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

Blackpool nurse and colleague jailed over drugging patients

An "evil" nurse who drugged patients on a stroke unit for an "easy shift" and a healthcare worker who conspired with her have been jailed.
Catherine Hudson, 54, was found guilty of giving unprescribed sedatives to two patients at Blackpool Victoria Hospital in 2017 and 2018.
She was also convicted of conspiring with Charlotte Wilmot, 48, to give a sedative to a third patient.
Hudson was jailed for seven years and two months. Wilmot was sentenced to three years.
Evidence during the trial highlighted the "dysfunctional" drugs regime on the stroke ward with free and easy access to controlled drugs and medication which led to "wholesale theft" by staff.
Prosecutors described it as a "culture of abuse" after police examined WhatsApp phone messages between the co-defendants and other members of staff.
The pair were investigated after a student nurse witnessed events while on a work placement on the stroke unit and told senior managers in November 2018, who called in police.
The whistleblowing nurse, who the prosecution had asked not to be named, told officers she had concerns over the use of insomnia medication Zopiclone, which can be life-threatening if given inappropriately.
She said Hudson had told her the patient had a Do Not Resuscitate Order in place "so she wouldn't be opened up if she died or... came to any harm".
Read full story
Source: BBC News, 14 December 2023
Patient Safety Learning

Trust reviewing 100,000 patients put ‘on hold’

A trust is reviewing more than 100,000 patients on its outpatient lists, after concerns emerged that some had ‘been lost whilst on hold’ for follow-up appointments.
A report from Buckinghamshire Healthcare Trust, leaked to HSJ, found 116,575 patient records without a scheduled follow-up after an outpatient consultation, with more than half of those left inappropriately without action, some dating back a decade.
The review was triggered after staff spotted cases in which patients had been “lost whilst on hold”, the report said.
The trust this week told HSJ that, since the initial discovery in the summer of last year, it had been validating the lists and reduced the number of outstanding records to 47,778. It aims to complete the reviews in the next two months.
It told HSJ it had undertaken a harm review and found no “systemic harm”.
Concerns have been raised over several years about the extent of overdue and unreviewed patients on follow-up lists, and the potential for them to deteriorate and come to harm. There are no national figures monitoring the patients, many of whom have long-term health needs.
Read full story (paywalled)
Source: HSJ, 15 December 2023
Patient Safety Learning

‘Long flu’: study finds flu patients at higher risk of longer-term illness

People who have been hospitalised with flu are at an increased risk of longer-term health problems, similar to those with long Covid, data suggests.
While the symptoms associated with such “long flu” appear to be more focused on the lungs than ongoing Covid symptoms, in both cases the risk of death and disability was greater in the months after infection than in the first 30 days.
“It is very clear that long flu is worse than the flu, and Long Covid is worse than Covid,” said Dr Ziyad Al-Aly, a clinical epidemiologist at Washington University in St Louis, Missouri, who led the research.
He was motivated to study the phenomenon after observing the scale of long-term illness experienced by people who have recovered from Covid.
“Five years ago, it wouldn’t have occurred to me to examine the possibility of a ‘long flu.’ But one of the major lessons we learned from this pandemic is that a virus we all initially thought could only cause acute disease is leaving millions of people with long Covid, he said. “We wondered whether this could be happening with other things. Could this be happening with the flu, for example?”
The research, published in the Lancet Infectious Diseases, found that while Covid patients faced a greater risk of death or hospital readmission in the following 18 months, both infections carried a significant risk of ongoing disability and disease.
Read full story
Source: The Guardian, 14 December 2023
Patient Safety Learning

Hundreds more middle-aged adults dying a month since Covid pandemic

Hundreds more middle-aged adults have been dying each month since the end of the pandemic, as obesity and NHS backlogs drive a surge in excess deaths.
New analysis of official statistics has revealed that there were an extra 28,000 deaths in the UK during the first six months of 2023, compared with levels in the previous five years.
The biggest rise in unexpected deaths has been among adults aged 50 to 64, who are increasingly dying prematurely from preventable conditions including heart disease and diabetes.
The Covid inquiry is now being urged to shift its focus from “tactical decisions made by politicians” and to examine the lasting disruption that has kept deaths persistently high since the virus peaked.
Experts believe that difficulties in accessing GPs since lockdown and record NHS waiting lists mean that middle-aged patients are missing out on life-saving preventative treatment such as blood pressure medication. Unhealthy lifestyles, obesity and widening health inequalities are also contributing to a rise in avoidable deaths.
Professor Yvonne Doyle, who led Public Health England during the pandemic, warned that the official Covid inquiry risks “missing the point” by focusing on the drama and WhatsApps of Westminster politicians. In an article for The Times, Doyle, who gave evidence to the inquiry six weeks ago, says that the tens of thousands of excess deaths since Covid “represent an underlying pandemic of ill health” that should be addressed.
Read full story (paywalled)
Source: The Times, 13 December 2023
Sam

Hospital violence ‘going through the roof’, says CEO

A London acute trust is planning to provide staff working in frailty units with body cameras and those in antenatal clinics with additional security, as violence and aggression against them goes ‘through the roof’.
Matthew Trainer, chief executive of Barking, Havering and Redbridge University Hospitals Trust in north east London, described the measures the trust is planning to take in response to growing staff concerns about their safety.
Speaking at a King’s Fund event about making NHS careers more attractive, Mr Trainer said: “We need to understand the impact of violence and aggression against the workforce and that’s going through the roof just now.
“Our ultrasound technicians have now asked for help as their antenatal scans are becoming so fraught. We are about to introduce body cameras in our frailty wards to help with the increase in violence and aggression against staff there.”
Mr Trainer – who joined BHRUT in 2021 from Oxleas Foundation Trust – said a long-running problem with violence and aggression in emergency departments was spreading to other departments.
Mr Trainer stressed the main problem, particularly in frailty units, was not patients’ own behaviour, but that of family and friends visiting them.
Read full story (paywalled)
Source: HSJ, 13 December 2023
Sam

Only half of trusts’ staff were trained ahead of troubled IT go-live

Only half of staff across two acute trusts were fully trained in the use of a new electronic patient record before its introduction, which led to disruption and patient harm, HSJ has revealed.
The implementation of Oracle Cerner’s EPR at Royal Surrey Foundation Trust and Ashford and St Peter’s Hospitals FT was carried out, despite the trusts not having achieved their target of 80% of staff having completed the necessary training, newly disclosed documents show.
HSJ has also seen an internal report by the Royal Surrey’s informatics team which warned of risks to patient safety and data problems, unless preparations improved in the three months leading up to go-live. 
The two acute trusts implemented the EPR in May last year under a programme called Surrey Safe Care, but there have been multiple problems ever since – including some of the issues that the internal report warned of.  
The trusts acknowledged the process had been “challenging” but said they had trained a higher proportion of the staff who were working in the two weeks after go-live, with Royal Surrey describing the findings of the internal informatics report as an “inaccurate representation” of readiness.
Read full story (paywalled)
Source: HSJ, 13 December 2023
Patient Safety Learning

Raychel Ferguson: Coroner rules death caused by 'inappropriate infusion'

A fresh inquest into the death of Raychel Ferguson has found she died of a cerebral oedema, or swelling in the brain, due to hyponatraemia.
He said the "inappropriate infusion of hypertonic saline fluid" was the most significant factor.
The nine-year-old died at the Royal Victoria Hospital for Sick Children in June 2001.
Coroner Joe McCrisken said her death was due to a series of human errors and not systemic failure.
He outlined three causes of the hyponatraemia but said he was satisfied the "inappropriate infusion of hypertonic saline fluid... played the most significant part".
The new inquest into Raychel's death was first opened in January 2022 after being ordered by the attorney general but was postponed in October when new evidence came to light.
Raychel was one of five children whose deaths over the course of eight years at the same hospital prompted a public inquiry.
In 2018 the Hyponatraemia Inquiry - which examined the deaths of five children in Northern Ireland hospitals, including Raychel - found her death was avoidable.
The 14-year-long inquiry was heavily critical of the "self-regulating and unmonitored" health service. In his report in 2018, Mr Justice O'Hara found there was a "reluctance among clinicians to openly acknowledge failings" in Raychel's death.
Read full story
Source: BBC News, 11 December 2023
Sam

Autistic man facing abuse in mental health hospital must be given home ‘urgently’, NHS and council told

The NHS and a local council have been told to urgently find a home for a 28-year-old autistic man who is facing psychological and physical abuse within a mental health hospital, after an independent review of his care.
Nicholas Thornton has autism and learning disabilities and is currently being held in the Rochford mental health unit, in Essex, after a decade of being locked away in places not able to care for him adequately.
Now an independent safeguarding review into his care provided at the Essex hospital has ordered the local authority and NHS to find him a home in the community because his relationship with hospital staff has become so bad he is facing psychological and physical harm.
He is one of the 2,045 people with learning disabilities and autism trapped within inpatient units across England.
Mr Thornton has been in the unit, run by the Essex Partnership University NHS Foundation Trust (EPUT), since May this year. He is not under a mental health section, nor does he need mental health treatment, but he is unable to leave because the local authority has not agreed on a place into which he can be discharged.
EPUT is currently facing a public inquiry probing the deaths of 2,000 patients following multiple reviews since 2016 from coroners, the police and health ombudsman criticising the care within the hospital.
A safeguarding report into Mr Thornton’s situation, seen by The Independent and Channel Four News, revealed staff working in the Rochford hospital told investigators they cannot adequately care for Mr Thornton themselves as they are not trained in supporting patients with autism.
Read full story
Source: The Independent, 13 December 2023
Patient Safety Learning

Revealed: Trusts paying the highest negligence premiums

The trusts paying the highest premiums for clinical negligence as a proportion of their income have been revealed through HSJ analysis of internal data.
Several acute trusts in and around London are now spending more than 4% of their income on premium costs to insure themselves against clinical negligence, according to internal NHS data.
One expert suggested trusts with higher proportions of ethnic minority patients often have high rates of negligence claims against them, partly due to the complexity of medical presentation, but also communication problems.
Lisa Jordan, head of medical negligence at law firm Irwin Mitchell, said trusts that act as tertiary referral centres tend to admit the most complex cases, which are more likely to lead to claims.
She added: “Trusts in areas with higher proportions of ethnic minority groups, also often have higher rates. That is in part about the complexity of medical presentation, and also communication problems.”
Helen Hughes, chief executive of Patient Safety Learning, said: “Scarce funds that could be spent proactively improving the quality of care are being spent on the costs of error and harm.”
Read full story (paywalled)
Source: HSJ, 13 December 2023
Patient Safety Learning

Public confused over physician associates working in NHS, research finds

Many people are deeply confused about the growing number of “physician associates” in the NHS and wrongly assume they are doctors, research suggests.
Around 4,000 physician associates work in the NHS in England. Ministers and health chiefs plan to increase the figure to 10,000 to help plug widespread gaps in the NHS workforce.
However, there is widespread confusion among the public about their role and relationship with fully trained medics, according to a survey commissioned by the British Medical Association (BMA).
A quarter of the representative sample of 2,009 people erroneously believed that a physician associate was a doctor, while a fifth made the same mistake about “physician assistants”.
Many respondents thought that a physician associate was more senior than a junior doctor, even though only the latter have a medical degree.
The expansion of physician associates has prompted a backlash by grassroots medics. They fear patients will be misled into thinking they have seen a doctor despite physician associates not having the same skills and training.
The government has moved to try to quell criticism of physician associates by legislating to ensure they are regulated by the General Medical Council (GMC).
Read full story
Source: The Guardian, 13 December 2023
Patient Safety Learning

Culture progress sees NHS Highland escalation eased

NHS Highland will no longer receive extra government support in leadership, governance or culture, following improvements after the Sturrock review.
The board was initially escalated to Stage 3 of NHS performance escalation framework in 2018 following concerns of a culture of workforce bullying and harassment.
An independent report by John Sturrock QC, commissioned by the Scottish government, confirmed “fear, intimidation and inappropriate behaviour” and called for wide-ranging changes.
The Healing Process was created in response, with an independent review panel established to speak to victims of bullying and come up with recommendations for the health board to make improvements.
A total of 272 current and former NHS Highland and local health and social care partnership staff provided testimony between 2019 and March this year, with more than £2.8m paid out to those affected by bullying.
Concerns were raised by some of the first people to go through the healing process that the system was “broken” and many victims could end up “bitterly disappointed”.
The board has also established systems and processes to allow colleagues to speak up in the wake of the Sturrock Review, including an independent Guardian Service and staff training in Courageous Conversations.
NHS Highland was handed oversight of its own escalation and de-escalation, rather than a Scottish government-led oversight group, in November 2021.
Following a letter of assurance from the board chair earlier this year, the Chief Executive of NHS Scotland, Caroline Lamb, agreed to the de-escalation in September.
Independent progress tracking shows the board has delivered significantly against many actions laid out by the review but the board concluded in its final June update that ‘culture change is not yet embedded at all levels of our organisation’.
Read full story
Source: Health and Care Scotland, 2023
Patient Safety Learning

Ditch normal procedures to avoid A&E handover delays, trusts told

Regulators have warned hospital leaders they may have to ‘depart from established procedures’ over winter to minimise ambulance handover delays.
In a joint letter to nursing and medical leaders, NHS England, the Care Quality Commission and professional regulators said it was “vital that we have a whole system approach to risk across the urgent and emergency care pathway”.
The push has come amid a huge increase in instances of crews being held outside emergency departments, resulting in extended response times for time-critical 999 calls.
The letter added: “We… understand there will be concerns about working under pressure, and that you and your teams may need to depart from established procedures on occasion to provide the best care.
“Please be assured that your professional code and principles of practice are there to guide and support your judgments and decision making in all circumstances. This includes taking into account local realities and the need to adapt practice at times of significantly increased pressure.
“In the unlikely event of a complaint to your professional regulator they will, as is their usual practice, consider carefully whether they need to investigate. If an investigation is needed, they will consider all relevant factors including the context and circumstances in which you were working.
“One area that may be an example of this is in handing patients over to emergency departments from ambulance services. There is a strong correlation between ambulance handover delays at emergency departments and ambulance category 2 response delays, meaning longer handovers increase the chances those in need will wait longer for an ambulance.”
Read full story (paywalled)
Source: HSJ, 11 December 2023
Patient Safety Learning

GPs don’t have time for NHSE ‘modernisation’ work, say ICBs

GP practices with the most outdated technology and processes do not have enough staff or funding to take part in NHS England’s performance recovery programme, integrated care boards are warning.
In new recovery plans which they were required to publish by NHSE, multiple ICBs have said that stretched capacity means hardly any practices have signed up to the “general practice improvement programme”, which is meant to help them implement the national primary care access recovery plan.
The ICBs pointed out that the programme is time consuming, and practices which take part are not always given funding to pay for staff time.
HSJ has reviewed the primary care recovery plans which all ICBs were required to bring to their board meetings in October and November, to explain how they were implementing the national plan published by NHSE in the spring.
NHSE’s plan sought to improve ease and speed of access through spreading “modern” methods and processes; as well as measures to save clinicians’ time, improving same-day access, and delivering more appointments.
But HSJ’s  review of the ICB plans found several warning that their uptake of the improvement plan was off track, especially for “intermediate” and “intensive” support, which require substantial time for the practices, and are likely to be required by those most in need of help.
Read full story (paywalled)
Source: HSJ, 12 December 2023
Patient Safety Learning

Maternity investment ‘nowhere near good enough’, says inquiry lead

The expert tasked by government and NHS England to investigate maternity scandals has criticised ministers for failing to provide the funding necessary to address the problems.
Donna Ockenden said the funding provided so far was “nowhere near good enough” and progress made to improve services had been “extremely disappointing”.
After her investigation into the deaths and harm of 295 babies and nine mothers at Shrewsbury and Telford Hospitals Trust, the Department of Health and Social Care endorsed recommendations to invest an additional £200m to £350m per year into maternity services.
IMs Ockenden suggests the recent impact of inflation, pay awards, and other rising costs means the full £350m is required.
According to NHSE an additional £165m per year has been invested since 2021, and the DHSC said this would rise to £187m from April.
Ms Ockenden, a senior midwife, told HSJ: “What I would like to say loud and clear to the government is that we are broadly 50 per cent of the way there in receiving the money we know is needed for maternity services. That is nowhere near good enough.
“There are workforce issues across [the whole team], whether that’s midwives, obstetricians or neonatologists, and it’s hardly surprising.
“The government must now do more – whilst we were grateful for the endorsement [of her report], the lack of progress in providing what is known to be the required funding is extremely disappointing.”
Read more (paywalled)
Source: HSJ, 11 December 2023
Sam

Women giving birth at under fire maternity unit left alone with unsupervised workers, NHS watchdog finds

Women in labour at a London maternity unit deemed “inadequate” were left alone with unsupervised support workers who were not given any guidance, an NHS safety watchdog has found.
In a scathing report of North Middlesex Hospital’s maternity services, the Care Quality Commission also found examples of delays to induction of birth for women, and one case of a woman with a still-born baby who was left waiting for the unit to call her in for an induction.
Inspectors have downgraded the maternity unit from “good” to the lowest possible rating “inadequate” following an inspection earlier this year.
Staff reportedly told inspectors they felt they were “criticised” or “bullied” when reporting safety incidents within the unit.
“We heard that the criticism or bullying was worse if the incident reported was relative to other staff and their perceived behaviours,” the report said.
There was also evidence the hospital was not recording the severity of safety incidents correctly for example two “never events”, which are among the highest category incidents, were categorised as “low harm”.
Other findings included women and babies came to harm as the hospitals did not follow standards to language interpretation despite covering a higher than average minority ethnic population.
Read full story
Source: The Independent, 11 December 2023
Patient Safety Learning

USA hospitals' latest PR concern: The Netflix documentary

After the $261 million verdict against Johns Hopkins All Children's Hospital, health system public relations departments have a new concern: unwillingly becoming the subject of a streaming service documentary.
Released on Netflix in June, "Take Care of Maya" tells the story of Maya Kowalski, whose family brought her to the St. Petersburg, Fla., hospital's emergency department in 2016 with chronic pain. After physicians suspected child abuse, the then-10-year-old was kept there apart from her loved ones for nearly three months, during which time her mother killed herself.
Millions of viewers watched the documentary, which detailed the family's then-unsuccessful attempt to sue the hospital. In November, a Florida jury awarded the Kowalskis the nine-figure sum for damages on counts including medical negligence and false imprisonment.
"The level of global exposure and awareness of this case helped drive the interest, engagement and discussions in the community," Karen Freberg, PhD, professor of strategic communication at University of Louisville (Ky.), told Becker's. "This is a situation where hospitals across the board must evaluate their crisis communication plans from this experience and see how they would address this situation if it happened to them."
She said any reputation-fixing lessons for this case, then, will come not from hospitals that have lost big lawsuits, but from companies that have been the subject of unflattering documentaries.
Read full story
Source: Becker's Hospital Review, 7 December 2023
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