, a mother of one from Manchester, at just 31 received the shocking news that she had a rare type of cancer, caused by her breast implants. 
Called breast-implant associated anaplastic large-cell lymphoma (BIA-ALCL), it’s a form of Non-Hodgkin’s Lymphoma, which affects immune cells.
The disease has been linked to implants manufactured by Allergan. While the US medical company has made no admission of liability, in 2019 it issued a voluntary global recall of these types of implants.
Now Emma, a manager of a civil-engineering company, is facing not just a shocking diagnosis, but learning she is the latest victim of a vast legal injustice.
Emma had her implants inserted in March 2014. That time gap, of just over a decade, means that under UK rules she is barred from taking a legal case against the makers. 
This is because there is a ten-year limit on making medical-device injury claims, even though it often takes more than ten years for patients to start suffering symptoms of harm.
It is a different situation in Europe, where the legal limit for such claims is being raised to 25 years.
This unfairness is highlighted by the fact that last August, in a landmark case, 140 women in the UK won an undisclosed sum from three companies, Johnson & Johnson, Boston Scientific and Bard after suffering years of misery caused by mesh, or transvaginal tape (TVT). 
The total sum is expected to run into millions of pounds. But thanks to the ten-year legal snare, thousands of other UK women such as Gail McCourt, who have the exact same type of injuries caused by the same mesh, aren’t allowed to pursue the same claims.
In a similar scenario, hundreds of British women are now pursuing compensation for harm they say was caused by a contraceptive implant called Essure. 
Read full story
Source: The Daily Mail, 11 February 2025
Patient Safety Learning

Thousands wait more than a day in A&E, data shows

Nearly 39,000 patients spent more than a day in North-West England's A&Es because there were no hospital beds for them, BBC North West has discovered.
Statistics show of those patients, more than 1,000 patients waited longer than three days, often spending much of that time on a trolley in the corridor.
The Royal College of Emergency Medicine (RCEM) has warned that nationally, the situation could be costing thousands of lives.
NHS England said they were dealing with rising demand and staff were working extremely hard but they understood how long waits impacted on patients.
Colin Gray was one of those patients. The 80-year-old spent 40 hours in A&E at Arrowe Park Hospital in Wirral after arriving by ambulance on 30 December with heart problems.
"I was in corridors from Monday until Thursday evening in the same clothes that I'd arrived in and probably in the same bedding on the trolley," he said
"It was just a mass of trolleys… the queue seemed to go on forever."
At the time, the trust which runs the site said the department, like most, was extremely busy.
"To maintain patient safety, we prioritise the patients in most urgent need of emergency care and unfortunately this may have meant a longer than expected wait for other patients especially those awaiting hospital admission," they said.
Read full story
Source: BBC News, 12 February 2025
Patient Safety Learning

The seven-year wait for a dentist: why Linda Colla pulled out her own teeth

In chronic pain, unable to find an NHS practice and priced out of private care, Colla – like millions of Britons – felt she had no choice but to take matters into her own hands.
Linda Colla holds an imaginary tooth between her forefinger and thumb and pulls it. Then she adds some rotation. Extracting her own teeth required wiggling and twisting, she explains. “It took me a couple of weeks to get each one out, because they just loosened and loosened and loosened. I used a tissue to get a better grip.”
She points to a front incisor. It was the first to come out. Then a canine and finally a big molar. “It sounds very dramatic, pulling them out. But actually they were already loose,” she says. There was some pain on extraction, but they had been causing her constant pain before that. “It was too painful to eat. They just had to come out.”
In 2018, Colla moved to east Devon. She contacted various dental surgeries and was told either that they didn’t take NHS patients or that they didn’t have the capacity to take any more. 
She went on a waiting list. “I got an email once – or was it a text? – asking if I still wanted to be on the list. I said yes, but I haven’t heard anything since.” She presumes, seven years on, she is still on that list.
To have a tooth removed privately costs at least £150. Colla couldn’t afford that. When her three remaining real teeth became too painful to live with, about three years ago, she felt she had no choice but to take matters into her own hands.
Thirteen million people in England – 28% of the adult population – have an unmet need for dentistry, according to an analysis in July by the British Dental Association (BDA). The number of people on waiting lists for an NHS dentist is estimated to be about 780,000.
When the BDA and the Daily Mirror called up 100 practices listed on nhs.uk as “accepting new patients when availability allows”, they found that 86 were not accepting new patients. Some practices reported a waiting list of up to 10 years. In March 2023, YouGov found that 10% of Britons had carried out their own dental work; 34% of those had pulled out – or tried to pull out – their teeth.
Read full story
Source: The Guardian, 12 February 2025
Patient Safety Learning

Hospital warned over 'significant' safety gaps

An acute trust has been served a warning notice due to “significant concerns” over patient safety in one of its emergency departments.
The Care Quality Commission said there was a lack of oversight of patients in the ED at Basildon Hospital, one of three main sites run by Mid and South Essex Foundation Trust (MSEFT), and that the absence of a robust booking system was putting them at risk of harm.
MSEFT has published the warning notice in the papers ahead of its board meeting this week. The notice followed an unannounced inspection in December and a follow-up visit last month.
The CQC said: “We have taken this urgent action as we believe a person will or may be exposed to the risk of harm if we do not do so.”
Ms Roberts said there was a lack of clinical oversight in the waiting room during the follow-up visit on 8 January. She said the only clinical staff in the large and busy waiting area were navigation nurses who were going in and out of rooms to assess patients.
MSEFT had said a nurse and health care assistant would be added to the waiting room team after the first visit, but inspectors did not see any during the follow-up, according to the letter. Ms Roberts said: “This puts patients at risk of unmonitored deterioration and harm.”
Read full story (paywalled)
Source: HSJ, 12 February 2025
Patient Safety Learning

Beware ill-fitting menstrual cups, warn doctors

Doctors are advising women to take care using menstrual cups, after one user developed temporary kidney problems because the cup was misaligned.
The patient, in her 30s, had been experiencing intermittent pelvic pain and blood in her urine for months, but had not linked the symptoms to the menstrual cup, which is used to catch monthly blood flow.
Although exceedingly rare, a poorly positioned cup inside the vaginal passage can press on other nearby structures, such as ureters - tubes carrying urine to the bladder, according to Danish doctors quoted in the British Medical Journal, external.
Selecting the appropriate size cup is important, as well as inserting it properly, doctors have stressed.
The patient made a complete recovery, but doctors have warned: "Correct positioning, along with choosing the correct cup shape and size, is important to prevent negative effects on the upper urinary tract.
"Menstrual cups can be bought and used without clinical advice from a health professional, which emphasises the importance of detailed and clear patient information material."
Read full story
Source: BBC News, 11 February 2025
Patient Safety Learning

USA: Flu visits reach highest levels since 2009 pandemic

Outpatient visits have surged to their highest levels since the peak of the 2009 swine flu pandemic, with influenza-related emergency department visits remaining very high across the US.
Notably, flu-related outpatient vists are now at their highest point since 2009, with 7.8% of visits for inflenza in the week ending 1 February 2025.
Nineteen states reported high respiratory virus activity and thirteen states reported very high activity.
The CDC reported that flu test positivity has risen to 31.6%, while COVID-19 positivity decreased to 4.9% and RSV positivity decreased to 6.6%. 

Emergency department visits for influenza remained very high, while visits for Covid-19 were low and RSV-related visits were moderate. 

Vaccination coverage for both COVID-19 and influenza remained low, and RSV vaccine uptake is also notably low for both children and adults. 
Read full story
Source: Becker's Clinical Leadership, 11 February 2025
Sam

More than 20 states sue Trump administration over ‘devastating’ funding cuts for medical research

Attorney generals from 22 states filed a lawsuit against the Trump administration on Monday over significant cuts to grant funding for universities, medical centers, and other research institutions last week.
The cuts would be “devastating” to staff members and faculty — and could even “prove deadly,” the 59-page lawsuit claimed. The new cap takes effect on Monday.
“The reduction of federal funding to the UCs as set forth in the NIH Notice would be devastating for the UC system,” the states noted. The University of California School system is the world's leading public research university system and the state’s third largest employer.
“UW has long relied on being able to negotiate these rates for years, and has built out its research facilities and headcount accordingly — nothing could have prepared UW for a sudden and stinging rebuke of the federal government’s previous positions,” they said of the University of Washington. “The impacts would be devastating not only to the many staff members and faculty who would likely lose their livelihood, but could also prove deadly.”
“A cut this size is nothing short of catastrophic for countless Americans who depend on UC’s scientific advances to save lives and improve healthcare,” UC President Michael Drake said.
“The discovery of new treatments would slow, opportunities to train the next generation of scientific leaders would shrink, and our nation’s science and engineering prowess would be severely compromised,” Harvard University President Alan Garber wrote.
Read full story
Source: The Independent, 10 February 2025
Patient Safety Learning

Why does no one want Scotland’s £90k patient safety job?

Applications have re-opened for a £90,000-a-year patient safety role after two previous attempts to fill the role were unsuccessful.
MSPs passed a law creating the post of Scotland's first ever Patient Safety Commissioner in September 2023.
But despite a hefty salary, they have been unable to fill the post.
The first round of interviews in April last year was unsuccessful with the cross party panel of MSPs turning down all of the candidates who were interviewed.
The second round in November saw them offer the job to one candidate but they turned it down.
The Commissioner’s role is to “advocate for the systematic improvement in the safety of health care and to promote the importance of the views of patients and other members of the public in relation to the safety of health care".
It was created in the wake of a UK Government commissioned review of the hormonal pregnancy test Primodos, Sodium Valproate in pregnancy and transvaginal surgical mesh.
Read full story (paywalled)
Source: The Herald, 10 February 2025
Patient Safety Learning

Professor James Reason, CBE, 1938-2025

Last week James Reason passed away. James, a British psychologist, was a key figure in patient safety and in the study of human factors and aviation safety. James wrote many books on human factors and risk management and received a CBE in 2003 for his services in the reduction of the risks in healthcare.
Among his many contributions was the introduction of the Swiss cheese model in his 1990 book, 'Human Error';  a conceptual framework illustrating how human errors can lead to catastrophic incidents when multiple layers of defence in a complex socio-technical system fail.  James also described the first fully developed theory of a just culture in his 1997 book, 'Managing the Risks of Organizational Accidents'. 
Read Steven Shorrock's fitting tribute to James Reason here.
Paying tribute to James, Helen Hughes, Patient Safety Learning's Chief Executive, said:
"James Reason was a giant among safety scientists, human factors experts and healthcare leaders. He was fiercely intelligent and hugely committed to sharing his insights and knowledge to make our lives safer. He gave his time and energy to many, researchers, students, clinicians, always with quirky tenacity and humour. The comments shared to Steven’s excellent testimony show how well Jim was respected and loved. He will be much missed."
Patient Safety Learning

'They made me feel my baby's death was my fault'

The mother of a week-old baby girl who died said she was made to feel her daughter's death was her fault.
Sarah Robinson said that after the birth of her daughter Ida Lock at the Royal Lancaster Infirmary in 2019, she had been asked by staff if she had smoked.
Lifelong non-smoker Ms Robinson told an inquest at Lancashire Coroners Court that a midwife had asked her if she was "sure" she had never smoked, because her placenta looked "gritty and fatty".
But an independent investigation found there had been several problems during her delivery, and last year the hospital accepted there had been some failings.
In 2015, an independent review into maternity care at the University Hospitals of Morecambe Bay NHS Trust - which runs the Royal Lancaster Infirmary - found that 11 babies and one mother had died in preventable circumstance between 2004 and 2013.
The inquest heard Ms Lock had spent months questioning what she had done wrong following Ida's death.
After pushing the Lancaster Royal Infirmary for a full explanation about what had happened, the couple were offered a meeting on 27 December 2019.
They said they were ushered into a room off a ward, handed a number of medical records and left to go through them.
"The message from that meeting was that Ida was very poorly when she was born.
"I fell into a vicious circle, constantly questioning whether I was the reason that my daughter had died, and what had I missed," Ms Robinson said.
In the spring of 2020, the couple received the outcome of a Healthcare Safety Investigation Branch (HSIB) inquiry, which had found significant failings in Ida's delivery.
But an investigation the trust had completed – which the family were not involved in despite asking to be – found no failures, instead describing teamwork and record keeping as "outstanding".
The couple told the inquest they had to battle the trust to understand what had happened.
Read full story
Source: BBC News, 10 February 2025
Patient Safety Learning

Nine in 10 women don’t know signs of heavy periods, research says

As few as one in ten women can pinpoint signs of heavy menstrual bleeding, as one of the UK’s top women’s health doctors says women and girls were “suffering in silence” from period problems, despite the availability of potential treatments.
Research by the charity Wellbeing of Women found that one in two women (51%) said their period negatively impacts their life, and the same proportion avoid exercise when on their period while nearly three in five (57%) experienced problems at work because of their period.
A Censuswide survey of 3000 people, commissioned by the charity, found that half of women also said their period symptoms had been dismissed, and just under a quarter said they felt their symptoms had been dismissed by a healthcare professional.
On Tuesday, the charity launched a new period symptom checker to help women and girls understand more about their menstrual cycle, which could help women talk to their GP about receiving better treatment.
The checker, which takes just four minutes to complete, asks various questions about health and reproductive symptoms, and at the end of the checker drafts a letter for women to give to their GP which can help open discussions about symptoms.
Wellbeing of Women said many women are "putting up with" disabling levels of pain and heavy bleeding, waiting for an average of two years before seeking help.
Professor Dame Lesley Regan, who was appointed as the first-ever Women's Health Ambassador for England under the Conservative government and is the chairwoman of Wellbeing of Women, said: "It is shocking that women are still suffering severe period pain and heavy bleeding in silence.
"A variety of medical treatments could be offered to girls and women with these distressing conditions.
"We hope that our new Period Symptom Checker will encourage women to speak up and seek help for their period problems.
"It aims to promote better engagement with GPs and other community healthcare professionals by creating a letter that outlines how their symptoms are affecting their everyday lives."
Read full story
Source: The Independent, 11 February 2025
Patient Safety Learning

New AI initiative to transform urgent and emergency care in North East London

NHS North East London in collaboration with Health Navigator and UCLPartners have launched a new, three-year programme, providing preventative care for patients with long-term conditions. This comes at a time when urgent and emergency care services in North East London are facing unprecedented pressure and demand is at an all-time high.  
Through advanced AI screening technology and targeted, phone-based clinical coaching, patients at high risk of needing unplanned emergency care will be identified and offered personalised support from healthcare professionals trained in delivering preventative care and self-management techniques.   
The initiative is designed to identify and better support people with long-term conditions, like asthma, by taking a proactive and preventative approach to healthcare delivery.   
Forecasting models estimate that the programme will save 26,673 unplanned bed days in North East London hospitals across the three years of the programme, with an anticipated reduction of 13,000 A&E attendances annually.   
Read full story
Source: UCL Partners Health Innovation, 12 December 2025
Patient Safety Learning

Time to act: hundreds of children sent out of area every day for mental health treatment

Royal College of Psychiatrists' analysis of the latest NHS England data shows a shocking 319 children and adolescents in England were forced to travel out of their area for mental health treatment from December 2023 to November 2024. This represents nearly one child every day.
These children and young people (under 18s) spent a total of 35,845 days away from their local area, also known as inappropriate Out of Area Placement (OAP)2 bed days, as a result of beds being unavailable in their local area.
To mark Children’s Mental Health Week, the Royal College of Psychiatrists is calling on the UK Government to set a target date to end OAPs in child and adolescent mental health services (CAMHS) across England.
Extremely vulnerable children and young people with serious mental illnesses, such as eating disorders, self-harm and psychosis, are being treated miles away from their loved ones and support networks, as a result of inappropriate OAPs. With family and friends having to travel so far, visiting often becomes impossible, which only leaves unwell children feeling more isolated, lonely and can be harmful to their recovery.
With so few specialist CAMHS beds available and services overstretched, many children are being treated in paediatric wards, without access to specialist mental health services during their stay, or even after discharge. These environments can feel overwhelming, particularly for those with neurodevelopmental conditions such as autism.
In addition to setting a target to end the use of OAPs for children, RCPsych is calling for increased availability of NHS CAMHS beds in areas where there is the greatest need. This can be achieved through the intelligent commissioning of beds in areas with persistently high occupancy rates, using models like provider collaboratives.
Rachel Bannister’s 15-year-old daughter was diagnosed with an eating disorder in 2014. She was sent to several hospitals far from the family home in Nottingham, including one in Scotland, hundreds of miles away. She was there for six months, including over Christmas.
Rachel said: “The whole family were devastated when she went away. I felt as if my heart had been ripped out and I had failed her. We are all still processing the trauma of it all many years later.
“During her time away, our telephone conversations revealed her longing for simple gestures such as a hug or a walk in the park. It was heart-wrenching for us to be unable to fulfil those basic needs.
“The lack of consistency in her care and treatment have hugely impacted her recovery. Additionally, it has been difficult and often impossible to involve wider family members or her social network in treatment, which I believe is fundamental to recovery."
Read full press release
Source: Royal College of Psychiatrists, 8 February 2025
Patient Safety Learning

Mesh campaigners call for compensation

Women harmed by pelvic mesh implants are still waiting for government compensation a year after a major report called for urgent action. Patient safety commissioner Dr Henrietta Hughes, who made that recommendation, called it "an injustice" for the thousands of lives destroyed. 
5 News hears from Kath Sansom, campaigner and founder of Sling the Mesh.  Listen at 24 minutes.
 
Sam

Woman stuck for 18 months on an NHS ward evicted from her hospital bed

"I feel very angry, upset, worthless, and like my mental health and my life does not matter," says Jessie, propped up in a hospital bed.
She is recording this in a video diary. Blue NHS curtains are drawn around the bed and all her possessions are stacked up in the tiny chaotic space this creates.
Among the piles of boxes and bags sit the dolls she holds to keep her calm.
Thirty-five-year-old Jessie spent 550 days in Northampton General Hospital. For nearly all that time, she was medically fit to leave but finding her a suitable place to go to was difficult.
The BBC has followed her story for more than five months as the NHS trust took costly High Court action against her, to have her evicted from the hospital bed she was occupying.
Jessie was eventually arrested and taken to a care home where she says she feels anxious.
Her story is an extreme example, but it demonstrates the acute pressures faced by a care system coping with more complex cases, the knock-on effect to the NHS, and how the person at the heart of it can feel lost.
North Northamptonshire Council, which is responsible for her housing and care, says it cannot comment because of an ongoing police investigation into Jessie's behaviour.
The hospital says it "is not the best environment for patients who are not in need of acute medical care".
The Department of Health and Social Care has told the BBC: "This is a troubling case which shows how our broken NHS discharge system is failing vulnerable people."
Read full story
Source: BBC News, 8 February 2025
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