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

Firefighters rescue gran, aged 83, after seven-hour ambulance delay

A gran was left lying outside in the cold facing a seven hour wait for an ambulance following a fall before finally being rescued — by firefighters. Betsy Hulme, 83, was left in agony with a broken hip when she tumbled in her back garden in Leek, Staffordshire.
Son Steve, 60, a former ambulance technician, dialled 999 only to be told it would be several hours until paramedics could get to them due to long handover delays. After a further three hours of Betsy waiting on cold concrete slabs while soaked in rain water, desperate Steve decided to drive to a nearby fire station to ask for help.
Fire crews then came to rescue to lift gran-of-four Betsy into her son's car who took her to hospital where she remains after undergoing a hip repair operation. Dad-of-two Steve, of Leek, has now branded emergency response times as “absolutely disgusting”.
He said: "It’s opened my eyes if I’m honest. It’s absolutely disgusting. I’m so grateful and thankful to the fire service - but it really isn’t their job. I can't remember in my time working as an ambulance technician going to someone and saying, 'I’m sorry it’s taken us twelve hours to get here'."
“It was never anywhere near those ridiculous times when I worked there until 2000 and something has gone drastically wrong since. I can't speak highly enough of the boys and girls who work in the NHS, it's the people above them. Its systemic change that's needed."
Read full story
Source: Wales Online, 4 April 2024
Sam

USA: Hospitals' safety culture gap

Healthcare workers' perceptions of safety at their organisations is improving, though a gap still remains between senior leaders and front-line workers, according to a Press Ganey report.
Press Ganey surveyed more than 1 million employees from 200 health systems in the USA in 2023. The poll included 19 questions related to safety culture across three domains: prevention and reporting, pride and reputation, and resources and teamwork.
Three takeaways:
Staff safety culture scores have risen from an all-time low of 3.96 (out of 5) in 2021 to 4.01 in 2023. This increase was largely driven by improvements around staff members' perceptions of resources and teamwork, including views on adequate unit staffing. "While these improvements are encouraging, there's still a lot of work to do," Press Ganey said. "Pre-pandemic rates were never the desired end state, and it’s important to note that nearly half (48.5%) of employees still have a low perception of safety culture."  Senior management reported the highest perceptions of safety culture at 4.53, while registered nurses and advanced practice providers reported the second- and third-lowest at 3.95 and 3.92, respectively. Security team members had the lowest perceptions of safety at 3.91. large gap was also seen between senior leaders and registered nurses regarding perceptions of workplace violence protections. Senior management gave their organizations a 4.30 out of 5 for having strong security measures in place to prevent violence, compared to just 3.36 for nurses.  Read full story
Source: Becker's Hospital Review, 3 April 2024
Patient Safety Learning

One of UK's best doctors died from a condition he was an expert in as he lay on understaffed hospital ward

One of the best doctors in the UK died on an understaffed Manchester hospital ward after falling sick with a condition he was an expert in treating, an inquest has heard.
Professor Amit Patel was among the ‘best doctors in the UK’, the first person in the country to be qualified in stem cell transplantation and cellular therapy, and intensive care medicine. He was also a beloved husband and father-of-two.
“He looked liked a corpse, 70 per cent of his blood was in his lungs, he was freezing cold and he looked like he was dead," his heartbroken wife told an inquest at Manchester Coroners Court. "I told my daughters, ‘daddy is dead’ – I didn’t have much hope he would be able to come out of that.”
Professor Patel's condition was being investigated by doctors at Wythenshawe Hospital, Manchester Royal Infirmary, and across the country. But, he was in the unimaginable position of being a nationally recognised expert in the illness. During his career, he had formed ‘national guidance’ on the illness and sat on the national multi-disciplinary panel to which the most serious cases, including his own, were referred.
 The court heard how he was experiencing the symptoms of hemophagocytic lymph histiocytosis (HLH) – a rare and life-threatening immune disorder where the body reacts inappropriately to a 'trigger’, such as an infection or cancer, and leads to inflammation. Patients can be predisposed to HLH by Still’s disease, another rare autoimmune condition also causing inflammation, which Professor Patel was suspected to have had.
Full article here.
Clive Flashman

WHO launches new toolkit empowering health professionals to tackle climate change

Climate change presents one of the most significant global health challenges and is already negatively affecting communities worldwide. Communicating the health risks of climate change and the health benefits of climate solutions is both necessary and helpful. To support this, the World Health Organization (WHO) in collaboration with partners has developed a new toolkit designed to equip health and care workers with the knowledge and confidence to effectively communicate about climate change and health.
The toolkit aims to fill the gaps in knowledge and action among health and care workers – all those who are engaged in actions with the primary intent of enhancing health, as well as those occupations in academic, management and scientific roles. Despite their recognized trustworthiness and efficacy as health communicators, many health and care workers might not be fully equipped to discuss climate change and its health implications. This toolkit seeks to change that narrative.
“Health and care workers play a key role in addressing climate change as a health crisis. Their unique position enables them to raise awareness, advocate for policy changes, and empower communities to mitigate and adapt to climate change,” said  Dr Maria Neira, Director, Department of Environment, Climate Change and Health. “By engaging in dialogue and action, health and care workers can catalyse efforts to safeguard human health as well as ensuring a resilient and sustainable future for all.”
Read full story
Source: WHO, 22 March 2024
Patient Safety Learning

NHS watchdog to review patient safety at Glasgow A&E department

Patient safety in the Accident & Emergency unit at the Queen Elizabeth University Hospital in Glasgow will be reviewed by an NHS watchdog.
Healthcare Improvement Scotland (HIS) was first contacted by 29 A&E doctors in May 2023 warning that safety was being "seriously compromised".
HIS last month apologised for not fully investigating their concerns.
The review will consider leadership and operational issues and how they may have impacted on safety and care.
In the letter to HIS, the 29 consultants highlighted treatment delays, "inadequate" staffing levels and patients being left unassessed in unsuitable waiting areas.
They claimed this resulted in "preventable patient harm and sub-standard levels of basic patient care".
The doctors also said critical events had occurred including potentially avoidable deaths.
The consultants said repeated efforts to raise the issues with health board bosses "failed to elicit any significant response".
Read full story
Source: BBC News, 4 April 2024
Patient Safety Learning

Trust appoints chair to lead independent suicides review

A trust has appointed a chair to lead an independent review into dozens of suicides that was sparked by allegations of record tampering.
Following questions from HSJ about the review’s chair and terms of reference, Cambridgeshire and Peterborough Foundation Trust said Ellen Wilkinson, a former medical director at Cornwall Partnership FT and its current chief clinical information officer, would chair the review. 
The trust, which is looking for a substantive CEO following Anna Hills’ departure earlier this year, said the review “will not examine individual patient deaths but will take a thematic approach and look at the learnings we can take from these tragic incidents”.
The trust told HSJ the terms of reference for the review of more than 60 cases of patients who died by suicide since 2017 were still being finalised.
The decision not to investigate individual cases has been criticised by the whistleblower whose concerns prompted the review in the first place, as HSJ reported in October.
While an employee of the trust, Des McVey, a consultant nurse and psychotherapist, carried out an investigation in July 2021 into the case of a 33-year-old man, who died by suicide in 2017.
Mr McVey told HSJ his review found the patient record had been tampered with and “his care plans were created on the day after his death” – a conclusion he stands by.
Read full story (paywalled)
Source: HSJ, 3 April 2024
Patient Safety Learning

GMC will no longer launch FTP proceedings for ‘minor’ concerns

The General Medical Council (GMC) has relaxed its fitness to practise (FTP) processes for doctors so that ‘minor’ concerns such as ‘pushing a colleague’ are not taken to tribunal. 
In an update to its guidance, the regulator has given FTP decision makers and case examiners ‘more discretion’ to throw out complaints if they represent a lower risk to public protection. 
Concerns which are ‘minor in nature and did not impact patient care’ will fall under this guidance.
This is part of the GMC’s efforts to carry out ‘more efficient and proportionate investigations’ and to ‘minimise’ stress for doctors during the FTP process. 
Two examples of concerns which will no longer need to be investigated, if there are ‘no aggravating factors’,  are:
A doctor giving false details to a market research company, in order qualify for free products. A doctor pushing a colleague out the way following a heated argument.  The regulator has said: "Decision makers will now be able to weigh the full circumstances of a concern earlier in the fitness to practise process to assess the overall risk to public protection including to public confidence in the profession– meaning some concerns may not need to be investigated or referred to a tribunal."
However, the guidance, which covers concerns relating to violence and dishonesty, emphasises that allegations which raise a risk to public protection will continue to be investigated. 
Read full story
Source: Pulse, 4 April 2024
Patient Safety Learning

Private ambulance service charging £99 opens to tackle patient delays amid concerns over a ‘two-tier’ system

A new private ambulance service will offer faster travel to A&E for those caught out by half-day waits for NHS ambulances, The Independent can reveal, in a sign of a growing “two-tier” health service.
MET Medical ambulance service will begin by charging £99 for a call-out, and could serve thousands of people a week, its chief executive Dave Hawkins has said.
Mr Hawkins, who is a paramedic himself, said he launched the service after seeing his elderly relatives wait too long for NHS ambulance services following falls.
It comes as waiting times for ambulance service reached a crisis point in the last year, with frail and vulnerable people waiting hours for an ambulance.
Ambulance response times hit record highs over 2022-23, with people who should have an ambulance within 20 minutes waiting an hour and 30 minutes in December 2023.
According to estimates from the Association of Ambulance Chief Executives, 34,000 patients were likely to have suffered harm due to these delays – this hit a high of more than 60,000 in December 2022.
MET Medical will still have to wait to deliver patients if they are seen as a priority, but it said its patients are likely to be lower priority and can be dropped at A&E without waiting for a handover.
Mr Hawkins said vulnerable patients waiting for an ambulance can wait up to 12 hours.
“It’s that moment when you’re out of options, it’s really a horrible place to be, particularly if it’s a loved one … It is a shame, like we’ve seen from the stats and everything, that the health service is failing us."
Read full story
Source: The Independent, 3 April 2024
Patient Safety Learning

Almost 10 million people in England could be on NHS waiting list

Almost 10 million people across England could be waiting for an NHS appointment or treatment, 2 million more than previously estimated, according to a survey by the Office for National Statistics (ONS).
The ONS survey of about 90,000 adults found that 21% of patients were waiting for a hospital appointment or to start receiving treatment on the NHS.
When extrapolated, this equates to 9.7 million people. In January, the waiting list stood at 7.6 million, according to official NHS statistics.
The survey found that the delays were most prominent among 16-24-year-olds, one in five of whom said they had experienced waiting times of more than a year.
Conducted in January and February, the survey was part of the annual winter coronavirus infection study of adults aged 16 and over.
The ONS said the survey was the first of its kind to assess the experiences of adults awaiting hospital appointments, tests or medical treatments. It said the data was experimental, based on self-reported data, and may differ from other statistics on waiting lists.
Read full story
Source: The Guardian, 3 April 2024
Patient Safety Learning

NHS faces ‘avalanche’ of demand for autism and ADHD services, thinktank warns

The NHS is experiencing an “avalanche of need” over autism and attention deficit hyperactivity disorder (ADHD), but the system in place to cope with surging demand for assessments and treatments is “obsolete”, a health thinktank has warned.
There must be a “radical rethink” of how people with the conditions are cared for in England if the health service is to meet the rapidly expanding need for services, according to the Nuffield Trust.
The thinktank is calling for a “whole-system approach” across education, society and the NHS, amid changing social attitudes and better awareness of the conditions. It comes days after the NHS announced a major review of ADHD services.
Thea Stein, the chief executive of the Nuffield Trust, said: “The extraordinary, unpredicted and unprecedented rise in demand for autism assessments and ADHD treatments have completely overtaken the NHS’s capacity to meet them. It is frankly impossible to imagine how the system can grow fast enough to fulfil this demand.
“We shouldn’t underestimate what this means for children in particular: many schools expect an assessment and formal diagnosis to access support – and children and their families suffer while they wait.”
Read full story
Source: The Guardian, 4 April 2024
Patient Safety Learning

Catherine died on the operating table. Now police are investigating

Catherine O’Connor was 17 when she died, having lost 14 litres of blood during high-risk surgery on her back.
At her inquest, the surgeon who operated on her, John Bradley Williamson, told the coroner the procedure at Salford Royal Hospital in Greater Manchester had “progressed uneventfully” and “the blood loss was perhaps a little higher than one would usually anticipate but was certainly not extreme”. The coroner recorded a verdict of death by misadventure.
Now Greater Manchester police are examining O’Connor’s death, in February 2007, and whether Williamson misled the coroner during the inquest in September that year.
Catherine's family are now demanding a new inquest into her death in 2007.
This is because in the days after O’Connor’s death, Williamson sent an internal letter to the head of the hospital’s haematology department, Simon Jowitt, describing the surgery as “difficult” and having involved “a catastrophic haemorrhage”. Williamson had also ignored advice to have a second surgeon present during the operation.
Officers led by Detective Inspector Michael Sharples have commissioned two expert reports and sought advice from the Crown Prosecution Service ahead of a meeting with the coroner, who has been asked to consider reopening O’Connor’s inquest.
Read full story (paywalled)
Source: The Times, 31 March 2024
Patient Safety Learning

Trusts face threat of legal action due to new quality standards

Trusts could be exposed to increased negligence claims as a result of new NHS England guidance for a rare spinal condition, a royal college has claimed.
The Royal College of Emergency Medicine (RCEM) has said updated national guidance on treating cauda equina syndrome could also lead to greater “inequity of access” due to issues accessing timely MRI scans at many accident and emergency departments.
An NHS Resolution report in 2022 found delayed MRI scans were a significant factor in high-value clinical negligence claims, particularly those relating to management of spinal conditions. 
The guidance issued by NHSE’s Getting It Right First Time programme national pathway guidance says emergency MRIs for suspected CES should be taken within four hours of requests to radiology, and where this is not possible, “standard operating procedures” involving local spinal and radiology services should be in place for urgent out-of-hours scanning. Local provision for this “must be in place by June 2024,” the guidance says.
NHSE said the GIRFT guidance has been endorsed by 11 clinical and patient bodies, including the Royal College of Radiologists and the Spinal Injuries Association.
But RCEM, understood to be the only clinical body not to endorse the guidance, has issued a position statement last month stating that “few EDs, outside of tertiary centres, have access to 24/7 MRI scanning”.
Read full story (paywalled)
Source: HSJ, 3 April 2024
Patient Safety Learning

DrugGPT: new AI tool could help doctors prescribe medicine in England

Drugs are a cornerstone of medicine, but sometimes doctors make mistakes when prescribing them and patients don’t take them properly.
A new AI tool developed at Oxford University aims to tackle both those problems. DrugGPT offers a safety net for clinicians when they prescribe medicines and gives them information that may help their patients better understand why and how to take them.
Doctors and other healthcare professionals who prescribe medicines will be able to get an instant second opinion by entering a patient’s conditions into the chatbot. Prototype versions respond with a list of recommended drugs and flag up possible adverse effects and drug-drug interactions.
“One of the great things is that it then explains why,” said Prof David Clifton, whose team at Oxford’s AI for Healthcare lab led the project.
“It will show you the guidance – the research, flowcharts and references – and why it recommends this particular drug.”
Read full story
Source: The Guardian, 31 March 2024
Patient Safety Learning

NHS gender identity clinics for children are ‘nowhere near ready’

The new NHS gender identity clinics for young people are “understaffed” and “nowhere near ready”, it was claimed on Monday as they officially started taking on patients.
A London hub, alongside a second in the northwest, will begin to see patients this week as they replace the Gender Identity Development Service (Gids) at the Tavistock and Portman NHS Foundation Trust.
The Gids clinic was ordered to close after a review by Dr Hilary Cass found it was “not a safe or viable long-term option”.
However, whistleblowers described as senior staff at Gids have expressed concerns about the preparedness and expertise of the new hubs, just as they open.
One, who spoke to the i newspaper under the condition of anonymity, said: “It’s been shoddy, disorganised, messy and unclear. And at times, it’s felt unsafe.”
Read full story (paywalled)
Source: The Times, 1 April 2024
Patient Safety Learning

Families must prove trust caused death of babies, despite inquiry’s damning conclusions

Families have been told they will have to prove liability for the harm caused to mothers and children at East Kent Hospitals University Foundation Trust before getting compensation.
This is despite the inquiry having examined each case in detail and concluding 45 babies could have survived, while 12 who sustained brain damage could have had a different outcome. It also determined 23 women who either died or suffered injuries might have had better outcomes had care been given to “nationally recognised” standards. 
However, NHS Resolution – which handles claims for clinical negligence – now says families must prove causation and a breach of duty of care before any compensation can be made. This stipulation has been made even in cases where the inquiry found different treatment would have been reasonably expected to make a difference to the outcome.
The investigation into the trust’s maternity care led by Bill Kirkup reported 18 months ago. Speaking to HSJ, its author said: “I am disappointed that East Kent families are facing these problems after everything that has happened to them. Of course, it is true that the independent investigation panel was not in a position to rule on negligence, but we did provide a robust clinical assessment of each case.
“I would have hoped that this could be taken into account in deciding to offer early settlement instead of a protracted dispute. It seems sad that a more compassionate approach has not been adopted.”
Read full story (paywalled)
Source: HSJ, 2 April 2024
Patient Safety Learning

Four-year-old girl left with hearing loss for over a year after being left untreated

Kara Dilliway was just three years old when she came down with a common ear infection in October 2022.
She recovered quickly, as was expected, but just days after the infection cleared her parents found she was struggling to hear and talk.
“We’d noticed she’d just started to say yes and no to things, that’s when we thought something is going on,” says her mother Sam Dilliway, a 41-year-old community care worker from Basildon, Essex. Doctors said she could have glue ear, a common condition in children – fluid build-up had started to cause problems with her hearing, and would need draining.
But what should have been a minor ailment has turned into a never-ending ordeal for the family. What was a simple case of glue ear could now leave her with hearing loss for up to two years as she awaits routine treatment.
It comes after data released in January found that over 10 million people have been left on NHS waiting lists for basic ear care services.
Dr Aymat says that the long-term effects of such conditions being left untreated in children can be severe. While glue ear is unlikely to leave permanent damage, there is always a small risk of permanent hearing loss. However, the developmental effects are far more likely and potentially long-lasting.
Read full story
Source: The Independent, 1 April 2024
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