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

NHS England plans cyber risk rating platform

NHS England is planning to develop a platform for assessing and managing the cyber risk in healthcare organisations.
It has indicated that it is preparing to publish a tender document for a cyber risk rating platform, and has ran a market engagement event with potential suppliers on its plans.
It said the platform would enable NHS organisations to better understand their security posture and how to mitigate potential threats that could impact on their operational activities, including the availability and management of patient data.
The move reflects the increasing focus on cyber security in the NHS.
In September NHS England announced a plan to adopt the Cyber Assessment Framework as its main mechanism for assuring relevant standards, and in October the Government’s Budget provided £2 billion for technology in the health service with an indication that this should include spending on cyber security.
NHS England also publishes cyber alerts for organisations in the sector.
Read full story
Source: UK Authority, 27 November 2024
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MPs back landmark bill to legalise assisted dying in England and Wales

MPs have taken a historic step toward legalising assisted dying in England and Wales by backing a bill that would give some terminally ill people the right to end their own lives.
Campaigners in favour of the terminally ill adults (end of life) bill said it was a significant move towards giving people more choice over the way they die, after the Commons backed the bill by 330 votes for to 275 against.
Brought by the Labour MP Kim Leadbeater, the bill would give terminally ill adults with less than six months to live the right to die once the request has been signed off by two doctors and a high court judge.
It still has further steps to go through before becoming law, and supporters believe assisted dying will not be an option for those with a terminal diagnosis for at least three years.
Figures involved in the hospice and end-of-life care sector who are neutral on the issue called for urgent funding and reform of palliative care to make sure patients have a real choice when dying.
Read full story
Source: The Guardian, 29 November 2024
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1,500 patients may need retest over potential results error

Hundreds of patients are being contacted over potentially incorrect results at a second NHS trust, as more laboratories report concerns over diabetes tests, HSJ understands. 
Bedfordshire Hospitals Foundation Trust was the first to report an issue over blood tests earlier this year, saying up to 11,000 patients may have received the wrong results – including a misdiagnosis of diabetes. 
But the Medicines and Healthcare Products Regulatory Agency has confirmed to HSJ that other laboratories across the country have reported concerns over the same device, which measure glucose control. 
The Hb1AC blood test is used to diagnose diabetes and prediabetes, as well as manage existing conditions. 
A spokeswoman said clinical care was unlikely to have been affected, but doctors were reviewing individual circumstances and patients would be contacted if they needed a new test. 
Several field safety notices have now been published for the Premier Hb9210 HbA1c analyser device, manufactured by Trinity Biotech.
Dr Janine Jolly from MHRA said the regulator was working closely with the manufacturer to ensure corrective actions were being put in place. 
Read full story (paywalled)
Source: HSJ, 27 November 2024
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UK will have men's health strategy, government says

The UK government has announced plans for a men's health strategy.
Health Secretary Wes Streeting said it would help tackle some of the "biggest issues affecting men of all ages".
This may include mental health and suicide prevention, heart disease and prostate cancer.
The strategy is expected to be published next year.
Men die nearly four years earlier than women, on average, and are disproportionally affected by a number of conditions, including heart disease and type 2 diabetes, according to the government, external.
They are also less likely to seek help for mental-health issues.
Streeting also highlighted social-media pressures, saying men faced similar issues to women around their self-esteem and body image and he would not "shy away" from the need to focus on men’s health.
"Nothing frustrates me more than when men’s health and women’s health are somehow pitted in opposition to each other, as if by focusing on a men’s health strategy we are in any way detracting from the brilliant work that successive governments have been doing on women’s health and actually much more work we need to do," he added.
Read full story
Source: BBC News, 28 November 2024
See our Men's health hub top picks
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Chair’s ‘insidious’ bullying ‘drove out trust CEO’

An acute trust’s former chief executive was driven out by “manipulative and insidious” bullying by its current chair, she has told a tribunal.
Susan Gilby left the Countess of Chester Hospital Foundation Trust at the end of 2022 following a breakdown in relations with chair Ian Haythornthwaite.
She is claiming unfair dismissal against the trust and Mr Haythornthwaite, saying she was “bullied, harassed and undermined” by the chair.
Dr Gilby joined the Countess initially as medical director in August 2018. This was shortly after its neonatal nurse Lucy Letby, later convicted of murder and attempted murder of babies, had first been arrested, and with investigations ongoing. Dr Gilby was made CEO in 2019, and was in post throughout the peak covid periods, before being suspended in December 2022, and resigning shortly after.
According to court documents, issues first arose in late 2021 when a new chair, Mr Haythornthwaite, was appointed.
Mr Haythornthwaite made efforts to “assert control through his subtle (and sometimes not so subtle) bullying techniques”, according to Dr Gilby, a former intensive care consultant and medical director.
“He would often tell me that ‘people’ (who he refused to name) had ‘said things’ about me, but would refuse to elaborate further,” Dr Gilby wrote in her witness statement.
Read full story (paywalled)
Source: HSJ, 28 November 2024
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Rise in number of pregnant women in England not getting help they need, survey finds

More than a third of pregnant women in England do not always get help from maternity staff during labour or childbirth, the NHS care regulator has found.
Even more – almost half – do not always get help when they are in hospital after giving birth, a Care Quality Commission (CQC) survey of almost 19,000 women’s experiences of maternity care found.
A significant minority of women do not have confidence in the staff who look after them when they are receiving antenatal care (30%), during their labour and birth (23%) and after they have delivered their child (31%), the research also shows.
In addition, one in seven do not get the pain relief they feel they need during labour and birth and a quarter are unable to ask staff questions after their baby’s birth.
The worrying findings underline the already acute concern about the quality of care provided by NHS maternity services in England, many of which the CQC has deemed to be unsafe.
Read full story
Source: The Guardian, 28 November 2024
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First breakthrough in treating asthma attacks in 50 years hailed as a ‘game-changer’

A new way of treating serious asthma and chronic obstructive pulmonary disease (COPD) attacks could be a “game-changer” and is the first leap in treatment for 50 years, researchers say.
Offering patients an injection is more effective than the current care of steroid tablets and cuts the need for further treatment by 30%, according to a study.
Benralizumab is a monoclonal antibody that targets specific white blood cells, called eosinophils, to reduce lung inflammation.
It is currently used as a repeat treatment for severe asthma at a low dose, but a new clinical trial has found that a higher single dose can be very effective if injected at the time of a flare-up.
Scientists at King’s said steroids can have severe side-effects such as increasing the risk of diabetes and osteoporosis, meaning switching to benralizumab could provide huge benefits.
Lead investigator Professor Mona Bafadhel, from King’s, said: “This could be a game-changer for people with asthma and COPD.
“Treatment for asthma and COPD exacerbations have not changed in 50 years, despite causing 3.8 million deaths worldwide a year combined.
“Benralizumab is a safe and effective drug already used to manage severe asthma.
“We’ve used the drug in a different way – at the point of an exacerbation – to show that it’s more effective than steroid tablets, which is the only treatment currently available.”
Read full story
Source: The Guardian, 28 November 2024
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Long wait for NHS mental healthcare has ‘stark consequences for children’s life chances’

One in three child and adolescent consultant psychiatrist posts in England are vacant, according to a “shocking” analysis laying bare the workforce crisis that experts say is fuelling “unacceptable” long waits for NHS care. Dr Elaine Lockhart, a consultant paediatric liaison psychiatrist who works in NHS child and adolescent mental health services (CAMHS), describes the frustrating but rewarding daily battle to meet the soaring demand and to help those most in need.
At a time when children’s mental health is supposed to be a public policy priority, waiting times for children’s and adolescent mental health services are unacceptably long. Some children wait more than two years to be treated. And that delay can have stark consequences for their mental health and their life chances.
Some of our most vulnerable children are ending up in crisis, needing urgent referrals and emergency care when they should have been treated effectively months before and allowed to enjoy what they will miss out on: their childhood.
Read full story
Source: The Guardian, 28 November 2024
Patient Safety Learning

Prisoners denied dignity while receiving NHS care, watchdog finds

A female inmate remained handcuffed to a male prison officer while she had a mammogram, in an example of prisoners being denied their dignity while receiving NHS care, a watchdog has revealed.
The incident is highlighted in a report by the Health Services Safety Investigation Body (HSSIB) into the difficulties prisoners can face when they leave jail to see a GP or visit a hospital.
Some inmates are put on a long chain, with the prison officer guarding them staying just outside the room, while others are made to wait in cupboards for their appointments, it found.
A government spokesperson said the report’s findings, based on interviews with more than 120 prisoners, were “deeply concerning”, especially about problems experienced by female inmates.
The prospect that prisoners will not have the same dignity and privacy during NHS appointments as other patients is a key reason why more than half do not attend those which occur outside prison.
HSSIB found that “did not attend” (DNA) rates for outpatient appointments during 2024 for those in prison “were high, at 52% and 57% for males and females respectively. This compares to a DNA rate in the general population of 26% for both sexes”, it said.
Read full story
Source: The Guardian, 28 November 2024
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‘I acted in good faith’ says Letby trust CEO

A former trust chief executive at the centre of the Lucy Letby scandal has defended his actions, stating both he and other executives were “acting in good faith”.
Tony Chambers, who led The Countess of Chester Foundation Trust from December 2012 until September 2018, spoke publicly for the first time since Letby’s conviction last year, giving evidence to the public inquiry into the events.
Neonatal nurse Letby was convicted last year of murdering seven babies, and attempting to murder seven more, from 2015-16, while working in the hospital.
Mr Chambers told the inquiry on Wednesday: “I stand by the decisions that we made. We were acting in good faith. I was acting in good faith. I listened to the doctors when they raised their concerns. I also listened to the nurses when they raised their support [for Letby].”
Since her conviction, Chester paediatricians have accused the executives of pushing back on concerns they raised, rather than taking them seriously. Part of their response was to commission several internal and external reviews.
Mr Chambers defended his actions. “I was being presented with things that, at times, felt quite binary. I never took a binary view. I listened to both. 
“Therefore, Letby was removed from frontline duties and therefore we also focused on the safety of the unit, redesignated [downgraded it so it did not take high-risk cases] and so forth, and all the inquiries that went through were done all in good faith.
“The biggest cause of unnatural, unexplained deaths in maternity and neonatal units is not deliberate harm, but failure in systems of care. There are many examples. The Kirkup report, the Ockenden report, many, many examples.”
Read full story (paywalled)
Source: HSJ, 27 November 2024
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‘Heroic leadership’ has prevented action on staff violence, says CEO

A “heroic” model of leadership has meant the NHS hasn’t made enough progress in tackling violence and aggression against staff and promoting sexual safety, a trust chief has said.
Sam Higginson, chief executive of Royal Devon University Healthcare Foundation Trust, said NHS leaders “probably haven’t done as much as we could have done in the past” to reduce violence and aggression and promote sexual safety.
In an interview with HSJ, Mr Higginson said these safety issues have been raised consistently in the RDUH’s staff surveys, and leaders need to talk about them “a lot more.”
In the latest NHS staff survey, the number of staff reporting physical violence from patients or members of the public was at 13.5 per cent nationally, and 12 per cent at RDUH. This proportion has been falling slightly in recent years but widespread concerns about staff safety remain.
A union has warned recently that NHS England is cutting several national initiatives aimed at reducing violence against staff.
Read full story (paywalled)
Source: HSJ, 27 November 2024
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Dallas anaesthesiologist convicted of tampering with IV bags sentenced to 190 years in prison

A Dallas anaesthesiologist who injected dangerous drugs into patient IV bags, leading to one death and numerous cardiac emergencies, was sentenced today to 190 years in prison.
Raynaldo Riviera Ortiz Jr., 60, was charged by criminal complaint in September 2022 and indicted the following month on charges related to tampering with IV bags used at a local surgical centre.
In April, following an eight-day trial, a jury convicted him of four counts of tampering with consumer products resulting in serious bodily injury, one count of tampering with a consumer product and five counts of intentional adulteration of a drug. He was sentenced today by Chief U.S. District Judge David Godbey for the Northern District of Texas, who found that Dr. Ortiz caused the death of his colleague and called his other conduct “tantamount to attempted murder.”
“The defendant betrayed the trust of patients by tampering with critical medical supplies, and the result was serious bodily injury,” said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division. “Today’s sentence reflects the seriousness of these offenses and should make clear that the department will work tirelessly to investigate and prosecute anyone who endangers patients by tampering with drugs.”
“This disgraced doctor acted no better than an armed assailant spraying bullets indiscriminately into a crowd. Dr. Ortiz tampered with random IV bags, apparently unconcerned with who he hurt. But he wielded an invisible weapon, a cocktail of heart-stopping drugs, concealed inside an IV bag designed to help patients heal,” said U.S. Attorney Leigha Simonton for the Northern District of Texas. “On at least nine separate occasions, he essentially attacked unconscious patients lying on an operating table, and even killed a colleague.  I am so proud of our office’s work in bringing Dr. Ortiz to justice and bringing a measure of solace to his victims and their families.”
Read full story
Source: Office of Public Affairs, 20 November 2024
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Bone-on-bone agony: the cruel reality of facing a three-year waiting list for a new knee

When Alexandra McTeare was told she might have to wait three years for knee replacement surgery, she felt desperate. “Because of how miserable your life is, how small it has become,” she says.
The problems with her knee started in 2017. “It was painful and would swell up, particularly in the heat.” She would take painkillers and keep her leg elevated when she was sitting down, and did stretching exercises for her muscles. But over the next few years, “it gradually got worse, the intervals between swelling episodes reduced and the pain increased”. It reached a point where it was no longer bearable.
Ten years ago, McTeare could get a GP appointment within a week. “Now, you phone up and you’re lucky if you get an appointment within a month, and nine times out of 10 it’ll be a nurse practitioner.” McTeare has nothing against nurse practitioners; she used to be a nurse herself and she was working for the NHS when they were introduced to GP practices. “But they’re not appropriate for everything,” she says. “People do need to be able to see a GP.”
Her knee didn’t get better. The opposite happened. “I didn’t believe it was a torn meniscus, it was going on and on, so I decided: to hell with it, I’ll pay and see somebody privately.” In March 2023, she saw an orthopaedic consultant, got an X-ray, was told she had arthritis in her knee and needed a total knee replacement. It took no more than half an hour and cost her £400. McTeare says she is lucky she could raise the money for a private consultation. But she wants to make something clear: “I have always despised private medicine.”
Read full story
Source: The Guardian, 27 November 2024
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NHSE board members face regulation under government proposals

A major consultation on introducing professional regulation of NHS managers and leaders proposes applying the measures to NHS England board members.
One of the questions in the Department of Health and Social Care’s consultation on regulating NHS managers, published this afternoon, asks participants whether “appropriate board members at arms-length bodies (for example, NHS England)” should face a system of regulation.
However, the consultation does not ask participants whether NHSE employees should be included in plans for an individual statutory duty of candour, which could see managers face legal penalties for failing to report safety concerns.
Instead, it only asks if managers at Care Quality Commission-regulated organisations should face tougher legal accountability, and at which level this should be considered.
The consultation, set to run for 12 weeks, will consider the type of regulatory system that would be deemed appropriate, which managers should be in scope, what kind of body should be responsible for its regulation, and what types of standards managers should be required to demonstrate.
Read full story (paywalled)
Source: HSJ, 27 November 2024
Patient Safety Learning

Plans to end NHS dental care crisis not working, warns spending watchdog

Plans to end the deepening crisis in access to NHS dental care are failing, leaving patients unable to get treatment, according to a warning from the government’s spending watchdog.
The National Audit Office’s (NAO) damning verdict on the “dental recovery plan” prompted patient groups to voice alarm that people’s struggles with decayed teeth represents “a serious public health concern”.
A pledge to provide an extra 1.5m treatments in England this year is in disarray amid falls in both the number of dentists doing NHS work and people receiving help from them.
There is “significant uncertainty” as to whether that ambition will be fulfilled because two key elements of the plan have not been achieved, an NAO investigation found. None of the promised new fleet of mobile dental vans has appeared and £20,000 “golden hellos”, to entice 240 dentists to work in areas of acute shortage, have only produced one extra dentist.
The plan, launched in February by the then Conservative government, promised that “everyone who needs to see a dentist will be able to do so” during 2024-25.
However, “based on initial analysis to date, the plan is not on track to deliver the additional courses of treatment,” the NAO concluded.
Even if the plan did provide what was promised, the NHS would still be offering 2.6m fewer treatments this year than before Covid hit in early 2020, it added.
Read full story
Source: The Guardian, 27 November 2024
Patient Safety Learning

Trust recalls 1,500 patients over potential misdiagnosis

Hundreds of patients are being contacted over potentially incorrect results at a second NHS trust, as more laboratories report concerns over diabetes tests, HSJ understands. 
Bedfordshire Hospitals Foundation Trust was the first to report an issue over blood tests earlier this year, saying up to 11,000 patients may have received the wrong results – including a misdiagnosis of diabetes. 
But the Medicines and Healthcare Products Regulatory Agency has confirmed to HSJ that other laboratories across the country have reported concerns over the same device, which measure glucose control. 
The Hb1AC blood test is used to diagnose diabetes and prediabetes, as well as manage existing conditions. 
One affected trust is Maidstone and Tunbridge Wells FT, which said around 1,500 patients had been identified for a retest following a technical issue affecting results in July.
A spokesman said the problem was escalated to the supplier as soon as possible, and that affected patients would be contacted by GPs. 
Read full story (paywalled)
Source: HSJ, 27 November 2024
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