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

‘Fragile’ IT blamed for critical incidents and patient harm

Outdated clinical IT systems at a large Midlands hospital trust are harming patients and causing delayed diagnoses and cancelled appointments, its CEO has admitted.
University Hospitals of North Midlands Trust’s chief executive Simon Constable warned the trust was continuing to experience “significant challenges with our digital clinical systems” and described an “excessive number of ‘priority 1’ [serious] incidents over the last 24 months.”
He said the incidents — linked to a long-term lack of funding for upgrades — had been escalated to the Stoke-On-Trent and Staffordshire Integrated Care Board and NHS England.
Mr Constable, who took over as CEO in the autumn, said the digital services team had worked to troubleshoot and create short-term fixes, but the trust’s systems were “highly complex and extremely fragile”, with one platform, called iPortal, more than a decade old and running on “unsupported code”.
He told the board: “As a result, we have experienced ongoing disruption, numerous periods of working in business continuity, and a loss of clinical confidence – all alongside significant winter pressures.” 
Mr Constable said at a “virtual risk summit” held last month about the issues, clinicians “described cancelled appointments, delayed discharges, diagnosis and treatment, staff impact and potential harm”. He said the trust’s business case for a new electronic patient record system had been updated to include the current high risk. 
Read full story (paywalled)
Source: HSJ, 20 January 2025
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Roof leaks and derelict buildings at hospitals with most empty space

More than 10,000 square metres of hospital space is being left vacant across some of England’s largest hospitals because of disrepair and decay.
HSJ asked the 15 acute hospitals with the most empty space what areas were vacant and why.
The analysis reveals for the first time why so much space is going unused in the worst-affected hospitals.
Leeds Teaching Hospitals Trust said entire floors of a wing were closed at Leeds General Infirmary because of a faulty roof. The site has the most vacant space of any nationally.
The trust said the 9,500 square metres of unused space at Leeds General Infirmary — 5% of its footprint — included two floors of the Brotherton Wing that previously housed outpatient services.
It said the integrity of the original roof had failed and led to water ingress, with the top floor shut for 10 years, and the one below closed more recently due to leaks.
LTH’s other major hospital, St James’ University Hospital, has a further 3,200sqm vacant because it is “not suitable for modern healthcare”.
Craige Richardson, director of estates and facilities, said the trust had closed some of its worst-impacted areas and relocated clinical services, but added this was “not sustainable”.
Read full story (paywalled)
Source: HSJ, 20 January 2025
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'Concerns remain' at trust where patients abused

A mental health trust where a "toxic culture" saw patients abused in 2022 has been rated as inadequate again despite some improvements.
The secure unit the Edenfield Centre in Prestwich, Greater Manchester, was the subject of a BBC Panorama investigation which revealed how patients were humiliated and bullied.
In its latest report into forensic inpatient and secure wards at the Greater Manchester Mental Health NHS Foundation Trust (GMMH), the Care Quality Commission (CQC) found issues with patient safety and pressures on staff and said some still felt unable to speak up about their concerns.
GMMH, which runs Edenfield, said it accepted the findings and had "worked at pace" to address the problems identified.
Inspectors from the CQC made an unannounced inspection in April and May 2024, giving the trust an overall rating of inadequate.
Alison Chilton, its deputy director of operations in the north, said: "The trust's processes didn't always ensure the environment was safe for people.
"We found some wards which carried out 15-minute security checks to keep people safe had gaps and missing signatures in their records."
Other issues included staff being asked to carry out observations for hours without a break, ligature risks not being identified and unsafe management of medicines.
Read full story
Source: BBC News, 18 January 2025
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My treatment was delayed so long I got cancer – and there are tens of thousands like me

Delays in NHS care have led to almost 40,000 compensation claims since 2010, costing more than £8bn
Sharni Marks endured multiple rounds of chemotherapy, leaving her weak and sick. She has lost her hair and her nails and suffers painful mouth ulcers. Now doctors have told her that her cancer treatment has probably made her infertile and she might need a hysterectomy.
All this was avoidable.
Marks, 31, was diagnosed with cancer last March after waiting more than a year and a half for the double mastectomy meant to reduce her risk of getting the disease.
The NHS has now accepted in a letter to her GP that her cancer developed during her long time on the waiting list. She is not alone.
Since 2010, there have been almost 40,000 compensation claims for injury and deaths caused by delays in care, costing more than £8.3 billion — enough to build 15 hospitals the size of the Queen Elizabeth Hospital in Birmingham.
The data comes from NHS Resolution, which handles compensation claims against the health service, and includes routine surgery and emergency care. The 39,686 successful compensation claims over the past 15 years are attributed to one of eight categories of delay such as surgery or diagnosis. Delay in treatment was the single largest category, costing the NHS £3.9 billion for 19,199 cases. Delays in diagnosis was the next biggest group at 16,164 claims, worth a total of £3.4 billion.
The government has been repeatedly warned about patients coming to harm from long waits. Coroners in England and Wales sent at least 192 warnings about the issue by the end of 2024, up from 62 in 2013.
Read full story
Source: The Times, 19 January 2025
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Where is the flu surging across the US? Hospitals restrict access as cases spike

U.S. hospitals are feeling the strain of this flu season, with many announcing visitor restrictions as cases remain elevated nationwide.
Minnesota hospitals are leaning on triage systems to deal with the influx of patients and hospitals in North Carolina and South Carolina have prohibited visits from children and teenagers.
Hospital visitors in Indiana have been strongly encouraged to wear face masks, and Washington state health officials reported that local emergency departments are seeing five times the threshold of flu visits that would alert officials to increased transmission.
The latest data from federal health officials estimates that there have been at least 9.1 million illnesses and 110,000 hospitalizations thus far this flu season. Emergency room visits are now very high.
There have also been 4,700 deaths, including 16 children who have died.
Read full story
Source: The Independent, 17 January 2025
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Cervical screening knowledge gap 'costing lives'

A knowledge gap around cervical screenings is currently "costing lives", a cancer charity says.
The Eve Appeal says more women need to know they can ask for adjustments to their cervical screenings, which can be painful, uncomfortable or distressing for some.
The test is thought to save about 5,000 lives every year in the UK, but many women do not get tested.
Research commissioned by the charity suggests most women do not know they can make the test easier by asking for longer appointments, smaller speculums, or move to more comfortable positions.
According to latest NHS England data, more than five million eligible women are not up to date , external with their routine screening, with the lowest uptake being among women aged between 25 and 29 (58%).
Eve Appeal chief executive Athena Lamnisos said this was "worrying" and that any barriers people experience around the screenings could be "easily overcome".
"There are really simple, straightforward things that you can ask for that patients just aren't aware of....basically, you can take control."
Read full story
Source: BBC News, 20 January 2025
Further reading on the hub:
Top picks: Six resources about improving access to cervical screening
Patient Safety Learning

NHS trusts warned that ‘legacy debt’ could pose patient safety risk

Clinical safety officers (CSOs) have warned that patient safety could be put at risk by healthcare organisations’ historical failure to comply with digital clinical safety standards.
The Digital Health Networks CSO Council has issued an advisory statement for NHS trusts and integrated care boards about the potential consequences of not completing tasks such as hazard logging and safety case reporting for software.
It follows a BBC investigation, published in May 2024, which found 126 instances of serious harm linked to IT issues across 31 trusts, including three patient deaths. 
“There will be a lot of trusts which have this ‘legacy debt’ of systems that they have had for many years, where they either haven’t asked the manufacturer for their side of the deal (which is required under DCB 0129) or they haven’t done their side of the deal in house (which is required under DCB 0160),” said Faye Clough, lead clinical safety engineer and CSO at Northumbria Healthcare NHS Foundation Trust.
She told Digital Health News that this could lead to “patient safety incidents, reports of IT incidents, IT errors, and the reputational damage that could come out of that for trusts”.
Read full story
Source: Digital Health News, 20 January 2025
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'I fear I'll die on hospital waiting list'

A man fears he will die before he reaches the top of a year-long waiting list to see a heart specialist.
John Crockford, 77, from Bridlington in East Yorkshire, has a history of cardiac problems and suffered three heart attacks in 2022.
He has had four stents fitted to open blocked arteries but said he had become so unwell he suspects another is needed.
York and Scarborough Teaching Hospitals NHS Foundation Trust said its patients were "prioritised by doctors according to clinical need", but recognised some were waiting longer than it would like.
Mr Crockford said he asked his GP practice to refer him to a cardiologist at Scarborough Hospital before Christmas, when he started to feel so breathless he was unable to do any physical activity.
The retired foster carer and retail worker said his symptoms were the same as those he experienced before previous operations to fit a stent.
Mr Crockford needs a scan to establish if the procedure is needed, but said he was alarmed when he received a letter from the hospital stating "patients are waiting up to 52 weeks" for their cardiology appointments.
He said: "That's before I can go and see a cardiologist, let alone have the scan.
"I don't know whether I'm going to snuff it before I get this year over, because all the time they're not doing it, these arteries are getting clogged up."
Read full story
Source: BBC News, 20 January 2025
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Death risk doubles for long A&E waits

Patients who spent more than 12 hours in A&E were twice as likely to die within 30 days as those treated, transferred or discharged within two hours, a landmark study has found.
From April to December this year there have been over 1.2 million instances of patients spending 12 hours or longer in A&E – a 19% rise on the same period the year before. Twelve-hour waits from arrival were relatively rare until recent years, and data was not previously published by NHSE.
The study revealed that, for patients who spent 12 hours or more in the department, the risk of post-discharge death was 2.1 times higher than those who spent two hours or less.
Mortality was 1.9 times higher for those who spent nine hours in A&E, 1.6 times for those who spent six hours, and 1.1 times for three hour stays, the ONS found.
The study also discovered the risk of death after 12 hours stays was greatest for older patients, those in the North East of England, those who presented with airway and breathing difficulties, and those who were admitted to inpatient care. 
Read full story (paywalled)
Source: HSJ, 17 January 2025
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Fake wounds help nurses raise pressure ulcer awareness

Nurses hoping to reduce the rate of pressure ulcers in their hospitals are using a mannequin and self-made fake wounds to help teach colleagues about spotting and treating tissue damage in their patients.
The training has been led by the clinical nurse educator, simulation and tissue viability teams at Hull University Teaching Hospitals NHS Trust and Northern Lincolnshire and Goole NHS Foundation Trust, which work together under the NHS Humber Health Partnership.
Members of the teams have toured wards at Hull Royal Infirmary and Castle Hill Hospital with a model of a bottom covered with fake pressure ulcers.
Kirsty Stephenson, a nursing simulation fellow based in the clinical skills building at Hull Royal Infirmary, said: “People learn in different ways and seeing what an ulcer actually looks like rather than a photograph in a textbook can help staff identify exactly what they’re looking for in patients.”
Angie Oswald, lead nurse for tissue viability, based at Hull Royal Infirmary, said the clinical simulation exercise had been invaluable in her team’s work to reduce the number of pressure ulcers in patients at both hospitals.
She said: “Clinical simulation is a fantastic teaching tool and offers clinical staff the chance to learn in a safe environment.
“Using the mannequins and the moulage helps them familiarise themselves with what they should be looking for if a patient does develop a pressure ulcer and what steps they can take to stop it getting worse.”
Read full story
Source: Nursing Times, 17 January 2025
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NHS Trust death: Inquest into St Albans woman’s empty oxygen cylinder

An inquest into the death of a woman under the care of West Hertfordshire Teaching Hospitals NHS Trust began on Monday 20 January.
Cecilia Harper (71) died in Watford General Hospital on 9 February 2022, while being transported from her ward to the radiology department. She had been admitted to the hospital five days earlier.
The mother-of-two had reported breathlessness while in hospital, after initially being provided with oxygen via nasal cannula, her oxygen dependency increased and Cecilia was provided with an non-rebreather oxygen mask for the journey and was accompanied by a porter and student nurse. She was conscious when she left the ward, yet by the time she arrived in the ultrasound room she had lost consciousness. A number of medical staff undertook CPR but Cecilia had sadly died.
Upon investigation, it was discovered that Cecilia’s oxygen cylinder was empty, it was not clear when this occurred. During the first day of the inquest, it was heard that research carried out by a doctor at the Trust indicated that 10% of patients transferred to the A&E CT department have insufficient oxygen for a return journey, while 9% of patients made the journey with oxygen cylinders switched off.  
However, a post-mortem report, which identified metastatic breast carcinoma as the cause of death, made no mention of the impact of the empty oxygen cylinder or oxygen dependency.
An inquest took place at the Coroner’s Office for the Area of Hertfordshire to determine the cause of Cecilia’s death. There have been two previous inquest review hearings to ensure all appropriate evidence has been sought, which has delayed proceedings.
The inquest, which was expected to take place over three days, concluded on Tuesday (21 January). The inquest sought to confirm the exact circumstances surrounding Cecilia’s death.
The coroner determined that Mrs Harper died from natural causes, but it is unclear whether there was any problem with oxygen supply, and it is unclear if there was a problem with oxygen supply, if it contributed to her death. 
Read full story
Source: Tees, 21 January 2025
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Fewer than 1% of U.S. clinical drug trials enroll pregnant participants, study finds

A new study by researchers from the Brown University School of Public Health found that pregnant women are regularly excluded from clinical drug trials that test for safety, raising concerns for the efficacy of these medications for maternal and child health.
The study, published in the American Journal of Obstetrics and Gynecology, analyzed 90,860 drug trials involving women ages 18 to 45 from the past 15 years and found that only 0.8% included pregnant participants. About 75% of the studies excluded them, potentially leaving critical safety and efficacy questions unanswered.
“When pregnant women are excluded from drug trials, it is harder to know if the medication is safe for mothers and their children,” said Alyssa Bilinski, an assistant professor of health services, policy and practice and of biostatistics at Brown’s School of Public Health. “In practice, this means that some people might decide to take medications even absent rigorous evidence, which could lead to harmful side effects. At the same time, others might avoid medications that could actually help them because there’s not enough data to give them confidence about safety.”
Read full story
Source: Brown University School of Public Health, 17 January 2025
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USA: Ohio woman sues hospital and police after she was arrested over miscarriage

Brittany Watts, an Ohio woman who was charged with abuse of a corpse after having a miscarriage, has filed a federal lawsuit accusing some of the medical professionals who treated her of conspiring with a police officer to fabricate the criminal case against her.
The lawsuit, which was filed last week and names the professionals, the officer, the hospital where Watts was treated and the city of Warren, Ohio, as defendants, is the latest development in a case that first made national headlines in late 2023 when Watts was first charged. Although a grand jury ultimately declined to move forward with the charge against Watts, the case sparked fears about how the fall of Roe v Wade and subsequent wave of abortion bans could endanger pregnant women and lead to police treating miscarriages as crimes.
“This case is a perfect example of the broader implications of the overruling of Roe v Wade in the Dobbs case. Brittany was not seeking an abortion,” said Julia Rickert, one of Watts’s attorneys and a partner at the civil rights law firm Loevy and Loevy. “But the repercussions of the Dobbs decision meant that her pregnancy and her choices and her medical crisis were viewed in a different way.”
Read full story
Source: The Guardian, 16 January 2025
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‘Life-or-death consequences’: families in the US fear rollback of school vaccine requirements under RFK Jr

With vaccine sceptic as Trump pick to lead US health policy, parents and advocates anticipate devastating changes.
Apolitical battle over school-based Covid protocols in early 2021 quickly turned personal for one Colorado family, whose son’s cystic fibrosis – a life-threatening genetic disease affecting the lungs and other vital organs – made him susceptible to complications from the virus.
Kate Gould said the classroom became a dangerous place for her son after hardline conservatives took over the Douglas county school board and the district removed masking requirements.
Almost four years later, Gould and her family live in southern California – where they moved during the pandemic for the mask and vaccine requirements in place at the time – and they and other parents, advocates and health experts are gearing up for what could be the next front of the school culture wars: a broader attack on school vaccine mandates by the incoming Trump administration.
Currently, all 50 states have vaccine requirements for children entering childcare and schools. But with Robert F Kennedy Jr – who has peddled baseless conspiracy theories and once said: “There’s no vaccine that is safe and effective” – potentially at the helm of the Department of Health and Human Services, advocates and parents are right to fear a rollback of requirements, enforcements and funding, according to interviews with about a dozen experts.
Kennedy’s legitimisation and the different levers he could pull, experts told the 74, could have an immense impact on vaccination rates and the spread of preventable, contagious diseases in school-aged children.
Read full story
Source: The Guardian, 16 January 2025
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Doctor admits inappropriately messaging teenage patient he met at a children’s hospital

A doctor has admitted to inappropriately messaging a vulnerable teen who he met in a hospital, and later went on to have a sexual relationship with.
Dr Cian Hughes, who lists himself as research scientist at Google on LinkedIn, began privately messaging the 13-year-old while she was a patient at Bristol Royal Hospital for Children. Dr Hughes, who was a 23-year-old medical student at the time, had been present during surgery on the young patient and later approached her about a research project, a tribunal heard.
Dr Hughes used his private email address to email the girl copies of her X-rays, and this began a chain of communication that ultimately led to a sexual relationship between them when the girl was 17, the tribunal heard.
The General Medical Council (GMC) brought a case against the doctor saying that he used his professional position to pursue an inappropriate relationship with the vulnerable patient. 
Read full story
Source: The Independent, 16 January 2025
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Large UK-wide pandemic preparedness tests planned this year

Emergency service teams, local councils and government officials will take part in a full, multi-day pandemic preparedness exercise, to help the UK prepare for potential future threats.
The test, which is likely to take place in the autumn, will involve thousands of people across different parts of the UK, minister Pat McFadden has announced.
The plans come in response to the first set of recommendations made by the Covid-19 Inquiry - the ongoing public inquiry into the handling of the pandemic.
The chair of the inquiry, Baroness Hallett, found the UK was "ill-prepared" for the coronavirus pandemic, and "failed" its citizens.
The national pandemic response exercise will be the first of its kind in nearly a decade, designed to test capabilities, plans and procedures in the face of new threats, the government says.
The government has also committed to training 4,000 people a year to be better prepared for crises such as pandemics, through a UK resilience academy, planned to open in April.
The Covid-19 inquiry report found the pandemic had a disproportionate impact on vulnerable groups.
A new national "vulnerability map" will be produced, Mr McFadden says, to highlight populations who may be vulnerable in a crisis, using data on age, disability, ethnicity and whether someone is receiving care.
It is designed to help people get more targeted local support.
Read full story
Source: The Guardian, 16 January 2025
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