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

CQC names best and worst for maternity experience

The trusts where maternity care has deteriorated the most according to patient surveys have been identified by the Care Quality Commission.
The regulator collected responses from 25,515 patients about their experiences of antenatal care, labour, birth and postnatal care across 121 trusts in February 2023. 
It then analysed where experiences of care were substantially better or worse overall when compared with survey results across all trusts in England.
Survey responses also painted a deteriorating picture of maternity care nationally, with answers to 11 questions showing a statistically significant downward trend compared to five years ago.
Five trusts were categorised as “worse than expected”, where patients’ experiences of using their services were substantially worse than the average.
Read full story (paywalled)
Source: HSJ, 12 February 2024
Patient Safety Learning

NHSE seeks to ease key elective target

NHS England is in negotiations with ministers to formally push back the target to eliminate 65-week waiters, HSJ has learned.
Discussions about the target are on-going as part of negotiations around the delayed 2024-25 planning guidance. It has been clear for months the March deadline to virtually eliminate 65-week waiters would be missed.

It has emerged some trusts with the largest waiting lists already appear to be working to a September deadline.
The news follows prime minister Rishi Sunak being forced to finally admit this week that his flagship NHS pledge from last January, that the waiting list would be falling by this year, had failed. This was something NHS bosses have warned of since summer.
Read full story (paywalled)
Source: HSJ, 9 February 2024Choose Single File...
Patient Safety Learning

The orthodontic treatments that led to lifetimes of pain

‘This is a very painful thing to admit,” says Emily Roberts, a 47-year-old teacher from south London, “but my entire adult life has been shaped by trying to survive what has been done to me.”
Roberts (not her real name) is one of hundreds of British people who believe that they have been unintentionally maimed by orthodontists — dentists who specialise in irregular teeth and jaws. Along with thousands of others around the world, they share their experiences and post photographs and x-rays on Facebook groups. They say that lifelong damage was done to them as children — not by shady backstreet operators but by regular high street practitioners. Many say that as a result their adult lives have been blighted by painful and debilitating symptoms.
“I’ve spent my entire adult life working on my body to try to get my posture right or get out of pain,” Roberts says. She has seen neurologists, osteopaths, pain-management specialists. Nothing has worked. 
She considered taking legal action against the orthodontist who initially treated her — for seven years in total — but the UK’s statute of limitations states that claims for dental negligence must be made within three years of the treatment and the time limit elapsed while she was still considering her options. 
Lauren Packham, 36, was 12 years old when she had four premolar teeth removed to correct an overbite that she says “wasn’t even that bad”. She then wore fixed braces and elastics to retract her teeth. In her twenties she had three wisdom teeth removed after they became painful. “If I knew what I know now, I wouldn’t have had them out,” she says.
In the past few years Packham, who lives in Plymouth, has suffered worsening jaw pain and migraines. She has also experienced sleep problems since her late teens. “If I sleep on my back, my breathing just cuts off. I’ve since had a diagnosis of sleep-disordered breathing.”
A Harley Street sleep specialist doctor she saw privately pointed to her orthodontic treatment as the likely cause of her health issues.
Read full story (paywalled)
Source: The Times, 11 February 2024
Further reading on the hub:
“I’ve been mocked, scolded and gaslighted”: a harmed patient’s experience of orthodontic treatment A patient harmed by orthodontic treatment shares their story Share your experience of orthodontist and dentistry services
Patient Safety Learning

Cluster of baby death inquiries as bereaved parents demand answers

Lawyers and charities tell of mothers told to ‘labour at home as long as they can’, dangerously few midwives and ‘lies’ during natal care.
As Rozelle Bosch approached her due date she had every reason to expect a healthy baby. Neither she, her husband nor the midwives knew that the child was in the breech position at 30 weeks.
When her waters broke a fortnight early, Bosch and her husband, Eckhardt, both first-time parents, had been reassured by NHS Lanarkshire that all was well and that the mother was “low risk”. They were sent home from Wishaw hospital and told to monitor conditions until the pregnancy became “active”.
Shortly before 11pm on 1 July 2021, her husband called an ambulance saying that Bosch was in labour and was giving birth. 
Bosch was in an upstairs bedroom on her knees and paramedics noted that “the baby was pink”. They soon asked the control room for a doctor or midwife to attend but none were available. By the time the ambulance took the family to hospital, the baby had turned blue.
Within two days, baby Mirabelle had died. She had become trapped with only her feet and calves delivered while the couple were still at home. A post-mortem has found that Mirabelle suffered oxygen deprivation to the brain from “head entrapment” during delivery.
Last month, her father explained to a fatal accident inquiry (FAI) at Glasgow sheriff court: “We were told Rozelle was healthy and Mirabelle was healthy. I think this was a lie and the consequences have me standing here today.”
The way that the tragedy unfolded is striking, not just because of the devastating consequences, but because it is not an entirely isolated case.
The same FAI is examining the deaths of two other newborns, Ellie McCormick and Leo Lamont, who also died in NHS Lanarkshire less than a month apart in 2019. Experts say it is rare for the Crown and Procurator Fiscal Service to group investigations in this way.
Darren Deery, the McCormicks’ lawyer and a medical negligence specialist with Drummond Miller, said he had noticed a “considerable increase” in parents contacting the law firm in the past three years.
Read full story (paywalled)
Source: The Times, 11 February 2024
Patient Safety Learning

Woman found under coat in Nottingham A&E died days later

An investigation has been launched after a woman died days after being found unconscious underneath her coat while waiting in A&E for seven hours.
The 39-year-old woman is understood to have first attended A&E at Queen’s Medical Centre in Nottingham on the evening of 19 January complaining of a severe headache. She was triaged and then observed by nurses three times. Her case was escalated but she was not seen by a doctor before being discovered.
When the woman was called to see a doctor, she did not respond. It was assumed that she had left A&E because she had waited so long. She was discovered and transferred to intensive care but died three days later on 22 January.
A source familiar with the hospital told LBC, which first reported the incident, that the A&E department could have up to 80 patients waiting at a single time and that wait times could be as long as 14 hours.
Dr Keith Girling, the medical director at Nottingham university hospitals NHS trust, said: “I offer my sincere condolences to the family at this difficult time. An investigation, which will involve the family, will now take place and until this has been concluded, we are unable to comment further.”
Read full story
Source: The Guardian, 10 February 2024
Patient Safety Learning

Locked in the back of an ambulance and sexually assaulted: Female paramedics reveal 'toxic culture' of harassment

The first time she was groped at work, Freya says she was 24 years old, a newly qualified paramedic, and was cleaning out the cupboards of the ambulance station crew room.
"He came behind me without me realising. I was cleaning away, and he put his hands around my body and grabbed my breasts," said Freya, which is not her real name.
"Then he said, 'Well, I won't bother doing that again'.
"People just laughed, some didn't even look up from the TV. Like it was nothing, completely normal."
Her story mirrors that of other current and former paramedics who, in several interviews with Sky News, painted a picture of widespread sexual harassment and a toxic culture of misogyny.
The head of the College of Paramedics, Tracy Nicholls, said: "Problems exist in every [NHS] trust, across all four countries in the United Kingdom."
NHS England told Sky News that any form of sexual misconduct was "completely unacceptable" and every trust had committed to an action plan to improve sexual safety.
Laura - not her real name - is currently a paramedic for a different ambulance service.
She describes sexual harassment as "incessant" in the profession. She says students and new recruits are routinely referred to as "fresh meat", subjected to sexual comments, questions and jokes - even in front of patients - and are continually sexualised by some male colleagues.
"It's exhausting," she said. "You come to work wanting to help your patients but every day you're dealing with inappropriate behaviour and sexual comments."
Read full story
Source: Sky News, 8 February 2024
Patient Safety Learning

Record 180,000 patients suffered ‘degrading’ 12 hour waits in A&E last month

The number of patients waiting more than 12 hours in A&E hit a record in January of almost 180,000 people.
Worsening pressures on A&E come as prime minister Rishi Sunak has officially missed his pledge, made in January last year, to cut the NHS waiting list.
NHS England began publishing previously-hidden data on patients waiting 12 hours or more last year, after reports by The Independent.
The latest figures for January show 178,000 people were waiting this long to be seen, treated or discharged after arriving from A&E – a record since February 2023 when the data was first published. In that month, 128,580 people waited more than 12 hours, and in December there were 156,000.
The number waiting at least four hours from the decision to admit to actual admission has also risen, from 148,282 in December to 158,721 last month – the second-highest figure on record.
Dr Tim Cooksley, past president of the Society for Acute Medicine, warned: “Degrading corridor care and prolonged waits causing significant harm is tragically and increasingly the expected state in urgent and emergency care.”
Read full story
Source: The Independent, 8 February 2024
Patient Safety Learning

Cancer waiting times in 2023 worst on record in England

Cancer waiting times for 2023 in England were the worst on record, a BBC News analysis has revealed.
Only 64.1% of patients started treatment within 62 days of cancer being suspected, meaning nearly 100,000 waited longer than they should for life-saving care. The waits have worsened every year for the past 11.
Macmillan Cancer Support chief executive Gemma Peters called the figures "shocking".
"This marks a new low and highlights the desperate situation for people living with cancer," she said.
"Behind the figures are real lives being turned upside down, with thousands of people waiting far too long to find out if they have cancer and to begin their treatment, causing additional anxiety at what is already a very difficult time.
"With over three million people in the UK living with cancer and an ageing population, this is only set to rise."
The records go back to 2010, shortly after the cancer target was introduced.
However, improvements have been made over the course of 2023 in how quickly patients are diagnosed with 72% told whether they have cancer or not within 28 days of an urgent referral.
Read full story
Source: BBC News, 8 February 2024
Patient Safety Learning

Bath surgeon sacked after raising safety concerns

A senior surgeon has raised concerns about the way whistleblowers are dealt with, claiming he was sacked after speaking out.
Serryth Colbert told the BBC that following attempts to "stop wrongdoing", he was investigated by the trust at Bath's Royal United Hospital.
As a result, he said he was dismissed for gross misconduct in October 2023.
The RUH said it has "never dismissed anybody for raising concerns and never will".
It added that Mr Colbert's dismissal related to "significant concerns about bullying" and its investigation into his conduct was "thorough" and "robust".
Mr Colbert said he raised safety concerns without regard for the impact it might have on his career.
"It was never a question in my mind. This is wrong. I'm stopping the wrongdoing. I stand for justice. I stand to protect patients," he said.
The BBC has seen no evidence his most serious concern was ever investigated and Mr Colbert is now taking the RUH to an employment tribunal.
Read full story
Source: BBC News, 9 February 2024
Patient Safety Learning

Doctors issue warning after spike in ‘freebirthing’

Doctors have warned of the risks of “freebirthing” – where a woman gives birth without the help of a medic or midwife.
Unassisted births, or “freebirths”, are thought to have been on the increase since the start of the Covid pandemic, when people may have been worried about attending hospitals and home births were suspended in many areas.
The practice is not illegal and women have the right to decline any care during their pregnancy and delivery. Some women hire a doula to support them during birth.
The Royal College of Obstetricians and Gynaecologists (RCOG) said women should be supported to have the birth they choose, but “safety is paramount” and families need to be aware of the risks of going it alone.
The Nursing and Midwifery Council (NMC) said it is in the early stages of collaboration with the Chief Midwifery Officer’s teams, the Royal College of Midwives (RCM) and the Department of Health to better understand professional concerns about freebirthing and what organisations may need to do.
Its statement on unassisted births supports women’s choice, but notes that “midwives are understandably concerned about women giving birth at home without assistance, as it brings with it increased risks to both the mother and baby”.
It also states that women need to be informed that a midwife may not be available to be sent out to their home during labour if they change their mind and wish to have help.
Read full story
Source: The Independent, 8 February 2024
Patient Safety Learning

‘One part of the solution’: how virtual NHS wards are now a reality

Harold Chugg spent much of early 2023 in a hospital bed because of worsening heart failure. During his most recent admission in June, the 75-year-old received several blood transfusions, which led to fluid accumulating in his lungs and tissues.
Ordinarily, he would have remained in hospital for further days or weeks while the medical team got his fluid retention under control. But Harold was offered an alternative: admission to a virtual ward where he would be closely monitored in the comfort of his own home.
Armed with a computer tablet, a Bluetooth-enabled blood pressure cuff and weighing scales, Harold returned to his farm near Chulmleigh in north Devon and logged his own symptoms and measurements daily, which were reviewed by a specialist nurse in another part of the county.
Virtual wards provide hospital-level care in people’s homes through the use of apps, wearables and daily “virtual ward rounds” by medical staff, who review patient data and follow up with telephone calls or home visits where necessary.
More than 10,000 such beds are already available across England and at least a further 15,000 are planned. Scotland, Wales and Northern Ireland are also funding their expansion.
But while proponents claim patients in virtual wards recover at the same rate or faster than those treated in hospital, and that the wards’ provision can help cut waiting lists and costs, some worry that their rapid expansion could place additional strain on patients and caregivers while distracting from the need to invest in emergency care.
“Virtual wards, if they deliver hospital-level processes of care, are just one part of the solution, not a panacea,” said Dr Tim Cooksley, a recent ex-president of the Society for Acute Medicine.
Read full story
Source: The Guardian, 7 February 2024
Patient Safety Learning

Primodos patients ‘betrayed’ after being left out of health scandals redress report

Campaigners have accused the UK government of betraying them after a review of redress for victims of health scandals excluded families who may have been affected by the hormone pregnancy test Primodos.
A report published on Wednesday by the patient safety commissioner, Dr Henrietta Hughes, found a “clear case for redress” for thousands of women and children who suffered “avoidable harm” from the epilepsy treatment sodium valproate and from vaginal mesh implants.
But despite the commissioner wanting to include families affected by hormone pregnancy tests in her review, the Department of Health and Social Care (DHSC) told her they would not be included.
Primodos was an oral hormonal drug used between the 1950s and 70s for regulating menstrual cycles, and as a pregnancy test. Hormone pregnancy tests stopped being sold in the late 1970s and manufacturers have faced claims that such tests led to birth defects and miscarriages. Last year, the high court dismissed a case brought by more than 100 families to seek legal compensation owing to insufficient new evidence.
The Hughes report states: “Our terms of reference did not include the issue of hormone pregnancy tests. This was a decision taken by DHSC and should not be interpreted as representing the views of the commissioner on the avoidable harm suffered in relation to hormone pregnancy tests or the action required to address this.
“The patient safety commissioner wanted them included in the scope but, nevertheless, agreed to take on the work as defined by DHSC ministers.”
Marie Lyon, the chair of the Association for Children Damaged by Hormone Pregnancy Tests, said the families of those who took the tests felt “left out in the cold” and betrayed that they were not included in the commissioner’s review.
“I feel betrayed by the patient safety commissioner, by the IMMDS [Independent Medicines and Medical Devices Safety] review and by the secretary of state for health – all three have betrayed our families because, basically, they have just forgotten us. It’s a case of ‘it’s too difficult so we will just focus on valproate and mesh’,” Lyon said.
Prof Carl Heneghan, a professor of evidence-based medicine at the University of Oxford, who led a systematic review of Primodos in 2018, said: “It’s unclear to me how the commissioner can keep patients safe if they are blocked and don’t have the power to go to areas where patient safety matters.”
Read full story
Source: The Guardian, 7 February 2024
Patient Safety Learning

Mesh and sodium valproate scandal victims need payouts soon, report says

Families of children left disabled by an epilepsy drug and women injured by pelvic mesh implants should be given urgent financial help, England's patient safety commissioner has said.
Dr Henrietta Hughes has called on the government to act quickly to help victims of the two health scandals.
It follows a review which found lives had been ruined because concerns about some treatments were not listened to.
It is estimated that, since the early 1970s, about 20,000 babies have been born with disabilities after foetal exposure to sodium valproate, which can harm unborn babies if taken in pregnancy.
Scientific papers from as early as the 1980s suggested valproate medicines were dangerous to developing babies, yet warnings about the potential effects were not added to some packaging until 2016.
Some families affected have been campaigning for decades to raise awareness of the potential effects of the drug, with some calling for compensation and a public inquiry.
Dr Hughes was asked by the government to look into a potential compensation scheme for those affected by that scandal, as well as the one involving some 10,000 women who were injured by their pelvic mesh implants - a treatment for pelvic organ prolapse (POP) and incontinence.
Read full story
Source: BBC News, 7 February 2024
Patient Safety Learning

‘Culture of fear’ at Sussex hospitals trust, Royal College of Surgeons reports

Bosses at hospitals where police are investigating dozens of deaths have been criticised for “bullying” and fostering a “culture of fear” among staff in a damning review by the Royal College of Surgeons in England.
The review focused on concerns about patient safety and dysfunctional working practices in the general surgery departments at the Royal Sussex County hospital in Brighton and the Princess Royal hospital in nearby Haywards Heath.
But the reviewers were so alarmed by reports of harassment, intimidation and mistreatment of whistleblowers that they suggested executives at the University Hospitals Sussex trust may have to be replaced.
They concluded: “Consideration should be given to the suitability, professionalism and effectiveness of the current executive leadership team, given the concerning reports of bullying.”
The report comes as Sussex police continue to investigate allegations of medical negligence and cover-up in the general surgery department and neurosurgery department, involving more than 100 patients, including at least 40 deaths, from 2015 to 2021.
The investigation was prompted by concerns from a general surgeon, Krishna Singh, and a neurosurgeon, Mansoor Foroughi, who lost their jobs at the trust after blowing the whistle over patient safety.
Read full story
Source: The Guardian, 6 February 2024
Patient Safety Learning

New Learning and Action Network set to improve maternal and neonatal health outcomes

The NHS Race and Health Observatory, in partnership with the Institute for Healthcare Improvement and supported by the Health Foundation, has established an innovative 15-month, peer-to-peer Learning and Action Network to address the gaps seen in severe maternal morbidity, perinatal mortality and neonatal morbidity between women of different ethnic groups.
Across England, nine NHS Trusts and Integrated Care Systems will participate in this action oriented, fast-paced Learning and Action Network to improve outcomes in maternal and neonatal health. Through the Network, the nine sites will aim to address the gaps seen in severe maternal morbidity, perinatal mortality and neonatal morbidity between women of different ethnic groups. Haemorrhage, preterm birth, post-partum depression and gestational diabetes have been identified as some of the priority areas for the programme.
The sites will generate tailored action plans with the aim of identifying interventions and approaches that reduce health inequalities and enhance anti-racism practices and learning from the programme. These will be evaluated and shared across and between healthcare systems.
The Network, the first of its kind for the NHS, will combine Quality Improvement methods with explicit anti-racism principles to drive clinical transformation, and aims to enable system-wide change.  Over a series of action, learning and coaching sessions, participants will review policies, processes and workforce metrics; share insights and case studies; and engage with mothers, parents, pregnant women and people.
The programme will run until June 2025, supported by an advisory group from the NHS Race and Health Observatory, Institute for Healthcare Improvement, and experts in midwifery, maternal and neonatal medicine.
Read full story
Source: NHS Race and Health Observatory, 24 January 2024
Patient Safety Learning

Oesophageal cancer test ‘should be made more available in UK’

A test that can detect oesophageal cancer at an earlier stage than current methods should be made more widely available to prevent deaths, charities have said.
The capsule sponge test, previously known as Cytosponge, involves a patient swallowing a dissolvable pill on a string. The pill then releases a sponge which collects cells from the oesophagus as it is retrieved.
The test can detect abnormalities that form as part of a condition known as Barrett’s oesophagus, which makes a person more likely to develop oesophageal cancer.
In the UK 9,300 people are diagnosed with oesophageal cancer a year, according to Cancer Research. The disease is difficult to detect because the symptoms for the cancer are not easily recognisable – and can be mistaken for indigestion – until a it is at an advanced stage.
The capsule sponge test can detect the cancer at an earlier stage than the current methods, such as an endoscopy, used to diagnose oesophageal cancer. However, it is only currently available to higher-risk patients as an alternative to endoscopy as part of NHS pilot schemes.
Cancer Research UK is working with the National Institute for Health and Care Research (NIHR) on a trial that will recruit 120,000 people to see if the capsule sponge test can reduce deaths from oesophageal cancer. If successful, the test could be rolled out more widely.
Mimi McCord, the founder of Heartburn Cancer UK, who lost her husband, Mike, to oesophageal cancer in 2002, said: “Cancer of the oesophagus is a killer that can hide in plain sight. People don’t always realise it, but not all heartburn is harmless. While they keep on treating the symptoms, the underlying cause might be killing them.”
Read full story
Source: The Guardian, 5 February 2024
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