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

Drug consumption rooms could save thousands of UK lives, study finds

Thousands of lives could be saved if safe rooms were set up in UK cities where people could be supervised while they get high, the world’s largest review of the effectiveness of drug-consumption rooms and overdose-prevention centres (OPCs) has found.
The part-government-funded study published on Thursday also found the facilities could slash the transmission of fatal diseases, as well as reduce drug litter, the pressure on ambulance callouts and the burden on hospitals.
Similar facilities already operate in France, the US, Germany, the Netherlands, Canada, Australia, Denmark, Greece, Belgium, Spain, Portugal, Norway, Luxembourg, Switzerland, Mexico, Iceland and Colombia.
Each unit hosts from 20 to 400 users a day and is supposed to provide somewhere for people to take drugs in the presence of trained health workers who intervene if an overdose occurs.
They also mean people don’t have to rush their drug taking, can access clean needles, and get help with other health issues, from testing for hepatitis B and HIV to accessing mental-health support.
But none has yet been deployed officially in the UK, and the report warns the absence “costs lives”.
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Source: The Guardian, 11 January 2023
Sam

The key NHS targets that have never been met

Most key NHS targets have been missed for at least seven years across the UK, BBC News research shows.
The review of records going back 20 years also reveals Northern Ireland and Wales have never met the four-hour accident-and-emergency (A&E) target.
The analysis focused on the three key hospital targets, covering A&E, cancer and waiting times for planned care.
In the past seven, the only one to have been met is the A&E target in Scotland - and that was during lockdown in 2020, when the number of visits to A&E plummeted.
All four nations said improving waiting times was a priority and investment was being made.
But King's Fund think tank chief analyst Siva Anandaciva said the findings should "act as a wake-up call".
"These are the key totemic targets," he said. "The length of time they have been missed is incredible."
Patients groups warned the delays were putting patients at risk.
Patients Association chief executive Rachel Power said the analysis showed the NHS was in "permacrisis".
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Source: BBC News, 10 January 2024
Sam

Law protecting women seeking emergency abortions is target in US supreme court case

Mylissa Farmer’s pregnancy was doomed. But no one would help her end it.
Over the course of a few days in August 2022, Farmer visited two hospitals in Missouri and Kansas, where doctors agreed that because the 41-year-old’s water had broken just 18 weeks into her pregnancy, there was no chance that she would give birth to a healthy baby. Continuing the pregnancy could risk Farmer’s health and life – yet the doctors could not act.
Weeks earlier, the US supreme court had overturned Roe v Wade and abolished the national right to abortion. It was, legal counsel at one hospital determined, “too risky in this heated political environment to intervene”, according to legal filings.
In immense pain and anguish, Farmer ultimately traveled several hours to Illinois, where abortion is legal. There, doctors were able to end her pregnancy.
Farmer’s account is detailed in a legal complaint she filed against the hospitals, arguing that they broke a federal law that requires hospitals to treat patients in medical emergencies. In a first-of-its-kind investigation, the US government sided with Farmer and declared that the two hospitals had broken the law.
The future of the government’s ability to invoke that law to protect women seeking emergency abortions is now in question. The law, the Emergency Medical Treatment and Labor Act (Emtala), is at the heart of the US supreme court’s latest blockbuster abortion case, which comes out of Idaho.
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Source: The Guardian, 9 January 2024
Sam

Family who had to investigate their 19-year-old autistic son's cause of death themselves blast inquest system

The family of an autistic teenager who died from an accidental overdose say they had to investigate the death themselves to find the truth of how he died.
Will Melbourne, 19, was found dead at his Cheshire home on December 18, 2020 after he mistakenly had taken a strong synthetic opioid 100 times stronger than morphine he bought on the dark web.
The inquest into Will's death took three years to come back and his family say had to investigate the matter themselves to find out what happened. 
Sally and John Melbourne said their lives were put on hold during the long wait for the inquest to be completed and the family were told at the pre-inquest hearing that the court were short-staff and had a backlog of 500 cases.   
Parents and friends of the teenager used a trail of digital "breadcrumbs" to uncover that Will had tried to buy oxycodone, a highly addictive opioid that helps with pain relief and anxiety, which turned out to be a synthetic opioid.
The blue pills Will had bought on the darknet were found beside his body. 
The family say the drugs were not tested until they raised it with the coroner's court a year after his death.
Will's blood sample had also been destroyed after the company storing it went into administration. 
The family said they were left traumatised by the time the inquest was concluded. 
Mrs Melbourne said: "We thought the inquest system was there to give us answers. Instead, we felt blocked at every turn. 
"It was outrageous that we had to take the investigation on ourselves."
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Source: Mail Online, 4 January 2023
Patient Safety Learning

Kettering hospital baby death was investigated by major crime team

In 2016, Kettering General Hospital (KGH) became the focus of a major criminal inquiry. Documents seen by the BBC reveal detectives looked for evidence of gross negligence manslaughter over the treatment of Jorgie Stanton-Watts, a vulnerable toddler.
Seven years of investigations followed, by the hospital, regulators and a coroner. The family has struggled to hold people to account.
Since Jorgie's death, a BBC investigation has heard from more than 50 parents with serious concerns about the treatment of their children, many of whom died or suffered injury.
The Northamptonshire hospital has also been inspected regularly.
In April the Care Quality Commission (CQC) downgraded the hospital's children's services to inadequate, the lowest possible rating.
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Source: BBC News, 10 January 2024
Sam

Managers fear ‘unfair’ professional regulation

More NHS managers support regulation of their roles than oppose it, despite many fearing its implementation will be unfair or disproportionate, a survey suggests. 
The trade union Managers in Partnership surveyed NHS managers working at Agenda for Change band 8a and above throughout the UK late last year, collecting 291 responses.
Asked whether they “in principle… support professional regulation of NHS managers”, 49% said they supported or strongly supported it. Just 19% said they opposed or strongly opposed, while the remainder were neutral.
However, respondents – 22% of whom said they were already covered by a professional regulator, and likely to be nurses, doctors or finance or legal professionals – appeared sceptical about the benefits. 
Asked whether they thought professional regulation of NHS managers would make processes for raising concerns/whistleblowing better or worse, only 26% said it would be better. 20% said these would get worse, and the remainder said it would be “about the same”. 
Read full story (paywalled)
Source: HSJ, 9 January 2023
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Letby inquiry: Former nurse director among ‘core participants’

The former nursing director at the hospital where Lucy Letby murdered seven babies will be among the 'core participants' of the Thirlwall Inquiry.
The inquiry, chaired by Lady Justice Thirlwall, will investigate how Letby was able to commit the murders and attempt six others while she worked as a neonatal nurse at Countess of Chester Hospital NHS Foundation Trust in 2015 and 2016.
This week, Alison Kelly, who was director of nursing and quality at the trust during the time of Letby's crimes, was announced as 1 of 10 core participants in the inquiry.
Also named were former Countess of Chester chief executive Tony Chambers, former medical director Ian Harvey and former human resources director Sue Hodkinson.
Ms Kelly and Mr Harvey were among the senior staff at the trust who were accused of failing to act when clinicians first raised concerns about Letby.
How managers responded to such concerns is one of the areas due to be investigated by the Thirlwall Inquiry.
A number of organisations are also on the list as core participants, including the Nursing and Midwifery Council (NMC), NHS England, the Royal College of Paediatrics and Child Health, the Department of Health and Social Care and Countess of Chester itself.
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Source: Nursing Times, 3 January 2024
Patient Safety Learning

New mothers being driven to suicide, senior midwife warns

The senior midwife tasked by the government and NHS to investigate serious maternity scandals has warned that new mothers are being driven to suicide and backed an MP’s review into birth trauma.
Donna Ockenden said it was “appalling” that women who should be in the “happiest times of their lives” were taking their own lives, after it was found suicide was the leading direct cause of deaths up to 12 months after giving birth.
Ockenden, who has exposed poor maternity care across the country, is preparing to give evidence to an inquiry launched by Theo Clarke, the Conservative MP for Stafford, on birth trauma.
Clarke thought she was going to die after giving birth to her daughter Arabella last year, having suffered a third-degree tear.
But it was the lack of help available that opened her eyes to the estimated 200,000 women a year who experience birth trauma.
Ockenden told The Times she had “huge respect” for Clarke’s inquiry and said: “I think that this whole issue of maternal trauma, sometimes long-term psychological trauma for families as well post a difficult maternity experience, is not necessarily given enough air time.”
Read full story (paywalled)
Source: The Times, 8 January 2023
Patient Safety Learning

Essex coroner warns of more deaths due to lack of mental health care

A coroner overseeing a teenager's inquest has warned there will be more deaths unless mental health services improve for autistic people at risk of self-harm.
Morgan-Rose Hart, 18, who had ADHD, autism and a history of mental illness had been a patient at a unit in Harlow, Essex, for three weeks.
An inquest jury concluded she died by misadventure contributed to by neglect.
Ms Hart, from Chelmsford, died in hospital six days after she was found unresponsive in the bathroom of her mental health accommodation in the Derwent Centre in Harlow, Essex in July 2022.
The inquest into her death heard staff observations were falsified and critical observations were missed.
In her Prevention of Future Deaths report, Ms Hayes said: "There is a significant shortfall of appropriate placements for people with autism who have mental health and self-harm risks in Essex both inpatient and in the community."
She added: "During the course of the inquest the evidence revealed matters giving rise to concern.
"In my opinion, there is a risk that future deaths will occur unless action is taken."
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Source: BBC News, 8 January 2024
Patient Safety Learning

Midwife quit over 'unsafe care' and staffing

A former midwife has told the BBC she quit because she could not live with herself if she provided poor care.
Hannah Williams says staff shortages meant she kept patients safe, but sometimes only "by the skin of her teeth".
BBC Verify analysis shows that the number of full-time equivalent midwife posts in England has gone up by 7% in the last decade. In comparison, the overall NHS workforce has increased by 34%.
The country has a shortage of about 2,500 midwives, and maternity units are struggling with safety concerns.
BBC research has also found that some trusts have more than one in five midwife jobs unfilled.
The Royal College of Midwives says staffing is the "most important issue" and the gap needs to close.
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Source: BBC News, 9 January 2024
Patient Safety Learning

Health inequalities ‘caused 1m early deaths in England in last decade’

More than 1 million people in England died prematurely in the decade after 2011 owing to a combination of poverty, austerity and Covid, according to “shocking” new research by one of the UK’s leading public health experts.
The figures are revealed in a study by the Institute of Health Equity at University College London led by Sir Michael Marmot. They demonstrate the extent to which stark economic and social inequalities are leading to poorer people dying early from cancer, heart problems and other diseases.
Using Office for National Statistics figures, the report’s author Prof Peter Goldblatt looked at the life expectancy of people across England who do not live in the wealthiest 10% of areas.
The report, titled Health Inequalities, Lives Cut Short, found that between 2011 and 2019, 1,062,334 people died earlier than they would have done if they lived in areas where the richest 10% of the population reside. A further 151,615 premature deaths were recorded in 2020, although this number was higher than expected because of the coronavirus pandemic.
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Source: Guardian, 8 January 2024
Patient_Safety_Learning

How portable X-ray machines are helping remote patients

Portable X-ray machines "can literally be the difference between life and death", says radiographer Sam Pilkington.
For most of us, if we need to be X-rayed the procedure is done in a hospital. But for acutely unwell patients, or for infection control, Ms Pilkington says that portable machines are very helpful.
This is because "they remove the excess burden of transportation from the patients", says the final-year student at the University of the West of England in Bristol, who is also a member of the Institute of Physics. Instead the X-ray equipment goes to them.
There are obvious advantages for remote locations, including battlefields, roadsides and disaster zones.
Read full story
Source: BBC News, 8 January 2024
Patient_Safety_Learning

A&E target set to be raised, despite NHS missing lower bar

NHS England and government are set to raise their target for four-hour A&E performance, despite most hospitals failing to meet the current ask.
HSJ understands officials are likely to use 2024-25 planning guidance to raise the “interim” target for four-hour performance from the 76% which trusts were asked to hit in 2023-24.
A new objective of 80% by March 2025 has been discussed, several sources said, but is not confirmed.
The 76% target has not been met during any month of 2023-24 so far, and most acute trusts are consistently falling well short of it.
Well-placed sources told HSJ  the target was likely to be increased despite “some doubts” among senior NHSE officials. One senior NHSE source said: “The target should be increasing incrementally as overall NHS A&E performance improves, [but] it hasn’t really improved this year.”
Read full story (paywalled)
Source: HSJ, 5 January 2024
Patient Safety Learning

At least 38 baby deaths in nine years after serious incidents in Irish maternity units

At least 38 babies died in the space of nine years after serious incidents in the country’s maternity units, it has emerged.
The total is based on research of both media reports of inquests and settled claims.
Before Christmas, a review by the  Irish Examiner  revealed 21 hospital baby deaths followed one or more serious incidents, between 2013 and 2021.
However, further study in the same nine-year period shows the toll to be higher. The worst year was 2018, when not only did at least 10 babies die, but three of them died at the same Dublin hospital over a five-month period.
In at least 18 of the 38 deaths, issues around foetal heartbeat monitoring (CTG) were raised either at inquest or in the High Court.
At least 18 of the inquests resulted in a verdict of medical misadventure.
As well as issues around heart monitoring, the Irish Examiner review shows that in at least seven of the 38 cases, maternity staff missed signs that a woman was in labour, leading to repeated recommendations around training.
In at least seven cases, mothers’ concerns were ignored.
Read full story
Source: Irish Examiner, 29 December 2023
Patient Safety Learning

Prescription drugs sold online without robust checks

Patients' lives are being put at risk because it is too easy to buy prescription-only medicines from online pharmacies, a leading pharmacist says.
A BBC investigation found 20 online pharmacies selling restricted drugs without checks - such as GP approval. In total, over 1,600 various prescription-only pills were bought during the investigation entering false information without challenge.
Regulator the General Pharmaceutical Council says extra checks are needed when selling some drugs online.
The BBC's findings highlight the "wild west" of buying medicines on the web, says Thorrun Govind, a pharmacist, health lawyer and former chair of the Royal Pharmaceutical Society.
"The current guidance basically tells pharmacies to be robust, but do that in your own way, and we know that under this current system, patients have died," she says.
The parents of a woman who died in 2020, after accidentally overdosing on medicines she bought online, are among those calling for stricter rules.
Katie Corrigan, from St Erth in Cornwall, had developed an addiction to painkillers after experiencing neck pain.
"Katie needed help, she didn't need more medication," says her mum, Christine Taylor.
Her GP had stopped supplying the drug after realising she had been allowed to request new prescriptions prematurely and been prescribed too much.
Instead, Katie, 38, was able to buy a painkiller and a drug used to treat anxiety from multiple online pharmacies without notifying her GP.
The coroner at Katie's inquest confirmed her GP had not been contacted by any of the pharmacies to check the drug was safe for her. In his final report, he said the safety controls were inadequate.
Read full story
Source: BBC News, 5 January 2024
Patient Safety Learning

NHSE to catalogue ‘harm and near misses’ where BMA rejects derogations

The NHS will start recording harm caused to patients during strike action where exemptions have been rejected by the British Medical Association (BMA).
BMA council chair Phillip Banfield yesterday accused NHS England of the “weaponisation” of the strike “derogation” process, saying trusts had this week submitted more of the requests, which would permit some striking doctors to return to work, and were not providing information needed to determine if they were justified.
NHS England wrote back to Professor Banfield, insisting it was only trying to prioritise safety, but also saying it would revise its own approach to derogation requests.
This will include: asking trusts whose requests were rejected by the BMA “to compile a picture” of the impact on services; reinforcing requirements to report patient safety incidents during strikes and after mitigation requests, so “we can evidence harm and near misses which might have been avoided”.
The letter says: “We have consistently asked local medical and other clinical leaders to consider applying to the BMA for patient safety mitigations where they have significant concerns for patient safety that cannot be mitigated through other options available to them, and where they can make a strong evidential case that the return of a limited number of junior doctors would address these risks.
“We have done this, in part, because we have received a number of reports over previous periods of action that some teams have been put off seeking patient safety mitigations because of their prior experience of having applications rejected, or not receiving a response in time. We are sure you would agree that this is an unsatisfactory position, and that where patient safety concerns exist, these should always be escalated appropriately.”
Read full story (paywalled)
Source: HSJ, 4 January 2024
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