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

'Ethnic bias' delayed care before Liverpool woman's death

"Cultural and ethnic bias" delayed diagnosing and treating a pregnant black woman before her death in hospital, an investigation found.
The probe was launched when the 31-year-old Liverpool Women's Hospital patient died on 16 March, 2023.
Investigators from the national body the Maternity and Newborn Safety Investigations (MSNI) were called in after the woman died.
A report prepared for the hospital's board said that the MSNI had concluded that "ethnicity and health inequalities impacted on the care provided to the patient, suggesting that an unconscious cultural bias delayed the timing of diagnosis and response to her clinical deterioration".
"This was evident in discussions with staff involved in the direct care of the patient".
The hospital's response to the report also said: "The approach presented by some staff, and information gathered from staff interviews, gives the impression that cultural bias and stereotyping may sometimes go unchallenged and be perceived as culturally acceptable within the Trust."
Liverpool Riverside Labour MP Kim Johnson said it was "deeply troubling" that "the colour of a mother's skin still has a significant impact on her own and her baby's health outcomes".
Read full story
Source: BBC News, 16 February 2024
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USA: Mississippi prison delayed woman’s cancer diagnosis until it was terminal, lawsuit says

A Mississippi prison denied medical treatment to an incarcerated woman with breast cancer, allowing her condition to go undiagnosed for years until it spread to other parts of her body and became terminal, according to a lawsuit filed on Wednesday.
Susie Balfour, 62, alleges that Mississippi department of corrections (MDOC) medical officials were aware she might have cancer as early as May 2018, but did not conduct a biopsy until November 2021, one month before she was released from prison. It was not until January 2022, after she left an MDOC facility, that a University of Mississippi Medical Center doctor diagnosed her with stage four breast cancer, according to her federal complaint.
Her lawsuit and medical records paint a picture of a prison healthcare system that deliberately delayed life-saving healthcare and for years repeatedly failed to conduct follow-up appointments that the MDOC’s contracted clinicians recommended.
Read full story
Source: The Guardian, 14 February 2024
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NHS apologises after hospital doctor took own life

The doctor in charge of medical training for NHS England has apologised unreservedly to the family of a medic who took her own life.
Dr Vaish Kumar, a junior doctor, left a suicide note blaming her death entirely on the hospital where she worked, her family revealed last year.
Dr Kumar, 35, was wrongly told she needed to do a further six months of training before starting a new role.
It meant she was forced to stay at Queen Elizabeth Hospital (QE) in Birmingham, where she had been belittled by colleagues, an inquest heard.
In a letter to Dr Kumar's family, seen by the BBC, NHS bosses admitted she did not need to do the extra training.
Dr Navina Evans, chief workforce and training education officer for England, told the family in the letter: "I wish to unreservedly apologise for these mistakes and for the impact they would have had.
"As an organisation we are determined to learn... not only across the Midlands but across England as a whole."
Read full story
Source: BBC News, 13 February 2024
Patient Safety Learning

Pelvic mesh compensation disappointingly low, says victim

A woman who described the time in her life after a pelvic mesh implant as "soul destroying" said proposed government compensation was "disappointingly low".
Claire Cooper, from Uckfield, is one of around 100,000 women across the UK who had transvaginal mesh implants.
England's patient safety commissioner suggested compensation could start at around £20,000.
Ms Cooper, 49, was originally given the mesh implant as a treatment for incontinence after childbirth.
However, after struggling with pain following the operation, Ms Cooper claimed doctors treated her as if she were "psychotic" and "a nuisance".
She said her experience was one of being "mocked".
"It was just soul destroying," Ms Cooper told BBC Radio Sussex. "I lost my fight because I was met at every turn with resistance so I just lost the ability to advocate for myself."
Ms Cooper eventually had surgery to remove the mesh, which she said one doctor compared to "cheese cutting wire". She is still living with chronic pain.
Read full story
Source: BBC News, 15 February 2024
Further reading on the hub:
Doctors shocking comments to women harmed by mesh
 
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IVF clinic investigated over possible damaged eggs

More than 100 patients who had eggs and embryos frozen at a leading clinic have been told they may have been damaged due to a fault in the freezing process.
The clinic, at Guy's Hospital in London, said it may have unwittingly used some bottles of a faulty freezing solution in September and October 2022.
But it said it did not know the liquid was defective at the time.
One patient at a second clinic, Jessop Fertility in Sheffield, has also been affected, the BBC has learned.
The fertility industry regulator, the Human Fertilisation and Embryology Authority (HFEA), said it believes the faulty batch was only distributed to those two clinics.
It is believed that many of the patients affected have subsequently had cancer treatment since having their eggs or embryos frozen, which may have left them infertile. This means they now may not be able to conceive with their own eggs.
Guy's Hospital's Assisted Conception Unit is now being investigated by the HFEA, because of a delay in informing people affected.
Read full story
Source: BBC News, 14 February 2024
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Top trust warns GPs of 15-week wait for scans

England’s largest hospital trust has written to GPs warning their patients face 15-week waits for routine MRIs, ultrasound and CT scans.
Guy’s and St Thomas’ Foundation Trust in central London said it was prioritising suspected cancer and other “urgent cases”, meaning “unfortunately waiting times for routine patients are now an average of 15-16 weeks for an appointment against a target of six weeks”.
This is much worse than national averages, which December figures showed were 3.2 weeks, 2.5 weeks and 3.3 weeks for MRI, CT and ultrasound waits respectively.
It its letter to GPs in Lambeth and Southwark – its main patches – GSTT said: “Current imaging referral demand outstrips capacity, despite these services consistently delivering near 120 per cent levels of activity compared to 2019-20.
“The radiology service is exploring multiple routes to increase imaging capacity, including increased weekend working, insourcing and outsourcing contracts, but there is still a significant shortfall of slots every week.”
In particular, it said primary care staff should expect long waits for the reporting of routine MRI scans.
Read full story (paywalled)
Source: HSJ, 13 February 2024
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Family of man who died after surgery delay calls Sussex NHS trust apology ‘hollow’

The family of a man who needlessly died after a 12-hour delay in surgery have called for changes at a troubled NHS trust as regulators expressed alarm about patient safety and waiting times.
The Care Quality Commission (CQC) upgraded the surgery department at the Royal Sussex county hospital in Brighton from “inadequate” to “requires improvement” at a time when it is at the centre of a police investigation into dozens of patient deaths, allegations of negligence and cover-up.
In their report, the regulator expressed concern about already long and lengthening waiting times, repeated cancelled operations and staff shortages that could compromise safety.
The inspection report comes as the Guardian can reveal the trust apologised and settled with the family of Ralph Sims, who died aged 65 after heart surgery in April 2019 when doctors failed to act appropriately to a drop in his blood pressure.
Sims, who was a keen runner, suffered a drop in blood pressure and developed an irregular heart rhythm eight hours after surgery to replace an aortic valve at the hospital.
An internal investigation into Sims’ treatment acknowledged that hospital staff failed to “recognise the significance of the fall in blood pressure”.
University Hospitals Sussex NHS foundation trust, which runs the hospital, accepted that the father of three should have returned to surgery to identify the cause of his deterioration. Instead, medics decided that he should be observed overnight.
Due to another emergency case, an angiogram was not carried out on Sims until just before noon the following day – 12 hours after the drop in pressure. The delay caused irreversible – and avoidable – heart muscle damage, leading to his death five weeks later.
The family said: It added: “Whilst the trust has apologised to our family it feels hollow. Ralph’s death was entirely unnecessary, and despite the issues in his care, it took the trust several years to apologise.”
Read full story
Source: The Guardian, 14 February 2024
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NHS nurses being investigated for ‘industrial-scale’ qualifications fraud

Hundreds of frontline NHS staff are treating patients despite being under investigation for their part in an alleged “industrial-scale” qualifications fraud.
More than 700 nurses are caught up in a potential scandal, which a former head of the Royal College of Nursing said could put NHS patients at risk.
The scam allegedly involves proxies impersonating nurses and taking a key test in Nigeria, which must be passed for them to become registered and allowed to work in the UK.
“It’s very, very worrying if … there’s an organisation that’s involving themselves in fraudulent activity, enabling nurses to bypass these tests, or if they are using surrogates to do exams for them because the implication is that we end up in the UK with nurses who aren’t competent,” said Peter Carter, the ex-chief executive of the RCN and ex-chair of three NHS trusts.
He praised the Nursing and Midwifery Council (NMC) for taking action against those involved “to protect the quality of care and patient safety and the reputation of nurses”.
Nurses coming to work in the UK must be properly qualified, given nurses’ role in administering drugs and intravenous infusions and responding to emergencies such as a cardiac arrest, Carter added.
Forty-eight of the nurses are already working as nurses in the NHS because the NMC is unable to rescind their admission to its register, which anyone wanting to work as a nurse or midwife in Britain has to be on. It has told them to retake the test to prove their skills are good enough to meet NHS standards but cannot suspend them.
The 48 are due to face individual hearings, starting in March, at which they will be asked to explain how they apparently took and passed the computer-based test (CBT) of numeracy and clinical knowledge taken at the Yunnik test centre in the city of Ibadan. The times recorded raised suspicions because they were among the fastest the nursing regulator had ever seen.
Read full story
Source: The Guardian, 14 February 2024
Patient Safety Learning

Families of disabled people tell BBC of battle for NHS care support

More than 100 families looking after severely disabled adults and children outside hospital, have told the BBC that the NHS is failing to provide enough vital support.
The NHS says help is based on individual needs and guidelines ensure consistency across England and Wales. However, some families describe the system as adversarial.
Only those living outside hospital with life-limiting conditions, or at risk of severe harm if they don't have significant support, get this help from the NHS.
It is provided through a scheme called Continuing Healthcare (CHC) for adults, and its equivalent for under-18s, Children and Young People's Continuing Care.
Cases in England are decided by NHS Integrated Care Boards (ICBs) - panels responsible for planning local health and care services. In Wales, they are overseen by local health boards.
The BBC has heard from 105 families who described serious concerns with how the two schemes are working - with most calling for reform.
One young man with 24-hour needs hasn't received any CHC help despite being eligible since February 2023 - his parents, who first applied for support on his behalf nearly two years ago, currently provide round-the-clock care
Another family were told overnight care for their teenage child - who is non-verbal, has severe mobility issues and requires 24/7 support - would be reduced from seven down to three nights a week, without a reason being given.
Read full story
Source: BBC News, 14 February 2024
Patient Safety Learning

‘Failure to act with candour’ over unsafe gas, report finds

There was an “unacceptable delay” and “failure to act with candour” in how a trust responded to a serious risk from staff nitrous oxide exposure, an independent investigation has found.
Mid and South Essex Foundation Trust found levels of nitrous oxide far above the workplace exposure limit at Basildon Hospital’s maternity unit during routine testing in 2021. However, staff were only notified and a serious incident declared more than a year later.
The exposure related to a mixture of nitrous oxide and oxygen, commonly known as gas and air, used during births. While short-term exposure is considered safe, prolonged exposure to nitrous oxide could lead to potential health issues.
Chief executive Matthew Hopkins has apologised, after a report by the Good Governance Institute said: “The inquiry found that there was an unacceptable delay in responding to and mitigating a serious risk that had been reported… As a result of this failure to act on a known risk, midwives and staff members on the maternity unit were exposed to unnecessary risk or potential harm from July 6 2021 to October 2022."
Read full story (paywalled)
HSJ, 14 February 2024
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Man with Down's Syndrome died in hospital after not being fed for nine days

A man with Down’s Syndrome and dementia died in hospital after not being fed for nine days.
The 56-year-old was admitted to Poole hospital with a hip fracture after falling over at a Bournemouth care home, where he had been receiving care.
On admittance, he was taken to the trauma and orthopaedics ward, where he was listed as ‘nil by mouth’, as he had trouble swallowing.
Nine days later, he died of pneumonia after a ‘series of errors’ at the hospital.
Now, the man’s father has been given £22,500 in compensation, after an incident investigation at the hospital.
Allegations made against the hospital included a failure to feed the patient for nine days, causing "his subsequent severe deterioration and death".
The hospital failed to adequately monitor and investigate his condition, while failing to provide senior doctors, it was alleged.
This left unsupervised junior doctors who did not have access to senior staff or any way to escalate their concerns, allegations said.
This, it was claimed, was not done when the patient was still nil by mouth after nine days, despite the fact he was suffering from pneumonia.
Read full story
Source: Yahoo News, 9 February 2024
Sam

Allow all pharmacy staff to prepare and assemble medication without supervision, says Community Pharmacy Scotland

Community Pharmacy Scotland (CPS) is calling for all pharmacy staff to be allowed to prepare and assemble medication without requiring supervision from a pharmacist or pharmacy technician.
Its comments came in its response to a Department of Health and Social Care consultation on pharmacy supervision, published on 7 December 2023, which sets out proposals to amend the Medicines Act 1968 and The Human Medicines Regulations 2012.
The consultation includes proposals to enable pharmacists to authorise pharmacy technicians to carry out, or supervise others carrying out, the preparation, assembly, dispensing, sale and supply of medicine; to enable pharmacists to authorise any member of the pharmacy team to hand out checked and bagged prescriptions in the absence of a pharmacist; and to allow pharmacy technicians to supervise the preparation, assembly and dispensing of medicines in hospital aseptic facilities
In its response, the CPS disagreed with the first of these proposals, arguing that “the preparation and assembly of [pharmacy] and [prescription-only] medications can be safely carried out from a registered pharmacy premises, without requiring supervision by a Responsible Pharmacist or an authorised pharmacy technician”.
CPS also said there is “a major flaw in the logic” of the government proposal because “it relies heavily on individuals rather than on safe systems”, making the proposed new way of working “vulnerable to changes in personal circumstance”.
“The environment, technology, training, conditions and [standard operating procedures] in the community pharmacy setting have a bigger effect on safety of preparation and assembly than supervision by an individual,” the response said.
Read full story
Source: The Pharmaceutical Journal, 12 February 2024
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NHS 'putting patients at risk' by letting 335 staff, including top doctors, do their jobs from abroad thousands of miles from the UK

The NHS has been accused of putting patients' lives at risk after it allowed hundreds of staff, including senior consultants and managers, to work thousands of miles from the UK.
A Mail on Sunday investigation has discovered that NHS staff at every level are working remotely in places as far flung as Australia and Japan.
Critics last night warned that the 'unacceptable and dangerous' arrangements could threaten patient safety.
Professor Karol Sikora, a former director of the World Health Organisation cancer programme, said: "Allowing staff to work from abroad is a huge mistake that can only undermine patient safety and the efficacy of treatment."
At least 335 NHS staff from 33 trusts have been allowed to work abroad in the past two years, according to data from Freedom of Information requests.
Until last year, Constantine Fragkoulakis, 42, was employed as a consultant radiologist at Sherwood Forest Hospitals Foundation Trust in Nottinghamshire. 
The trust said its radiologists "routinely interpret images and write reports away from the hospitals where they are based". 
But Mr Fragkoulakis admitted there had been "a lot of IT issues, so there was no patient care involved or clinical work'. He added: 'Essentially it was just meetings that I did."
Another consultant radiologist, Branimir Klasic, 50, is being allowed to work two weeks each month in Croatia by the Aneurin Bevan University Health Board in South Wales. 
It said recruitment was "increasingly challenging" and that it was "open to exploring ways of working that ensures we can provide the skills and expertise that our patients need". 
A Department of Health spokesman said: "We are clear that ways of working, which are agreed between NHS employers and its staff, should never impact on NHS patients or services."
Read full story
Source: Daily Mail, 10 February 2024
Sam

Mental health advanced choice documents ‘would reduce sectioning’

Fewer people with mental illnesses would endure the trauma of being sectioned if advanced choice documents – setting out a treatment plan while they are well – were included in Mental Health Act reforms, a leading psychiatrist has said.
Advanced choice documents are the only proven way to reduce the number of people detained under the Mental Health Act in England and Wales, which is one of the reforms’ core objectives, said Dr Lade Smith, the president of the Royal College of Psychiatrists.
Research suggests that the use of these documents can reduce compulsory detention rates in psychiatric units, often known as sectioning, by 25%, minimising traumatic experiences for people with bipolar, schizophrenia and other psychotic illnesses.
“It’s high time there was reform of the Mental Health Act because the rates of detention are increasing, especially for marginalised groups, those who are poor or from a minoritised ethnic community, especially black Caribbean … Advanced choice docs were a recommendation of the review, I don’t know why they haven’t gone through,” said Smith.
Advanced choice documents are especially effective in reducing the significantly higher detention rates for black people with mental illnesses, as they can help patients feel more autonomous and reduce unconscious bias.
Advanced choice documents are similar to those used in palliative care. Patients work with a healthcare professional when they are well to outline the signs that they are experiencing a manic or psychotic episode, effective treatments, and their personal preferences.
This could include background information and trigger questions to help healthcare practitioners establish delusional thought patterns; medications and doses which have been effective previously; and requests to be put in hospital for their own safety, or – more unusually – that of others.
Read full story
Source: The Guardian, 12 February 2024
Sam

NHS not ready for new Alzheimer's drugs lecanemab and donanemab, warns charity

Alzheimer's patients could lose out on two groundbreaking new drugs because the NHS is unprepared, a leading charity has told BBC Panorama.
Lecanemab and donanemab slow down the early stages of the disease - which is the most common form of dementia.
But Alzheimer's Research UK says the NHS is not ready to roll out the drugs, which could be licensed this year.
The treatments would then be subject to an assessment of cost and benefits before they are made available.
Lecanemab and donanemab represent a step forward because they target one of the causes of Alzheimer's, rather than treating the symptoms.
However, their effectiveness depends on early diagnosis - and very few people have the specialist scans or investigations which would be needed.
Questions also remain over potentially harmful side-effects of the drugs and whether the benefit they offer represents value for NHS money.
Read full story
Source: BBC News, 12 February 2024
Sam

More than 40 NHS mental health patients make fresh rape and sexual assault allegations

Dozens of new allegations of sexual assault and abuse, including claims of rape and of patients being made pregnant, have emerged following an investigation into Britain’s mental health wards.
One patient with a mental health disorder became pregnant by a member of staff. Allegations of rape, and of children being groomed by healthcare assistants, were among the 40 horrifying new reports of abuse made against rogue NHS Trusts.
The investigation, conducted by The Independent, alongside Sky News, revealed more than 20,000 allegations of sexual assault and harassment across more than 30 NHS England mental health trusts since 2019.
Several patients, who have come forward with their own harrowing stories, had allegedly been harmed by healthcare assistants, who currently are not regulated.
Natalie, whose name has been changed, was one of several patients groomed and asked to share sexually explicit photos by a healthcare assistant working at a children’s mental health ward in 2020.
Natalie, who was 16 at the time, told The Independent: “The first few conversations [after I was discharged] were very innocent. However after weeks and months, he started speaking in a sexual nature, asking me to send explicit photos of myself, posting explicit photos of himself and asking to meet up for sexual advances, I didn’t realise it at the time, but he was grooming me; this was all over Snapchat.
“I feel and still feel very small, and that I wasn’t looked at as a person [by the hospital], and they only saw me as a patient with no feelings that mattered. It felt like another incident at ... that just got swept under the rug.”
Read full story
Source: The Independent, 10 February 2024
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