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

CQC examining service which ‘gave 14 people unnecessary cancer treatment’

Fourteen patients have raised concerns they may have received unnecessary chemotherapy with “debilitating side effects” at the same hospital, some for a decade or more, HSJ has been told.
The Care Quality Commission confirmed it was discussing concerns that University Hospitals Coventry and Warwickshire treated patients with temozolomide for far longer than deemed safe, and unnecessarily.
One man was treated with temozolomide for a brain tumour for more than 14 years, the BBC reported, despite NHS guidelines recommending treatment programmes of between six and 12 months.
The law firm Brabners, which is now representing five patients concerned they are in a similar situation, told HSJ it had spoken to others who had received the treatment for more than a decade. It had heard from 14 people as of yesterday, it said.
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Source: HSJ, 28 January 2025
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18 ICBs warned over deaths following care failures

Disjointed, delayed, and substandard care for people with both mental illness and additional needs are highlighted throughout reports sent to integrated care boards on the deaths of 24 people, HSJ has found.
A lack of inpatient beds, poor communication, staff shortages, and care fragmentation were common concerns raised with 18 ICBs in relation to 24 deaths linked to mental health care since the boards’ creation in July 2022, HSJ analysis reveals.
Of a total of 53 “prevention of future death reports” addressed to ICBs, 24 focused primarily on mental health – the most common theme of the reports.
Many of those who died were young, and many had additional needs, such as autism, ADHD or learning disabilities. They often endured long delays because of poorly-connected physical and mental health services. Some were refused multiple referrals because of the complexity of their needs.
Twenty-two of the 24 deaths were from suicide or self-harm.
Read full story (paywalled)
Source: HSJ, 28 January 2025
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WHO freezes recruitment and slashes travel to mitigate US withdrawal

The World Health Organization (WHO) is introducing immediate cost-cutting measures including a freeze on all but critical staff recruitment, according to an email from the Director-General to staff sent last week.
The body is also prioritising activities related to health priorities, “significantly reducing” travel, limiting procurement and suspending office upgrades.
All meetings will be virtual except in “exceptional cases” and only essential missions to provide technical support to countries will go ahead, according to the email.
This comes in response to the announcement by President Donald Trump that he is pulling the United States out of the global body.
“This announcement has made our financial situation more acute” and “created uncertainty for the WHO workforce,” said Tedros.
The shock decision by the US will undermine the reform process of the past five years. This will introduce even more precarity for staff at the global body as they battles to respond to a growing tide of health challenges, that are worsening with climate change.
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Source: Health Policy Watch, 24 January 2025
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Four US states consider new laws for people who have abortions to be punished as murderers

South Carolina, Oklahoma, North Dakota, and Indiana legislatures are considering bills that would classify abortion as homicide and therefore allow patients who have abortions to be charged with murder. Three of the states have the death penalty for murder.
All four states already have bans or very strict restrictions on abortion. South Carolina bans abortion after six weeks of pregnancy, North Dakota has a total ban on abortion that is currently in the courts, and Oklahoma and Indiana have complete bans already.
Read full story (paywalled)
Source: BMJ, 27 January 2025
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Chronic fatigue syndrome: Outcry over Cochrane decision to abandon review of exercise therapy

A decision to cancel a planned update of a Cochrane systematic review of exercise therapy for chronic fatigue syndrome has met with anger from a group advising the review and the patient community.
The decision has reignited calls for the review, which includes studies only up to May 2014, to be withdrawn for being outdated and misleading.
The review recommends exercise therapy to treat myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), concluding that this “probably has a positive effect on fatigue in adults compared to usual care or passive therapies.”
However, this treatment approach is controversial and has been criticised by patient groups who say that it can make symptoms worse. Guidelines from the National Institute for Health and Care Excellence, published in 2021, specifically advise against graded exercise therapy. Guidelines from the US Centers for Disease Control and Prevention also state that exercise therapy is not a cure for ME/CFS and that standard exercise recommendations for healthy people can be harmful for people with ME/CFS.
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Source: BMJ, 27 January 2025
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Woman's cancer diagnosis after wrong smear results

A woman has expressed her anger after being diagnosed with cervical cancer more than two years after her smear test result was incorrectly recorded as normal.
Amie Wood, 39, from Bewdley, Worcestershire, had a smear test that was reported as negative by the Royal Wolverhampton NHS Trust in October 2019.
Although negative, it showed high-risk human papillomavirus (HPV), a virus that can lead to cancer, the HPV persisted and she was subsequently diagnosed with cervical cancer in January 2022.
The NHS trust said it expressed its regret and apologised to Ms Wood.
Following her diagnosis, Ms Wood had a hysterectomy.
Ms Wood said she suffered increased anxiety about her health, and felt unable to return to her part-time second job as a personal trainer.
"To be diagnosed with cervical cancer and undergo a hysterectomy was heartbreaking enough, but then I found out that my smear results had been misreported and it could have all been avoided," she said.
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Source: BBC News, 28 January 2025
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Mental health ‘Care gaps, poor communication and a 26-day stay in A&E’ lay behind death

A coroner has ordered an integrated care board to fill gaps in its services and address mental health bed shortages following the death of a 29-year-old with autism and ADHD who spent 26 days in A&E.
Matthew “Matty” Sheldrick (they/them), who identified as non-binary, died from self-ligature outside Royal Sussex County Hospital after returning to A&E one month on from the 26-day stay. Matty had struggled to access community services for support with their mental health, autism, and ADHD.
Confusion about and delays to appointments during their time in hospital and the community contributed to a sense of hopelessness, according to Matty’s mother, Shelagh Sheldrick.
In two prevention of future death reports published last month, senior area coroner Penelope Schofield said Matty received “no meaningful therapeutic input” during their prolonged first stay in an A&E short-stay ward and that the environment “contributed to the deterioration of their mental health difficulties”.
In a report addressed to Sussex Integrated Care Board, Ms Schofield raised concerns over a lack of funding for private mental health beds for autism patients, and the fact that oversubscribed public providers “very often” rejected referrals for autism patients because of “additional risks”.
Read full story (paywalled)
Source: HSJ, 28 January 2025
Sam

Wegovy maker Novo Nordisk rebuked by watchdog over failure to disclose payments to UK health groups

The pharmaceutical watchdog has reprimanded Wegovy maker Novo Nordisk for failing to correctly disclose dozens of payments to the UK health sector as it sought to boost sales of its slimming drugs.
The Danish drug giant – Europe’s most valuable listed company – systematically misreported, under-reported or did not disclose funding given over seven years to pharmacy firms, obesity charities, training providers, professional bodies and patient groups.
Even after admitting to errors and conducting an internal review, it failed to accurately report its spending. The company has now been formally reprimanded by the Prescription Medicines Code of Practice Authority (PMCPA), which said it had brought the industry into disrepute.
Finding 48 breaches of the industry code, it said serious compliance failings – committed while Novo Nordisk was already the subject of an audit after previous breaches – “raised questions about the culture of the company and demonstrated poor governance and a lack of care”.
It said that “by failing to publicly disclose payments, inaccurately reporting and misreporting payments to healthcare organisations and patient organisations over an extended period of time”, it “had brought discredit upon, and reduced confidence in, the pharmaceutical industry”.
Read full story
Source: The Guardian, 26 January 2025
Patient Safety Learning

Inquest may reopen into girl who died on rogue surgeon’s table

A coroner wants to reopen an inquest into the death of a teenager who died during an operation by a disgraced NHS surgeon.
The Sunday Times exposed a report in 2022 that said the once-renowned spinal surgeon John Bradley Williamson’s “unacceptable and unjustifiable” actions contributed to the death of 17-year-old Catherine O’Connor at Salford Royal Hospital in February 2007.
Greater Manchester police has concluded an investigation and passed its findings to the Bolton coroner, Timothy Brennand, who will seek permission to reopen the inquest. The teenager’s family believe they have evidence showing Williamson misled the initial inquest.
The prime minister intervened last week to promise a meeting with ministers after MPs raised dozens of other cases of patient harm linked to the surgeon, which they say need investigating. 
More than a dozen staff at Salford Royal, once hailed as the safest hospital in England, have spoken out about what they described as Williamson’s bullying, toxic behaviour and the unsafe surgery that left many of his patients with severe complications.
A review of 130 patients treated by Williamson between 2009 and 2014 found 23 had screws misplaced in their spines; five lost excessive blood during surgery; more than 40 had problems with consent; and in 35 cases there was poor surgical practice.
Read full story (paywalled)
Source: The Times, 25 January 2025
Patient Safety Learning

An embarrassing but predictable end to Scotland's National Care Service

The Scottish government is scrapping its plans to create a National Care Service.
It is an embarrassing but perhaps predictable end to years of ambitious talk about finally coming up with a solution to the social care crisis.
In a statement at Holyrood, the government tore up parts of the bill that would require major structural changes to the Scottish social care system.
The downfall of the plan wasn't money or lack of ambition necessarily. And there was cross-party agreement on what needed to be done. The problem was a frustrating lack of consensus on how to get there.
It is also the end of the process that has been costly too. More than £30m has already been spent on planning the policy cover the last three years.
In 2021, Ms Sturgeon branded the National Care Service the "most ambitious reform since devolution".
Now, the plan is in tatters, and it tells us a lot about how difficult social care reform is and what might lie in store for the Westminster government.
Read full story
Source: Sky News, 27 January 2025
Patient Safety Learning

Wes Streeting accused of lack of transparency on puberty blockers trial just weeks before it starts

Wes Streeting has been accused of causing “distress and uncertainty to trans people” and failing to provide clear information on the puberty blockers trial, which is understood to be starting soon.
Puberty blockers were banned indefinitely in the UK for under-18s in December after the Cass Review found there was insufficient evidence to show they were safe. It recommended a clinical trial to determine the effectiveness and safety of the medication.
It is understood the Department for Health and Social Care (DHSC) expects the trial to begin within the next few weeks and conclude in 2028.
But NHS sources told The Independent they are not expecting to publish any details about the trial until February – just one month before it is set to begin – leaving young people wanting to access the medication guessing if they will be part of the trial.
Trans charities and campaign groups have so far received little to no information on who will be able to participate in the trial, how they will access it and when it will start, with Stonewall urging the government to “provide certainty to an extremely vulnerable group”.
Meanwhile, Tammy Hymas, head of communications and advocacy at charity Mermaids, told The Independent the “severe delays and complete absence of details” on the clinical trial has “left trans youth feeling abandoned”.
Read full story
Source: The Independent, 26 January 2025
Patient Safety Learning

Sewage leaks and ops delayed - life at hospitals awaiting rebuild

The Princess Alexandra Hospital in Essex has been plagued by problems with its ageing buildings and equipment in recent years.
It has regular difficulties with floods and sewage leaks across its site, which dates back to the 1960s.
There have been reports of patients slipping on flooded floors, foul smells of faeces filling A&E and leaks on wards and in the operating theatre areas, posing a risk to patients and staff alike.
Along with broken equipment and other building-related problems, it leads to so-called "infrastructure" incidents occurring three times a week on average, according to official NHS data analysed by the Liberal Democrats.
Over the summer, two of the main operating theatres were out of action, disrupting care for patients needing hip and knee surgery.
"We were unable to get the ventilation parts. We were unable to get the light fittings," hospital chief operating officer Stephanie Lawton told the BBC.
"It took us several weeks to get those theatres repaired. The infrastructure is quite old now - it's very difficult to maintain."
Back in September 2019, there was delight at the hospital when it was announced at the Conservative party conference that a new hospital would replace the existing one. Hospital bosses were soon predicting the doors at the new site would open in 2024 as Boris Johnson promised England 40 new hospitals, including upgrades of existing sites, in his 2019 election manifesto.
But by 2023 the planned finish date for Princess Alexandra had slipped to 2030 - and this week it became one of 18 hospitals to be told there rebuilds would be delayed even further.
Read full story
Source: BBC News, 25 January 2025
Patient Safety Learning

Increase regulation of online sale of weight-loss jabs, pharmacists say

Pharmacies are demanding tougher regulation of the online sale of weight-loss jabs amid a predicted new year’s boom in demand.
The National Pharmacy Association (NPA), who represent independent community pharmacies, urged the regulator to require greater consultation with patients before dispensing weight-loss jabs and other high-risk medication online.
Current rules, the NPA said, “leaves the door open for medicines to be supplied without appropriate patient consultation and access to patient records”.
Nick Kaye, chair of the NPA, said: “Obesity is one of the biggest challenges facing our country and pharmacies want to play their part in helping patients lose and maintain a healthy weight. Weight-loss injections can play an important role in efforts to tackle obesity when prescribed as part of a carefully managed treatment programme for patients who are most in need of support.
“However, we are concerned that the current regulations allow some patients to inappropriately access weight-loss injections without proper consultation or examination of historical medical records.”
The NPA urged regulators to require that pharmacies conduct a full two-way consultation with patients before dispensing “higher-risk” medication such as weight-loss jabs.
Read full story
Source: The Guardian, 27 January 2025
Patient Safety Learning

Quarter of people in England had poor NHS care in past year, report says

A quarter of people in England experienced poor NHS care over the last year but fewer than one in 10 of them complained about it, a report by the patient watchdog has revealed.
When people did complain, more than half were not satisfied with either the process involved or the outcome, Healthwatch England said. Complaints take many months to resolve.
It found a widespread lack of public confidence in the health service’s handling of complaints, and “little evidence” that it was discharging its duty to use complaints to improve care.
Louise Ansari, the watchdog’s chief executive, accused the NHS of doing too little to take complaints more seriously and urged it to adopt “a culture of listening and learning” from them so that patients’ concerns would start to carry more weight.
The NHS has not responded properly to repeated concerns about the way it deals with complaints raised by official bodies and inquiries, and appears to be stuck in “a cycle of repeating the same mistakes”, the report said.
Ansari said: “We flagged failings with the NHS over a decade ago, following the patient safety scandal at Mid Staffordshire hospital. Ten years on, our research shows that the public still lack confidence in the NHS complaints system.”
The health service has not heeded its call for an overhaul and demonstrates persistent “serious failings in how NHS organisations listen and respond to patient feedback”, the watchdog said.
Read full story
Source: The Guardian, 27 January 2025
Related reading on the hub:
How to make a complaint How do I make a complaint: Sources of help and advice
Patient Safety Learning

Shock testimony of NHS nurse reveals harrowing reality of A&E today

When I had last set eyes on the man who had been brought in with a suspected heart condition, he was in a wheelchair wedged into an alcove normally used to store hospital equipment.
He was clearly seriously ill and should have been in a cubicle attached to a monitor – but then you could say the same for the dozens of others, crammed into the corridor outside my hospital’s frantically busy A&E department, the only physical space available left to us.
I say ‘space’ – there wasn’t any. Even the corridor was filled to capacity with patients on trolleys, in wheelchairs and waiting room chairs, along with other ‘walking wounded’ patients and relatives, all trying to navigate their way to and from the vending machine at the far end.
So crammed, that when the man in the wheelchair suffered a cardiac arrest it was impossible for the crash team to get to him to resuscitate him.
There was literally no room to reach him, less still to lie him on the floor and perform CPR.
That man died right there in his chair as his frantic wife screamed for help.
It was – and is – inhumane, but then I could use that word to describe a lot of what is unfolding in our emergency departments these days, and in which corridor nursing, which should really only be used in exceptional circumstances, has become a daily reality without which A&E departments couldn’t function at all.
This last week the sheer monstrous scale of the problem was laid bare in a report from the Royal College of Nursing, which featured the testimony of more than 5,000 nurses and exposed the daily horrors unfolding in emergency departments up and down the country.
It’s a picture I certainly recognise only too well after 25 years on the frontline of nursing in a busy Greater London hospital.
Read full story
Source: The Daily Mail, 24 January 2025
Patient Safety Learning

A&E will be swamped by half of England’s population every year unless NHS reformed, warns top doctor

England’s top doctor has warned the equivalent of half the country’s population will be attending emergency departments every year within a decade unless more work is done to move healthcare out of hospitals.
NHS national medical director Professor Sir Stephen Powis said if the health system wants to avoid a situation of overcrowded A&Es by 2034 then it “must go for broke” by moving more care into communities.
A&Es in England faced the busiest year on record in 2024, with 27.42 million attendances across the year, 7.1 per cent higher than in 2023, according to NHS England.
In a speech at Liverpool Medical Institution on Wednesday evening, Professor Powis said caring for more patients outside of hospitals was key to reducing pressure on accident and emergency departments long term.
“Because we know that if A&E attendances increase at the same rate as they have over the past 10 years – NHS staff will need to manage six million more A&E attendances every year from 2034,” he is expected to say.
“That would mean the equivalent of almost half the population attend A&E at least once every year – that is simply not feasible for a 21st-century health system.
“If the NHS is to avoid a situation of overcrowded A&Es in 10 years’ time – we must go for broke in moving care from hospital to the community.”
Read full story
Source: The Independent, 22 January 2025
Sam
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