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

More than 2,000 NHS buildings in England older than NHS, figures show

Millions of patients are being put at risk in crumbling hospitals that are unfit for purpose, MPs have said, as figures reveal more than 2,000 NHS buildings are older than the health service itself.
Health bosses have repeatedly warned ministers of the urgent need to plough cash into replacing rundown buildings in order to protect the safety of patients and staff. The maintenance backlog has risen to £11.6bn in England.
Now analysis of NHS Digital data has found that at 34 out of 211 NHS trusts in England at least one in four buildings have been standing since before 1948, the year the NHS was founded.
Sewage leaking from sinks on to wards are among the issues affecting more than 2,000 buildings that predate the health service. Last month it was reported that the ceiling of an intensive care ward collapsed on to a patient on life support and a falling lift broke a doctor’s leg. One hospital is said to have been using its intensive care unit as a storeroom because it deemed it unsafe for patients.
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Source: The Guardian, 15 April 2024
Patient Safety Learning

UK swapped to fatal US blood products to save money, minutes suggest

The British government was willing to risk infecting NHS patients to get “lower-priced” blood products, according to a document that campaigners claim proves state and corporate guilt in one of the country’s worst ever scandals.
A public inquiry into the deaths of an estimated 2,900 people infected with conditions such as HIV and hepatitis will publish its final report in May, four decades after the NHS started prescribing blood and blood products – including from drug users, prisoners and sex workers – sourced from the USA.
Within the thousands of documents disclosed to the inquiry, internal company minutes have emerged that campaigners say provide the final compelling piece of evidence of the commercial greed and state negligence that destroyed thousands of lives.
In November 1976, Immuno AG, an Austrian company that was a major supplier to the Department of Health, was seeking a licence change to allow it to supply a blood product from those paid to donate in the US rather than donors without a financial incentive in Europe.
According to the minutes of a meeting of medics in the company, it had been “proven” that there was a “significantly higher hepatitis risk” from a concentrate known as Kryobulin 2 made from US plasma compared with that from Austria and Germany.
The company had concluded there was a “preference” in the UK for the cheaper US option. The memo of the meeting said: “Kryobulin 2 will be significantly cheaper than Kryobulin 1 because the British market will accept a higher risk of hepatitis for a lower-priced product. In the long-term, Kryobulin 1 will disappear from the British market.”
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Source: The Guardian, 14 April 2024
Patient Safety Learning

ADHD medication shortage continues, pharmacists say

The continuing shortage of ADHD medication is causing those with the condition increasing stress and anxiety, the BBC has been told.
Pharmacists said the problem persists despite a government assurance it would be resolved by the end of last year.
In September, the Department for Health and Social Care (DHSC) blamed the UK-wide scarcity on "increased global demand and manufacturing issues".
It said the disruption was "expected to resolve" between October and December.
Lorraine Jukes, who has ADHD, said: "Here I am in April 2024, with only four days of medication left."
The 36-year-old, from Iffley, Oxford, said she was "frantically phoning through lists of pharmacies" and being told there was no stock and no indication of any being available before she runs out.
Oliver Picard, vice chair of the National Pharmacy Association, said: "We were told it would be resolved in December.
"Some of the medication is starting to come back. In March, we had the supply of a certain brand of ADHD medication, we are now seeing shortages of other ADHD medication and we don't have a date for resupply.
"Sometimes we can get some but will be limited to one packet per month pharmacy and that's not helpful either. It's hugely frustrating."
Read full story
Source: BBC News, 15 April 2024
Patient Safety Learning

One in seven callers could not reach GP in worst-performing ICS

People attempting to contact their GP practice are almost three times as likely to report failing to get through in some integrated care systems (ICS) than others, according to NHS England-commissioned data.
The survey figures, collected for the first time by the Office for National Statistics (ONS), show 8.5% of people nationally who tried to call their GP between mid-January and mid-February this year said they could not reach the practice. This equates to 1.5 million people across England, according to the ONS.
In Northamptonshire – the worst performing ICS – 14.7% of callers did not manage to make contact. That is the equivalent of around one in seven people. By comparison, only 3.9% of callers in Gloucestershire, the best performing ICS, could not get through. The findings are broadly similar when population and age are accounted for.
Read full story (paywalled)
Source: HSJ, 12 April 2024
Patient Safety Learning

Gang culture at neurosurgery department, doctor alleges

A "gang culture" existed at an NHS neurosurgery department, a doctor has claimed at his employment tribunal.
Neurosurgeon Mansoor Foroughi is one of two surgeons who alleges patients were put at risk at University Hospitals Sussex, where police are investigating 105 cases of alleged medical negligence.
Four whistleblowers at the trust previously told BBC Newsnight that patients had died unnecessarily while others were "effectively maimed".
They also complained of a "Mafia-like" management culture.
Mansoor Foroughi alleges one colleague was approved to perform complex spinal surgery without adequate training.
He claims a second surgeon undertook procedures that led to a "disproportionate" level of deaths.
Mr Foroughi says a third surgeon undertook private work whilst on call to the NHS, which if true would be a breach of the NHS Code of Conduct.
Universities Hospitals Sussex dismissed Mr Foroughi following a disciplinary hearing which upheld three allegations against him. He alleges the trust punished him because he raised these safety concerns.
The trust said it would "vigorously contest" his claims.
Read full story
Source: BBC News, 11 April 2024
Patient Safety Learning

NHS boss calls for sexual harassment to be ‘stamped out’ – as health service faces Me Too moment

The boss of the NHS has made a dramatic intervention in The Independent highlighting the shocking amount of sexual abuse against staff in the health service, arguing that a #MeToo moment is needed to safeguard staff.
Amanda Pritchard hit out at the “unacceptable” levels of abuse faced by doctors and nurses, demanding that health trusts be judged on their progress in tackling sexual harassment.
She has called for sexual harassment against NHS staff to be “stamped out” after it emerged that one in eight workers – 58,000 – had reported experiencing unwanted sexual behaviour last year.
Writing exclusively for The Independent, Ms Pritchard said the abuse now levelled at doctors and nurses is unacceptable – with some staff being raped at work, groped, and shown pornography.
“The #MeToo movement has powerfully called out this unacceptable behaviour and fuelled important discussions right across society, and the NHS must not be exempt,” Ms Pritchard wrote.
Around 58,000 NHS workers reported being subjected to unwanted sexual behaviour last year (PA)
“But we can’t just call out unacceptable behaviour and move on: we need to stamp it out across all parts of the NHS.”
Read full story
Source: The Independent, 13 April 2024
Patient Safety Learning

Staff mental health support axed by NHSE

A dedicated mental health and addiction support service for secondary care staff is shutting to new patients, as NHS England is set to cut its funding.
The NHS Practitioner Health programme, which was rolled out nationally in October 2019, is halting new registrations for secondary care staff from 15 April.
NHS England has informed the provider its funding will be cut for secondary care staff, subject to a review it is carrying out of wider services. The Practitioner Health programme for GPs and dentists is expected to continue for another year, although its future beyond that is also unclear, HSJ was told.
An announcement published on X, formerly known as Twitter, said: “New secondary care patients will be signposted to alternative sources of support, including your GP, occupational health departments and organisational employee assistance programmes.”
Its axing comes amid severe pressure on NHS budgets nationally and locally, with overall funding barely keeping up with anticipated inflation in 2024-25, and many integrated care systems forecasting large deficits.
Medical unions and senior doctors have criticised the axing of the service.
Read full story (paywalled)
Source: HSJ, 12 April 2024
Patient Safety Learning

IT system which sparked safety alert dropped by 13 trusts

More than a dozen trusts have changed their maternity IT system – or are in the process of doing so – following a national patient safety alert.
NHS England issued the alert  in December, after a fault was discovered with the Euroking maternity EPR, supplied by Magentus Software. It said information recorded in the EPR could overwrite previously recorded data, meaning the system could mislead clinicians.
While no cases of patient harm have been reported, NHSE instructed trusts using the system to “consider if Euroking meets their maternity service’s needs” and “ensure their local configuration is safe” by June.
A spokesperson for Euroking said: “We have identified a solution to the issues raised in the NPSA [alert], which has been shared with NHSE and with our customers. We’re now meeting each customer and are working with them individually to support the changes that need to be made based on their local configurations. We will continue working with the trusts to support them meeting the deadline outlined in the NPSA.
“As the NPSA outlined, it has been issued as a precautionary measure and there is no evidence of harm being caused to patients.”
Read full story (paywalled)
Source: HSJ, 12 April 2024
Related reading on the hub:
NHS England warns electronic patient record could pose ‘serious risks to patient safety’: what can we learn?  
Patient Safety Learning

NHS waiting lists: Rishi Sunak fails on key pledge as 7.5m people languish

Rishi Sunak has failed to deliver on his key promise to cut NHS waits, the health secretary has admitted, as new figures show that the overall waiting list now stands at 7.5 million.
An extra 300,000 patients are waiting for hospital care compared with January last year, when the prime minister pledged that, under his government, “NHS waiting lists will fall and people will get the care they need more quickly” .
Victoria Atkins, the health secretary, admitted that Sunak had failed to deliver on his promise but argued: “I don’t think anyone could have thought that it was an easy promise to make and it was going to be easy to achieve.”
Read full story (paywalled)
Source: The Times, 11 April 2024
Patient-Safety-Learning

A&E target missed despite tough line from NHSE

The headline A&E target was missed in March despite NHS England’s controversial last-ditch attempts to deliver it.
Four hours A&E performance was 74.2 per cent in March—1.8 percentage points lower than NHSE’s 76 per cent threshold—but up from 71.5 per cent in the same month last year.
NHSE’s attempts to improve four hours performance ahead of a year-end deadline—which included new cash incentives, asking directors to sign personal commitments, and encouraging trusts to focus on less sick patients—saw March performance 3.3 percentage points higher than 70.9 per cent in February.
Around a third of acute trusts (38 of 119) met the 76 per cent target in March–more than double the number of trusts above the threshold in February (15).
An interim ambulance response time for category 2 incidents, set at 30 minutes, was also missed in 2023-14—despite some improvement, and despite the government providing significant extra funding.
The average response time across the year was 36m 23s—better than 2022-23 when it was 50m—but much worse than the pre-covid average of 21m 47s in 2018-19 and 23m 50s in 2019-20.
Many ambulance trusts have continued to struggle with delays in handovers to A&E departments and South Western Ambulance Service Foundation Trust – which has seen some of the worst delays over the winter—averaged 45m 54s for category 2 incidents in March.
Read full story (paywalled)
Source: HSJ, 11 April 2024
Patient-Safety-Learning

Hospital patient spent nine days in locker room

A woman who feared she was having a heart attack said she spent nine days in a hospital staff room because of a shortage of beds. Zoe Carlin, 23, was admitted to Altnagelvin Hospital in Londonderry in March after experiencing severe chest pain.
She said she spent more than a week in a “locker room” where she had to use a hand bell to call staff during what she described as a “dehumanising” ordeal. The Western Health and Social Care Trust (WHSCT) said it faced "extreme pressures" in its hospital emergency departments but could not comment on individual cases due to confidentiality.
“For the full nine days I was in this alcove,” she told BBC Radio Foyle’s North West Today programme. “It’s basically the nurses' locker room. You can see the nurses’ lockers with their names on them. They [staff] just said there’s not enough beds,” she added. A privacy screen did not fully cover the room’s doorway and she had no access to a private bathroom. She said she was forgotten about at meal times on three occasions.
A spokesperson for WHSCT said, "We are acutely aware of the continuing challenges and extreme pressures not just in our emergency departments but across both of our acute hospital sites with full escalation of beds on all wards and departments. In the Western Trust, when we learn of examples where care falls below the standard we expect, we review the circumstances and explore ways to improve care in the future."
Read full story
Source: BBC News, 11 April 2024
Patient-Safety-Learning

Adult transgender clinics in England face inquiry into patient care

Adult transgender clinics in England are facing a Cass-style inquiry into how they treat patients after whistleblowers raised concerns about the care they provide.
NHS England has announced that it is setting up a review of how the seven specialist services operate and deliver care after past and present staff shared misgivings privately during a previous investigation.
As a first step, NHS England will send “external quality improvement experts” into each of the clinics to gather evidence about how they care for patients, to help guide the inquiry’s direction.
The move follows the publication on Wednesday of a landmark review by Dr Hilary Cass, a former president of the Royal College of Paediatrics and Child Health, which recommended sweeping changes in the way that the health service treats under-18s who are unsure about their gender identity.
In a letter responding to Cass’s report, which NHS England sent on Tuesday to the seven trusts that host adult gender dysphoria clinics (GDCs), it told them: “We will be launching a review into the operation and delivery of the adult GDCs, alongside the planned review of the adult gender dysphoria service specification.”
Robbie de Santos, director of campaigns and human rights at Stonewall, an LGBT rights charity, said: “Gender healthcare for adults in the UK is, simply put, not fit for purpose. Many trans adults are being forced to go private at great personal expense to avoid waiting lists in excess of half a decade. We would welcome a review aimed at tackling this unacceptable state of affairs and building capacity into the system.”
Read full story
Source: Guardian, 10 April 2024
Patient-Safety-Learning

Deaths inquiry extended to last three years

A statutory inquiry into deaths of mental health patients will now cover fatalities that took place as late as December 2023.
The inquiry’s investigations are focused “on the trusts which provide NHS mental health inpatient care in Essex”. This includes: “Essex Partnership University Foundation Trust, and the North East London Foundation Trust and their predecessor organisations, where relevant.”
NELFT was not specifically mentioned in the original terms of reference although the inquiry told HSJ it had been within the original scope. The inquiry will also now cover deaths of NHS patients from Essex who died when under the care of private sector providers.
The inquiry’s previous terms of reference covered a period ending in 2020. However, the inquiry’s chair, Baroness Kate Lampard, proposed extending the inquiry’s scope last year due to “ongoing concerns” over services at EPUFT. 
Read full story (paywalled)
Lampard Inquiry: Terms of reference
Source: HSJ, 11 April 2024
Patient-Safety-Learning

The four-hour A&E target is a sham. Hospitals are gaming the numbers and the sickest are left at risk

In the next few days, once the data has been collected, the Government will come out and say that, thanks to its policies, the situation in A&E is improving.
Despite estimates released recently by the Royal College of Emergency Medicine that soaring waits for A&E beds led to more than 250 needless deaths a week in England alone last year, the Government will point to declining numbers of patients who breached the four-hour target this March.
The four-hour target means we're meant to see and either discharge or admit patients within four hours of their arriving in A&E.
But it's a sham, writes Professor Rob Galloway in the Daily Mail. Because, for the past month, the four-hour data has been manipulated, the result of two policies introduced earlier in the month by the Government.
Read full story
Source: Daily Mail, 3 April 2024
Sam

Man suffered psychosis after Trust failed to inform him of steroids side-effects

A man who suffered a psychotic episode which lasted for weeks was not fully informed about potential extreme side-effects of taking steroids medication, England’s health service Ombudsman has found.
Andrew Holland was prescribed steroids in early January 2022 by Manchester Royal Eye Hospital after losing vision in his left eye and suffering a severe infection in his right eye.
The 61-year-old from Manchester was given the medication as treatment for eye inflammation, but soon began suffering from disrupted sleep and severe headaches.
These side-effects developed into more serious ones, including becoming aggressive, psychotic, and inexplicably wandering the street at different times of the day and night.
After several hospital visits due to his symptoms, Andrew attended Manchester University NHS Foundation Trust’s emergency department in mid-January with a severe headache and later became an inpatient.
He was diagnosed with steroid induced psychosis, with symptoms including hallucinations, insomnia and behaviour changes.
Though no failings were found with Manchester University NHS Foundation Trust in prescribing Andrew with steroids for the eye condition, the Ombudsman discovered a missed opportunity to fully inform him of potential extreme side-effects. He was therefore unable to make a fully informed decision about whether to take them or not.
The Trust apologised for an ‘unsatisfactory experience’. However, the Ombudsman found relevant guidelines were not followed. Moreover, there had been no acknowledgement of mistakes in communication about the side-effects. Nor was any attempt made to correct them.
Read full story
Source: PSHO, 10 April 2024
Patient Safety Learning

The ICSs ‘diverting’ the most GP referrals through controversial model

There is huge regional variation in the rate at which health systems are preventing patients joining the elective waiting list through “advice and guidance” to GPs, according to analysis by HSJ.
Some systems – including Northamptonshire – have managed to ramp up these “diverts” to such an extent that they now report around one A&G case to every 3.5 cases cleared from the waiting list through treatment or seeing a consultant.
This contrasts with others, such as Lancashire and South Cumbria, which only reports one A&G case for every 16 cleared from the waiting list.
Advice and guidance involves GPs consulting specialists before making direct referrals and around half the time this results in a referral being avoided. The model is set to be a cornerstone of NHS England’s new outpatient transformation strategy, which is due imminently.
Victoria Tzortziou-Brown, vice chair of the Royal College of GPs, said the analysis “confirms reports we’ve heard from our members – that there is too much regional variation in the use of the ‘advice and guidance’”.
She added: “Some GPs report that when advice and guidance is properly resourced and well implemented, it can be a helpful tool for improving communications with their colleagues in secondary care.
“[But] it is clear that more time, funding and capacity needs to be dedicated to allow clinicians to communicate efficiently and effectively whilst respecting professionalism.”
Read full story (paywalled)
Source: HSJ, 9 April 2024
Related reading on the hub:
Rejected outpatient referrals are putting patients at risk and increasing workload pressure on GPs 
Patient Safety Learning
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