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

NHS: Woman waited nine months for hospital discharge

A woman who spent nine months in hospital waiting for a suitable care home placement became a "shadow of her former self", her mother has said.
Jocelyn Ullmer, 60, from West Sussex, saw her health deteriorate after being admitted to hospital in June last year.
Her mother, Sylvia Hubbard, 86, said: "We tried to get her out of hospital, but no-one wanted her."
Across England, around 60% of patients classed as fit to leave remain in hospital at the end of an average day.
Figures show the biggest obstacle is a lack of beds in other settings, such as care homes and community hospitals.
The government said it was investing £1.6bn over the next two years to help improve the situation.
Read full story
Source: BBC News, 8 November 2023
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Mouth-cancer deaths fear over NHS dentist shortage

Lack of access to dentists is costing lives because mouth cancers are not being spotted or treated early enough, a health charity has told BBC News.
The disease killed more than 3,000 people in 2021 - up 46%, from 2,075 a decade ago, latest figures obtained by the Oral Health Foundation show.
And last year, a BBC News investigation revealed 90% of UK NHS dental practices were not accepting new adult patients.
The government has announced plans to increase dental-training places by 40%. It also said the NHS was treating more people for cancer at an earlier stage than ever before.
Oral Health Foundation chief executive Nigel Carter says dental check-ups "are a key place for identifying the early stage of mouth cancer".
"With access to NHS dentistry in tatters, we fear that many people with mouth cancer will not receive a timely diagnosis," he adds.
Read full story
Source: BBC News, 8 November 2023
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NHS to offer 150,000 people with type 1 diabetes an artificial pancreas

More than 150,000 adults and children with type 1 diabetes in England and Wales are to be offered an artificial pancreas on the NHS, which experts are hailing as a “gamechanger” that will “save lives and heartbreak”.
The groundbreaking device, also called a hybrid closed-loop system, uses a hi-tech algorithm to determine the amount of insulin that should be administered and reads blood sugar levels to keep them steady. A world-first trial on the NHS showed it was more effective at managing diabetes than current devices and required far less input from patients.
Final draft guidance from the National Institute for Health and Care Excellence (NICE) recommends that people in England and Wales should benefit from the wearable device if their diabetes is not adequately controlled by their current pump or glucose monitor. The decision to give the go-ahead for widespread use of the artificial pancreas was announced on Tuesday at NICE’s annual conference in Manchester by Dr Sam Roberts, its chief executive.
The artificial pancreas has been found to be better at keeping blood sugar levels within a healthy range, cutting the risk of people suffering complications from diabetes. It works via a continuous glucose monitor sensor attached to the body which transmits data to a body-worn insulin pump.
This pump then calculates how much insulin is needed and delivers the precise amount to the body. Hybrid closed-loop systems mean people do not need to rely on finger-prick blood tests or injecting insulin to control their blood sugar levels.
Yasmin Hopkins, who took part in trials of the artificial pancreas, said: “From day one it was amazing. Before the closed-loop system, I would experience a lot of highs, which I’d then overcorrect, go low and eat a lot of sugar. All of that has been eradicated.
“This technology gives me the freedom to get on with my life and live without fear of what might happen in a few hours, days or years.”
Read full story
Source: The Guardian, 7 November 2023
Related reading on the hub:
How safe are closed loop artificial pancreas systems?  
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Record NHS drug shortages as HRT, contraceptives and ADHD medicines run low

Britain faces record shortages of medicines amid a row between drug makers and the NHS over payments. 
Patients face issues getting hold of drugs for epilepsy and ADHD, as well as hormone replacement therapy (HRT) for the menopause. 
A total of 111 drugs are currently facing supply issues, according to the British Generic Manufacturers Association (BGMA). This is the highest level on record and more than double the number of drugs facing shortages at the start of 2022. 
The BGMA blamed an NHS drugs levy for the supply issues, saying it was discouraging pharmaceutical companies from supplying the health service.
Dr Leyla Hannbeck, chief executive of the Association of Independent Multiple Pharmacies, said pharmacists were “spending long hours in the day trying to source medicines for patients and this is on top of all the other activities they do in a busy pharmacy”.
She said: “Our pharmacy teams see firsthand the anxiety and stress experienced by patients caused by medicines shortages.” Shortages have also led to more abuse and aggression towards pharmacists, she said.
Read full story (paywalled)
Source: The Telegraph, 
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US nurse charged with killing 2 patients admits to trying to kill 17 more

A former Pennsylvania nurse admitted she tried to kill 19 people at multiple different care facilities, piling dozens of new charges on the woman who allegedly administered lethal doses of insulin to numerous patients, killing two.
On Thursday, the state's attorney general's office announced the new charges against Heather Pressdee, who now faces two counts of first-degree murder, 17 counts of attempted murder and 19 counts of neglect of a care-dependent person.
The 41-year-old nurse was first arrested in May for killing two nursing home patients and injuring a third.
From 2020 up until her arrest, prosecutors say Pressdee gave 19 patients at five different care facilities excessive amounts of insulin, some of whom were diabetic and needed it and others who did not.
The plaintiff would typically administer these insulin doses overnight while fewer staff members were working and as "emergencies wouldn't prompt immediate hospitalization," Pennsylvania Attorney General Michelle Henry said.
"If Pressdee sensed the victim would 'pull through' there is a pattern of her taking additional measures to try to kill the victims before they could be sent to the hospital by either administering a second dose of insulin or the use of an air embolism to ensure death," the criminal complaint, which also said Pressdee admitted to harming patients with intent to kill, said.
Read full story
Source: Scripps News, 3 November 2023
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GP leaders in England call for a pause in recruitment of physician associates

The BMA’s GP committee for England (GPC England) has called for an immediate pause in the recruitment of physician associates (PAs) in general practice.
In an emergency motion passed on 2 November the committee expressed “concerns over the increasing trend of PAs being used to substitute GPs” and called on practices and primary care networks to stop PA recruitment “until appropriately safe regulatory processes and structures are in place.”
GPs and GP registrars were also reminded that they can refuse to sign prescriptions and turn down requests for investigations made by PAs.
Read full story (paywalled)
Source: BMJ, 3 November 2023
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Drug that can halve breast cancer risk offered to 289,000 women in England

Drug that can halve breast cancer risk offered to 289,000 women in England
Anastrozole to be made available to women who have been through the menopause and have family history of breast cancer
Almost 300,000 women at higher risk of developing breast cancer are being given access to a drug that can halve their risk in a “major step forward” in the fight against the disease.
An estimated 289,000 women in England who are at moderate or high risk of breast cancer will from Tuesday be able to take the tablet to try to prevent it from developing, NHS bosses said.
The drug, anastrozole, is being made available to women who are in greater danger because they have been through menopause and have a major family history of Britain’s commonest form of cancer. It displays “remarkable” potential to reduce the number of people who go on to develop the disease, the head of the NHS said last night.
Every year, around 56,000 women in the UK are diagnosed with breast cancer – about 150 a day. While survival rates have improved, it still claims about 11,500 lives each year.
“It’s fantastic that this vital risk-reducing option could now help thousands of women and their families avoid the distress of a breast cancer diagnosis,” said Amanda Pritchard, NHSC England’s chief executive. The drug will be taken as a 1mg tablet once a day for five years.
Read full story
Source: The Guardian, 7 November 2023
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Struggling trust CEO says provider has ‘turned dial’ following care scandals

A mental health trust at the centre of several care scandals has ‘turned the dial’ on improvement, its chief executive has said, following the Care Quality Commission noting some progress but retaining a ‘requires improvement’ rating
The CQC said earlier this month that improvements had been made at some services at Tees Esk and Wear Valleys Foundation Trust, including for its forensic secure inpatient service, where the rating was raised from “inadequate” to “good”. But the improvements were not enough to shift its overall “requires improvement” rating.
Chief executive officer Brent Kilmurray argued the CQC report was evidence the trust was going in the right direction following a number of highly critical reports relating to patient deaths, but he also told HSJ it was a “challenge” for the trust to “tell a balanced story around where we are making progress”.
TEWV has recently admitted care failings relating to the deaths of two inpatients in 2019 and 2020, following prosecution from the CQC. The trust will go on trial for alleged failings relating to another death in February next year.
Read full story (paywalled)
Source: HSJ, 6 November 2023
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Poor maternity care at Hull Royal Infirmary risked babies' lives, say mums

Maternity services at Hull Royal Infirmary have recently been described in a damning report by the health watchdog as chaotic, unsafe and not fit for purpose. Three mothers, who claim staff missed signs of life-threatening conditions that could have killed them or their babies, have spoken to the BBC about their harrowing experiences at the hospital.
One woman, a BBC journalist who does not want to be named, said she knew her newborn son was seriously ill within minutes of giving birth at the infirmary in 2021.
"As soon as they handed him to me, I noticed something was wrong. He was panting and his breathing wasn't right," she said.
Over the course of an hour, she said her concerns were dismissed by the newly-qualified midwife who said his breathing was "completely normal".
"She kept reassuring me over and over that's how babies breathe. I felt like I was drowning surrounded by lifeguards," she said.
But after being examined by a more experienced midwife, the baby was rushed to intensive care and diagnosed with potentially fatal sepsis.
"It was like time stood still. The midwife ripped him off me and she slammed an oxygen mask on his face, called the crash team and he was taken away to the neonatal intensive care unit.
"The anger I felt was overwhelming because I'd been saying for nearly an hour he was seriously ill. I was right and he had sepsis."
A few months after her son's birth, she read about an inquest into the death of a four-day-old baby who had sepsis and was born at Hull Royal Infirmary.
A coroner found that midwives had failed to respond to his infection quickly enough.
"My blood ran cold because it was exactly the same circumstances that happened to me and that baby died. I thought they clearly haven't learned anything," she said.
Read full story
Source: BBC News, 6 November 2023
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DRC offers free maternity care to cut death rate among mothers and babies

Pregnant women across the Democratic Republic of the Congo are to be offered free healthcare in an effort to cut the country’s high rates of maternal and neonatal deaths.
Women in 13 out of 26 regions in the country will, by the end of the year, be entitled to free services during pregnancy and for one month after childbirth. Babies will receive free healthcare for their first 28 days under the scheme, which the government plans to extend to the rest of DRC – although there is no timetable for that yet.
However, health workers have raised concerns that hospitals and medical centres are ill-equipped to cope with any increased demand on services. Some told the Guardian there were not enough staff, facilities or equipment to successfully introduce the $113m (£93m) programme, which is supported by the World Bank.
The rollout of the programme comes amid nationwide strikes by nurses, midwives, technicians and hospital administrative staff, who are calling for higher pay and better conditions.
Congo has one of the highest number of maternal and neonatal deaths in the world. Latest figures record the maternal morality ratio at 547 deaths for every 100,000 live births, and its neonatal rate – the number of babies dying before 28 days of life – at 27 per 1,000 live births. 
The minister of public health, Roger Kamba Mulamba, said the programme would free women from a “prison sentence”.
He said: “Mothers today get healthcare without fear when they are pregnant. Babies today do not die because they have no access to antibiotics. Mothers today do not die because they cannot afford to pay for a caesarean delivery.”
Read full story
Source: The Guardian, 6 November 2023
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Patient safety at risk as pharmacists replace GPs, doctors warn

Doctors are warning that patient safety is being put at risk as podiatrists and pharmacists replace GPs “on the cheap”.
Dozens of family doctors have contacted The Telegraph claiming that talk of a GP shortage is “a big lie” and that they are being replaced by less qualified, cheaper staff, in a “crisis”.
Documents seen by The Telegraph show staff including podiatrists, pharmacists and physician associates being used in lieu of GPs to diagnose and treat patients with conditions they are not trained in.
In the most extreme cases, poorly children with viral infections, asthma-related issues and concerns about menstruation have been seen and diagnosed by a podiatrist – a healthcare professional trained exclusively to care for feet.
It is not clear what happened to any of the patients afterwards, or if their parents were aware they had seen a podiatrist rather than a doctor.
One GP said it was “a matter of patient safety” and the notion of “everything being supervised” did not work at a GP practice like it does in hospitals.
Read full story (paywalled)
Source: The Telegraph, 4 November 2023
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Private health firm Sciensus fails to fix defects that led to UK patient’s death

A private health company paid millions by the NHS has failed to fix safety defects that led to the death of a cancer patient, the Guardian can reveal.
Three patients were hospitalised and a fourth died when they were given the wrong doses of a powerful chemotherapy drug after a catastrophic IT failure at the medicine manufacturing unit of Sciensus in April this year.
The incident, first revealed by the Guardian in July, prompted an investigation by the Medicines and Healthcare products Regulatory Agency (MHRA). Its inspectors found “significant deficiencies” at the Sciensus manufacturing facilities and ordered the partial suspension of its manufacturing licence.
However, six months after the IT blunder, Sciensus has not fixed the problems identified by the regulator, according to people familiar with the matter. As a result, the suspension of its licence – originally due to be lifted last month – has been extended until July next year.
Sciensus is the UK’s biggest provider of medicines services to NHS and private patients at home. It is contracted by the NHS and other organisations to deliver and administer medicines to more than 200,000 people with conditions such as heart disease, diabetes, dementia, HIV and cancer.
Read full story
Source: The Guardian, 5 November 2023
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Stevens hits out at raft of ‘pound foolish’ government decisions

‘Chronic short-termism’ by government is undermining the nation’s ability to respond to another pandemic, a previous NHS England chief executive has said. 
In his first written statement to the covid public inquiry, Lord Stevens said ministers had failed to upgrade NHS infrastructure and modernise social care, delayed public health improvements, and cut testing and research programmes.
This is despite the 2023 national risk register identifying a further pandemic as the highest risk, with “5-25%pa
Lord Stevens – NHSE CEO from 2014 to summer 2021 – said it was “encouraging the government has now permitted NHS England to publish a funded long-term workforce plan”, but added: “There is also a strong case for revisiting several other national decisions.
“These include the dismantling of some community infection surveillance infrastructure; cancelling some scientific and clinical research programmes developed during the pandemic; postponing various preventative health measures; deferring reform of social care; and further delaying upgrades of health buildings, equipment and technology.”
Read full story (paywalled)
Source: HSJ, 3 November 2023
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Maternity care ‘in crisis’ as pregnant women are forced to delay induced deliveries

Pregnant women are being forced to wait days longer than expected for “urgent” inductions of labour as NHS staff shortages and a lack of beds lead to severe delays.
New mothers told i the delays, which the health watchdog has found can last up to five days, increased the anxiety they felt during labour.
One first-time mother, who wanted to remain anonymous, said that her ordeal has put her off having any more children. The woman, who gave birth to a son in August, said she was “pushed” to book an induction when her waters broke and her baby was almost two weeks overdue. Despite being told by multiple healthcare professionals she needed to “give birth within 24 hours” due to a risk of infection, she did not end up delivering her baby for another 49 hours – without being induced.
A birthing expert told i she has “never seen a crisis in maternity” like it during her almost 10 years working in the sector.
It comes after it was revealed that the Care Quality Commission (CQC) watchdog has issued warnings to seven hospitals due to delays to the induction of labour since last year.
Read full story (paywalled)
Source: inews, 5 November 2023
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Hospital management criticised over helipad death

A trust failed to identify risks associated with a helipad in one of its car parks, contributing to the death of an elderly woman who was blown over as a heavy search and rescue helicopter came into land. 
The Air Accident Investigations Branch found multiple factors contributed to 87-year-old Jean Langan’s death at Derriford Hospital in Plymouth in March 2022. Ms Langan was on her way to an appointment when she was blown over and another person seriously injured.
Crispin Orr, chief inspector of air accidents, said: “Our in-depth investigation revealed systemic safety issues around the design and operation of hospital helicopter landing sites which need to be addressed at a national level.”
Read full story (paywalled)
Source: HSJ, 2 November 2023
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Martha’s rule must be available 24/7, England’s patient safety commissioner says

Patients and their relatives will be able to request a second opinion from senior medics around the clock when the “Martha’s rule” system starts in hospitals in England.
The government’s patient safety commissioner, asked by the health secretary, Steve Barclay, to advise on how to implement the change, has said access to a medic’s opinion must operate 24/7.
Dr Henrietta Hughes made clear to Barclay in a letter that inpatients and families worried that their loved one’s health is deteriorating should be able to seek a second opinion at any time of day or night.
In her letter, which she published on Wednesday, Hughes also said the availability of that service must be widely advertised in hospitals, so patients know they can use it.
She told Barclay that all staff in acute and specialist medical NHS trusts in England “must have 24/7 access to a rapid review from a critical care outreach team who they can contact should they have concerns about a patient”.
Hughes added: “All patients, their families, carers and advocates must also have access to the same 24/7 rapid review from a critical care outreach team which they can contact via mechanisms advertised around the hospital and more widely if they are worried about the patient’s condition. This is Martha’s rule.”
Read full story
Source: The Guardian, 3 November 2023
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