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

Baby death inquiries are poor and incomplete, experts say

Deaths of newborn babies should be more thoroughly investigated by health boards in Scotland, experts have said after reviewing an increase in infant mortality.
The team found inquiries into baby deaths conducted by health boards were “poor quality, inconsistent and incomplete”.
The experts added that information about staffing levels on maternity wards at the time of the deaths was so poor that they could not draw any conclusions.
They were also unable to determine if health boards enlisted independent, external advisers when considering if deaths could have been prevented.
Helen Mactier, a retired neonatologist and chairwoman of the Neonatal Mortality Review, said: “This review has helped to get a clearer understanding of the increase in neonatal deaths that occurred in 2021-22.
“We understand that there are still unanswered questions, and our recommendations are focused on ensuring that future opportunities to learn are not missed and acted on in a timely and comprehensive manner.”
Read full story (paywalled)
Source: The Times, 27 February 2024
Patient Safety Learning

ADHD drugs shortage fuels online black market

Drugs used to treat ADHD are being openly traded in "potentially lethal" doses to UK buyers on encrypted apps, a BBC North West investigation has found.
Criminals are cashing in on a national shortage to offer the prescription tablets in a secret mail-order service.
The BBC found an unregulated online market stacked with medication which high street chemists were struggling to stock.
It is feared patients are turning to the black market in desperation, but one psychiatrist has warned some of the drugs could contain other potentially harmful chemicals.
Thousands of people with ADHD have been unable to get prescribed medication amid a major supply shortage.
The BBC has heard how the situation has left children and adults in limbo and with the shortage set to last until December many are believed to be turning to illegitimate traders to help treat the condition.
The BBC took these findings to Dr Morgan Toerien, associate specialist in mental health at Beyond Clinics in Warrington, who said: "A lot of these drugs are potentially lethal, not just dangerous - particularly if you weren't used to taking them and if you took a higher dose.
"During my work in illicit drug treatment, we've tested people alleged to have taken a lot of the drugs seen on this channel and they don't actually contain what they say they do."
He said people could be taking a tablet purporting to be to treat ADHD, but could be "far more dangerous".
Read full story
Source: BBC News, 28 February 2024
Patient Safety Learning

NHS to target same elective activity next year

Health systems will be asked to deliver the same amount of elective activity next year as they were tasked with completing in 2023-24, HSJ understands.
Local leaders have been issued with varying interim targets for 2024-25 that produce an average national threshold of 7% more activity than pre-covid levels, on a value-weighted basis.
It means the target for the current year has effectively been rolled over into next, suggesting the elective recovery is a year behind schedule.
Even if systems hit their thresholds next year, they will still fall well short of the central target set out in the elective recovery plan in 2022.
Recent weeks have seen other elective ambitions ditched or watered down, including the prime minister’s headline pledge to bring the overall waiting list down. It is likely a result of the government accepting it cannot push more elective activity due to ongoing strikes and overspending.
Read full story (paywalled)
Source: HSJ, 27 February 2024
Patient Safety Learning

NHSE looks to scrap ‘follow ups’ target

NHS England is looking to ditch a key elective target that aimed to deliver large reductions in follow-up appointments, HSJ has learned.
Senior sources privately admit progress has not been made against the target to cut the volume of the most common type of outpatient follow-up by 25 per cent target.
This is supported by publicly available data. While this only gives a partial picture, the data suggests the volumes have actually increased compared to pre-covid levels.
The volume-based target is widely viewed as unrealistic and senior figures told HSJ it had also “masked” some genuine progress trusts have made in reforming outpatient services and reducing less productive appointments.
Sources familiar with discussions said having a volume-based target to reduce a subset of patients while trying to increase overall activity volumes had been logistically complex.
NHSE is instead pushing for a new “ratio-based” target which sources said would be a better measure to reduce the least productive types of outpatient follow-ups and be a fairer measure of progress.
Read full story (paywalled)
Source: HSJ, 26 February 2024
Patient Safety Learning

UK trails other countries on waiting times for cancer treatment, study finds

Cancer patients in the UK wait up to seven weeks longer to begin radiotherapy or chemotherapy than people in comparable countries, research has revealed.
The stark findings are yet more damning evidence of the extent to which the UK lags behind other nations, as experts warn that people’s chances of survival are being affected by long waits for treatment.
In the first research of its kind, experts at University College London analysed data from more than 780,000 cancer patients diagnosed between 2012 and 2017 in four comparable countries: Australia, Canada, Norway and the UK. Eight cancer types were included: oesophageal, stomach, colon, rectal, liver, pancreatic, lung and ovarian cancer.
The two studies, published in the Lancet Oncology, were the first to examine treatment differences for eight cancer types in countries across three continents. UK patients experienced the longest waits for treatment, the research found.
The average time to start chemotherapy was 48 days in England, 57 in Northern Ireland, 58 in Wales and 65 in Scotland. The shortest time was 39 days in Norway.
In radiotherapy, the UK fared even worse. It took 53 days on average for treatment to begin in Northern Ireland, 63 in England, 79 in Scotland and 81 in Wales.
Cancer Research UK, which part-funded the two studies, said delays to begin treatment were partly a result of the UK government’s lack of long-term planning on cancer in recent years. Countries with robust cancer strategies backed by funding had seen better improvements in survival rates, it said.
Read full story
Source: The Guardian, 27 February 2024
Patient Safety Learning

Wales Covid families want answers as inquiry arrives

Accountability is top of the wishlist from the Covid inquiry as it comes to Wales, say bereaved families and those charged with protecting vulnerable people.
Over the next three weeks the focus will largely be on the decisions made by the Welsh government during the pandemic.
From the timings of lockdowns to the rationale of doing things differently to the UK government, the hearings will scrutinise actions taken in Wales.
For many, it will be a chance to hear the justifications for policies that they say left them feeling unsupported and alone.
Ann Richards did not get to say a final goodbye to her husband Eirwyn before he died from hospital-acquired Covid in January 2021.
Ann still wonders if non-urgent healthcare had been fully up and running, could Eirwyn have been discharged sooner, or perhaps even avoided a hospital admission altogether?
Additional rules put in place to reduce the spread of the virus meant there were delays in getting a purpose-built wheelchair – delaying his discharge from hospital.
"I understand there had to be rules in place," said Ann. "But it's the wellbeing of the patients I think they lost a lot of."
Read full story
Source: BBC News, 26 February 2024
Patient Safety Learning

'Overwhelming' response to birth trauma inquiry

An inquiry into birth trauma has received more than 1,300 submissions from families.
It is estimated that 30,000 women a year in the UK have suffered negative experiences during the delivery of their babies, while 1 in 20 develop post-traumatic stress disorder.
The investigation is a cross-party initiative, led by MPs Theo Clarke and Rosie Duffield, in collaboration with the Birth Trauma Association.
Ms Clarke the Conservative MP for Stafford, triggered the first ever parliamentary debate on the issue in October.
In an emotional exchange in the House of Commons, she described her own experience following her daughter's birth at the Royal Stoke University Hospital in 2022.
She bled heavily after suffering a tear and had to undergo two-hour surgery without general anaesthetic, due to an earlier epidural.
The Birth Trauma Association, which is administering the inquiry, invited the public to submit written accounts of their own experiences.
Dr Kim Thomas, from the association, said she had received an "overwhelming" number of personal accounts. Some cases date back as far as the 1960s.
Read full story
Source: BBC News, 25 February 2024
Patient Safety Learning

'Daily life is a struggle without my ADHD medicine'

"Taking medication meant my brain was quiet for the first time; it was amazing, I cried because I was so happy," Jass Thethi, whose life was transformed after an ADHD diagnosis just over a year ago, told a BBC North West investigation.
But the 34-year-old's joy was short-lived because, like more than 150,000 others who live with the condition and are reliant on medication, Jass has been affected by a UK-wide medicine shortage that started in September.
Jass, who lives in Levenshulme, Greater Manchester, said: "When the medication shortage started I had to go back to white knuckling everyday life… I had to take the decision to change things and I had to quit the job I was doing."
The charity ADHD UK said it had recorded a "significant decline" in the availability of medicines, with only 11% having their normal prescription in January, a drop from 52% in September.
The Department of Health and Social Care (DHSC) said increased global demand and manufacturing issues were behind the shortages.
Dr Morgan Toerien, associate specialist in mental health at Beyond Clinics in Warrington, said Jass's experience was not unique and many patients' lives had been "completely destabilised".
Read full story
Source: BBC News, 27 February 2024
Have you (or a loved one) ever been prescribed medication that you were then unable to get hold of at the pharmacy? 
To help us understand how these issues impact the lives of patients and families, please share your experience and insights in our Community post.
We would also like to hear from pharmacists working in community or hospital settings, and others who have insights to share on this issue. 
Patient Safety Learning

Over 30 sepsis deaths linked to ‘systemic’ failings, investigation reveals

Major progress made in sepsis care during the previous decade has been significantly reversed amid repeated failures in recognising and treating the condition.
HSJ has identified 31 deaths in the last five years where coroners have warned of systemic problems with diagnosing and treating sepsis, including nine cases relating to children. Many of the deaths were deemed avoidable.
Meanwhile, investigations suggest a majority of acute trusts are failing to record their treatment rates for sepsis, which is deemed a crucial aspect of driving improvements.
Repeated shortcomings raised by coroners, including 10 separate cases in 2023, include delays or failures to administer antibiotics, not following protocols for identifying sepsis, and inaccurate, missed or skipped observations.
Health ombudsman Rob Behrens, who issued a report on sepsis failures last year, said the same mistakes were “clearly being repeated time and time again”.
He added: “What is chilling to me is that these [coroners’ reports] fit in almost exactly with the issues we raised in our sepsis report… and even the 2013 sepsis report issued by my predecessor, including unnecessary delays, wrong diagnosis, and failure to provide adequate plans for sepsis.”
Read full story (paywalled)
Source: HSJ, 27 February 2024
Patient Safety Learning

They bite, they hit, they spit: patients assault staff at Nottingham hospital

“I’ve seen patients take swings at doctors because they’re not happy with the time it’s taken or the doctor’s diagnosis. I’ve seen fire extinguishers set off and thrown at people, computers lifted and thrown across the emergency department and people run out of cubicles and punch other patients – people they don’t know – for no reason.”
Roger Webb, a security supervisor at the Queen’s Medical Centre hospital in Nottingham, is recalling some of the more unsavoury incidents he has witnessed in the course of his work.
“I’ve been struck in the groin, had scratches all over my arms where people have dug their nails in. I’ve been bitten and I’ve been spat at while trying to deal with situations. The spitting is the most depressing of those, though, because it’s so contemptuous and so horrible. And legally it’s assault.”
Like staff across the NHS, those at the QMC have seen a rise in abusive, threatening and intimidatory behaviour by patients and their relatives in recent years. In 2021-22, Nottingham University hospitals (NUH), the NHS trust that runs the QMC and its sister City hospital, recorded 1,237 incidents of aggression, violence and harassment. But it had many more – 1,806 – during the following year, 2022-23.
Last year brought another increase. In the six months between April to September alone, NUH recorded another 1,167 incidents, leaving 2023-24 likely to be the worst ever on record.
Staff have been hit, spat at, threatened, verbally abused and racially abused during this roll call of unpleasant incidents. Racially aggravated harassment has increased notably.
Some of the incidents have led to perpetrators being charged and convicted. Worryingly, in a growing number of cases, the patient has been responsible for several incidents while receiving one single episode of care.
Care delays are the main trigger for abuse at the QMC. But such incidents also arise when staff are treating drunks, rival gangs, people who are high on drugs and those with mental health problems.
Read full story
Source: The Guardian, 25 February 2024
Sam

UK eating disorder charity says calls from people with Arfid have risen sevenfold

The number of people in the UK who have avoidant restrictive food intake disorder (Arfid), in which those afflicted avoid many foods, has risen sevenfold in five years, figures show.
The eating disorders charity Beat received 295 calls about Arfid in 2018 – comprising 2% of its 20,535 inquiries that year. However, it received 2,054 calls last year, which accounted for one in 10 of its 20,535 requests for help. Many were from children and young people or their parents.
Andrew Radford, Beat’s chief executive, said: “It’s extremely worrying that there has been such a dramatic increase in those seeking support for Arfid, particularly as specialist care isn’t always readily available.”
Patchy provision of NHS help meant many people were experiencing long delays before accessing support, he added.
Eight in 10 eating disorder service providers did not state on their website whether or not they offered Arfid care, research by Beat found.
“All too often we hear from people who have been unable to get treatment close to home or have faced waits of months or even years to get the help they need,” Radford said.
Arfid is much less well-known than anorexia or bulimia. It is “an eating disorder that rarely gets the attention it deserves”. The sharp increase in cases should prompt NHS chiefs to end the postcode lottery in care for Arfid and ensure that every region of England had a team of staff fully trained to treat it, he added.
“Unlike other eating disorders such as anorexia or bulimia, Arfid isn’t driven by feelings around [someone’s] weight or shape,” Radford said. “Instead, it might be due to having sensory issues around the texture or taste of certain foods, fear about eating due to distressing experiences with food, for example choking, or lack of interest in eating.”
Read full story
Source: The Guardian, 26 February 2024
Patient Safety Learning

Mums call for Strep B screening to save babies

Mothers of babies who died or suffered brain damage from a Group B Strep (GBS) infection say routine screening is needed.
Oliver Plumb, from the charity Group B Strep Support, said it was a "small number of babies" exposed to the bacteria that developed a serious and potentially fatal infection.
He said around 800 babies a year developed the infection - which is about two babies a day - and about one a week will die, while another a week will be left with a lifelong disability.
"It's a heart-breaking start to life for families and that often the first they hear of Group B Strep is when their baby is sick or in intensive care".
The charity has called for GBS to be a notifiable disease to make it a legal responsibility for infections to be reported. It added that current figures could be "missing around one fifth of the infections".
There was a "postcode lottery" in terms of how many families will hear about GBS, he said. The charity also backed calls for screening.
"In the UK we don't sadly have a routine testing programme, that's at odds with much of the rest of the high-income world. "
A DHSC spokesperson said a public consultation on the notifiable diseases list was carried out last year.
"DHSC and UKHSA are considering the responses and confirmation of any changes will be published in due course," they said.
Several reasons for not recommending routine screening have been given by the committee, including that results can change in the last few weeks of labour, and that GBS does not cause infection in every baby.
Read full story
Source: BBC News, 26 February 2024
Further reading on the hub:
Leading for safety: A conversation with Jane Plumb, Founder of Group B Strep Support  
Patient Safety Learning

Newly installed EPR contributed to A&E death, warns coroner

A newly installed electronic patient record contributed to the “preventable” death of a 31-year-old woman in an emergency department, a trust has been warned.
Emily Harkleroad died at University Hospital of North Durham in December 2022 following “failures to provide [her] with appropriate and timely treatment” for a pulmonary embolism, a coroner has said.
The inquest into her death heard emergency clinicians had raised concerns about a newly installed electronic patient record, provided by Oracle Cerner, which they said did not have an escalation function which could clearly and quickly identify the most critical patients.
The inquest heard the new EPR, installed in October 2022, did not have a “RAG rating” system in which information on patient acuity “was easily identifiable by looking at a single page on a display screen” – as was the case with the previous IT system.
The software instead relied on symbols next to patients’ names which indicate their level of acuity when clicked on, but did “not [provide] a clear indication at first glance” of their level of acuity.
Rebecca Sutton, assistant coroner for County Durham and Darlington, said that “errors and delays” meant Ms Harkleroad did not receive the anticoagulant treatment that she needed and “which would, on a balance of probabilities, have prevented her death”.
“It is my view that, especially in times of extreme pressure on the emergency department, a quick and clear way of identifying the most critically ill patients is an important tool that could prevent future deaths.”
Read full story (paywalled)
Source: HSJ, 23 February 2024
Patient Safety Learning

Lying in agony in urine-soaked sheets: the horrific reality of patient life on an NHS ward

Left in agonising pain, with staff ignoring his cries for help, Martin Wild called 999 from his hospital bed, desperate for someone to get him the medication he needed.
This was just the beginning of the 73-year-old’s “nightmare” experience at the hands of Salford Royal Hospital.
Over nearly five months, the former car salesman says he was subjected to prolonged periods of neglect, including being left to lie in urine-soaked sheets, pleading for medication.
He lost so much weight that, according to his wife, he became skin and bone. One staff member involved in his care said they’d never seen a hospital patient neglected to such a serious degree.
Mr Wild told The Independent that his time at Salford Royal Hospital has shattered his belief in the NHS and that he believes it is not fit for purpose.
“It was a nightmare in that ward. I didn’t feel like there was much caring going on,” he said.
“I used to lie there at night; I could hear people shouting and screaming for help. It was like being in the third world.”
Read full story
Source: The Independent, 24 February 2024
Patient Safety Learning

Physician associate law may confuse patients, says BMA

The House of Lords is being urged to throw out plans for non-doctor associate roles to be licensed by the same body as doctors.
Under a planned new law, physician associates (PAs) will be regulated by the General Medical Council (GMC).
The British Medical Association (BMA) believes this could lead to patients confusing the different roles, which it says could have "tragic consequences".
There are about 3,200 PAs working in GP surgeries and hospitals in England, with 10,000 more planned in the next decade or so.
They were introduced to help doctors with their work - examining and diagnosing patients and discussing treatments with them - although PAs are currently unregulated.
Unlike doctors, they do not have to hold a medical degree, but they usually have a degree in a life science and have to undertake a two-year training course.
The BMA, the union representing doctors in the UK, believes that regulation by the GMC could lead to a "blurring of the lines" between PAs and doctors.
In an open letter to the House of Lords ahead of a debate on Monday, the BMA's chairman Prof Phil Banfield said: "PAs are not doctors. They do not hold a medical degree and are not medically trained, despite misleading statements made by some.
"We know that patients are already confused about telling the difference between PAs and doctors, and this legislation will make this problem worse.
"Keeping the GMC as the regulator exclusively of doctors would mean we retain the clear distinction between doctors and PAs."
Read full story
Source: BBC News, 25 February 2024
Patient Safety Learning

Hospital IT system warning after 'preventable' death

A coroner has issued a warning over a hospital’s new computer system after the death of a 31-year-old woman.
Emily Harkleroad collapsed on 18 December 2022 and was taken to the University Hospital of North Durham, where she died the next morning from a pulmonary embolism – a clot on the lung.
The assistant coroner for County Durham and Darlington concluded, on balance, that Ms Harkleroad’s death could have been prevented, external. She also noted computer system concerns had been raised by a number of clinicians.
Read full story
Source: BBC News, 24 February 2024
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