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

NHS England to investigate why dead people invited for Covid and flu jabs

The NHS has launched an investigation after it sent “priority” letters to people who died years ago, in some cases decades, urging them to book flu and Covid-19 jabs to reduce their risk of serious illness.
The health service is asking eligible patients to arrange appointments for both vaccines to avoid a potential “twindemic” of flu and coronavirus this winter, which would pile further pressure on hospitals and GP surgeries.
“You are a priority for seasonal flu and Covid-19 vaccinations,” the two-page letter tells recipients. “This is because you are aged 65 or over (by 31 March 2024).
However, some of the letters, which contain personal information such as NHS numbers, have been sent to people who died years ago. Others have been sent to people who are not eligible for the vaccines, with no connection to the addressee.
In a statement, NHS England told the Guardian it was investigating. It declined to answer questions about when the error was first discovered, what had caused it and how many people had been affected.
“We have been made aware of some letters sent in error and appreciate this may have been upsetting for those who received it – we are working as quickly as possible to investigate this,” a spokesperson for NHS England said.
Read full story
Source: The Guardian, 24 October 2023
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Four trusts report quarter of all ‘critical incidents’

More than a quarter of ‘critical incidents’ have been declared by just four trusts since the start of the crisis in urgent and emergency care.
Data obtained by HSJ shows 241 critical incidents have been declared by organisations due to “operational” or “system pressures” between April 2021, when long waits for urgent care began to surge upwards, and last month. Four trusts account for 68 of these (28%).
Critical incidents are declared when the level of disruption “results in an organisation temporarily or permanently losing its ability to deliver critical services, or where patients and staff may be at risk of harm”. These incidents may require “special measures and support from other agencies, to restore normal operating functions,” according to the NHS England definition. 
Most critical incidents were only in place for a few days before being stood down by the trust or system, but some were in place for much longer – sometimes for several months at a time, the data suggests.
Read full story (paywalled)
Source: HSJ, 25 October 2023
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Jasper Brooks inquest: Baby died due to 'neglect' at hospital

A coroner has found neglect contributed to a baby's death at the hospital where he was born.
Jasper Brooks died at the Darent Valley Hospital in Kent on 15 April 2021. The coroner found gross failures by midwives and consultants at the hospital and says Jasper's death was "wholly avoidable".
Jasper was a second child for Jim and Phoebe Brooks. Due to a complication during pregnancy of her first child, Phoebe was booked in to have an elective Caesarean section to deliver Jasper. But in April 2021 those plans changed overnight.
A check-up found Phoebe had raised blood pressure. She was told to remain in hospital and that the C-section would happen the following morning - nine days earlier than planned - when there were more staff on duty.
Jasper's parents say the midwives caring for Phoebe repeatedly failed to listen to her and Jim's concerns - that she was shaking violently, feeling sick, and thought she was bleeding internally.
"We felt like an inconvenience - no-one wanted to deal with me that night," Phoebe says. "The doctor didn't want to do my C-section, the midwife that's meant to be looking after me, she just doesn't really care.
"I remember saying clearly to her, 'my whole body is shaking - something's happening, and no-one's taking the time to listen to what I'm saying or listen in on my baby'."
At the inquest hearing, midwife Jennifer Davis was accused by the family's barrister, Richard Baker KC, of "failing to act on signs of blood loss, failing to determine if Phoebe was in active labour, and failing to call a senior doctor when necessary".
Jasper was born without a heartbeat, so a resuscitation team was called. But during the inquest, the family learned that further errors were made because the correct people failed to attend the resuscitation.
There was no consultant neonatologist on site - a doctor with expertise in looking after newborn infants or those born prematurely. Intubation, the process of placing a breathing tube into the windpipe - which should only take a few minutes - did not occur for 18 minutes. There was also a delay in administering adrenaline to try to stimulate Jasper's heart.
Read full story
Source BBC News, 24 October 2023
 
Patient Safety Learning

Confirm there is no plan to ‘replace doctors’, NHSE told

The medical regulator has told NHS England to ‘directly tackle’ a perception there is a plan to replace doctors with physician associates amid an ‘intense’ debate about their future.
General Medical Council chief executive Charlie Massey wants NHS England and health systems in the devolved nations to address several issues surrounding the expansion of medical associate roles.
This follows intense debate over recent weeks, including multiple media reports of safety incidents where the involvement of physicians and anaesthesia associates has been questioned. The debate has been partially prompted by ambitions in the long-term workforce plan to increase their numbers, and the impact this would have on post-graduate medical training.
Last week almost 90% cent of Royal College of Anaesthetists members voted to pause the rollout of anaesthesia associates, after an extraordinary general meeting. This prompted NHSE leaders to stress to trusts that associates should be working within established guidelines and have appropriate supervision.
In response, Mr Massey has written to NHSE, calling for it to: “Directly tackle the perception that there is a plan for the health services to ‘replace’ doctors with PAs or AAs by convening and leading a system-wide discussion on an agreed vision for these roles.”
Read full story (paywalled)
Source: HSJ, 25 October 2023
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Sepsis killing too many as lessons not learned, warns NHS watchdog

Sepsis is still killing too many patients due to the same hospital failings that occurred a decade ago, a damning report by the NHS ombudsman has warned.
Avoidable mistakes include delays in spotting and treating the condition, poor communication between health staff, sub-standard record keeping and missed opportunities for follow-up care, according to Rob Behrens, the parliamentary and health service ombudsman (PHSO).
Despite some progress since a previous report on sepsis by the ombudsman in 2013, lessons are not being learned and repeated mistakes are putting people at risk, Behrens said. Major improvements are urgently needed to avoid more fatalities, he added.
“I’ve heard some harrowing stories about sepsis through our investigations, and it frustrates and saddens me that the same mistakes we highlighted 10 years ago are still occurring,” said Behrens. “It is clear that lessons are not being learned. Losing a life through sepsis should not be an inevitability.”
Melissa Mead, whose one-year-old son, William, died from sepsis in 2014 after concerns were dismissed by doctors, said: “I think this report, nine years on from William’s death, really lays bare the incidences of sepsis cases.”
Mead, who peer-reviewed the study, added: “Too many lives are being lost in preventable circumstances.”
Read full story
Source: The Guardian, 25 October 2023
Further reading on the hub:
Top picks: Six resources about sepsis
Patient Safety Learning

Government progress against recommendations on patient safety in the NHS to be evaluated

The Health and Social Care Select Committee have commissioned an Expert Panel to consider the Government’s progress against accepted recommendations from public inquiries and reviews on patient safety.
The Panel will consider a range of recommendations made by public inquiries and reviews on both patient safety and whistleblowing and subsequently select a number of these for evaluation. The Panel will in its final report provide a rating of the Government’s progress against each of these recommendations.
Panel members are:
Professor Dame Jane Dacre (Chair). Sir Robert Francis KC Anita Charlesworth Professor Stephen Peckham Sir David Pearson Professor Emma Cave Read full story
Source: House of Commons Health and Social Care Select Committee, 24 October 2023
Patient Safety Learning

Plan to pump 10,000 fake doctors into the NHS is insane and dangerous

You might not have heard of a ‘physician associate’ - and that’s not your fault. They probably won’t tell you. A physician associate walks and talks like a doctor, but they are no replacement for one.
To become a physician associate you need to complete a two-year postgraduate course or three-year apprenticeship. But despite much less learning than the five years a junior doctor must undergo to be qualified, they are often paid more than them.
Which is why the government’s plan to flood the NHS with 10,000 more of them over the next 15 years doesn’t make any sense. There’s certainly no money-saving aspect. This is simply another corner-cutting exercise to quickly plug gaps in a struggling NHS that will put patients at risk.
Far from saving doctors work (their original purpose), they often create more. Physician associates are unregulated so cannot be held accountable for their mistakes, meaning doctors must recheck any critical decisions they make. Critical decisions are made quite frequently in hospitals.
But they’re not just overstretching doctors and creating more work; they’re harming patients. A recent Daily Mail investigation has found brain bleeds misdiagnosed as inconsequential headaches and lung disease mistaken for a chest infection.
Doctors say they are “increasingly concerned” by this.
Read full story
Source: LBC, 16 October 2023
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Crumbling concrete: Raac found in 18 more hospitals in England

Eighteen more hospitals in England contain potentially crumbling concrete, bring the total affected to 42, the Department of Health and Social Care has confirmed.
The reinforced autoclaved aerated concrete (Raac) has also been found in 214 schools and colleges in England as well as thousands of other buildings.
NHS Providers, which represents hospitals, said the concrete "puts patients and staff at risk".
Full structural surveys are taking place at all newly confirmed sites.
The government said it was committed to eradicating Raac from NHS buildings completely by 2035.
Seven of the worst-affected hospitals will be replaced by 2030 as part of the programme to build 40 new hospitals in England, it added.
Read full story
Source: BBC News, 21 October 2023
Patient Safety Learning

Whistleblower raises alarm over ‘inadequate’ investigation into 60 suicides

A trust pressured into commissioning an external review of dozens of suicides faces fresh criticism and questions about the probe’s credibility after it emerged the investigation will not investigate each case but instead look to ‘identify themes’.
Cambridgeshire and Peterborough Foundation Trust originally said it would carry out the review of more than 60 patient suicides internally. But following criticism, it U-turned on this decision and last month agreed to an externally-led process.
Read full story (paywalled)
Source: HSJ
Patient_Safety_Learning

As RSV cases tick up, CDC warns that a key drug to keep babies safe is in short supply

The Centers for Disease Control and Prevention alerted doctors nationwide Monday about a limited availability of certain doses of a newly approved antibody drug given to infants to prevent RSV infection.
Cases of RSV, or respiratory syncytial virus, have started to rise as cold and flu season begins.
"RSV season is here," said Dr. Buddy Creech, a pediatric infectious disease doctor at Vanderbilt University Medical Center in Nashville, Tennessee. "We are seeing a substantial increase in the amount of RSV such that in many areas, it has become the most commonly identified respiratory virus causing disease in children.
"This is one of the reasons why there's probably a lot of scrambling going on," he said, "to identify those babies at highest risk and to try to prioritize them, since it's such a limited resource right now."
Read full story
Source: NBC News, 23 October 2023
Patient_Safety_Learning

Welsh Ambulance Service declares extraordinary incident due to delays

An ambulance spent 28 hours outside a hospital after an "extraordinary incident" was declared due to delays.
The Welsh Ambulance Service said 16 ambulances had waited outside the emergency department at Morriston Hospital, Swansea, at one time.
It said multiple sites across Wales were affected.
The extraordinary incident, which asked people to only call 990 if their emergency was "life or limb threatening", is now over.
Read full story
Source: BBC News, 23 October 2023
Patient_Safety_Learning

Thousands of men miss out on life-extending prostate cancer drug

Thousands of patients in England and Northern Ireland are missing out on a life-extending prostate cancer drug that is more widely available on the NHS in Scotland and Wales, say experts.
Charity Prostate Cancer UK said it was "unacceptable" that men in parts of the UK were facing a postcode lottery.
Although not a cure, abiraterone can help stop prostate cancer spreading to other parts of the body.
NHS England said it would review the drug's use for more men next year.
Read full story
Source: BBC News, 23 October 2023
Patient_Safety_Learning

Man who died after heart problem was dismissed as anxiety was seen by physician’s associate

A 25-year-old who died from a heart haemorrhage after being diagnosed with a panic attack had been seen by a non-medical school trained physician associate (PA) but not a doctor, it has emerged.
Ben Peters, 25, attended the emergency department at Manchester Royal Infirmary on the morning of 11 Nov 2022 with chest pain, arm ache, a sore throat and shortness of breath.
While waiting, he endured a “severe episode of vomiting”.
Peters was diagnosed with a panic attack and gastric inflammation by the PA and sent home with two medications, after a supervising consultant, who the coroner found never reviewed the patient in person, agreed with the diagnosis.
Less than 24 hours later, Peters died from a rare complication of the heart that had resulted in a tear of the heart’s major artery, known as aortic dissection, and led to a fatal haemorrhage.
The Aortic Dissection Charitable Trust (TADCT) says around 2,000 people in Britain die from the condition each year, which can be “reliably diagnosed or excluded” using a CT scan, but “misdiagnosis affects one-third of patients”.
A prevention of future deaths notice issued by Chris Morris, the area coroner for Greater Manchester South, written to Manchester University Foundation Trust, said: “It is a matter of concern that despite the patient’s reported symptoms, in view of his age and extensive family history of cardiac problems, Mr Peters was discharged from the Ambulatory Care Unit without being examined or reviewed in person by a doctor."
Read full story
Source: The Telegraph, 21 October 2023
Patient-Safety-Learning

Welsh Ambulance Service declares extraordinary incident due to delays

An ambulance spent 28 hours outside a hospital after an "extraordinary incident" was declared due to delays.
The Welsh Ambulance Service said 16 ambulances had waited outside the emergency department at Morriston Hospital, Swansea, at one time.
It said multiple sites across Wales were affected, "specifically" in the Swansea Bay health board area.
Lee Brooks, director of operations, told BBC Radio Wales Breakfast the situation was "heart-breaking".
The service said people should only call 999 if their emergency was "life or limb threatening".
Judith Bryce, assistant director of operations at the Welsh Ambulance Service, said on Sunday the service was experiencing "patient handover delays outside of emergency departments. This is taking its toll on our ability to respond within the community."
Read full story
Source: BBC News, 23 October 2023
Patient-Safety-Learning

Finance directors ‘incensed’ at comments by safety watchdog

The Health Services Safety Investigation Branch has been accused of taking “divisive potshots” at NHS finance directors.
Speaking at an event to mark the watchdog becoming an independent body, HSSIB chief investigator Rosie Benneyworth said: “We need a position where finance directors in every organisation are as responsible for safety as the person leading the safety agenda and vice versa… Often you see the finance director and safety lead don’t work effectively together and we need to change that.”
Dr Benneyworth said progress on safety would not be made unless it was tackled “in the same breath” as operational and financial matters.
In response, the Healthcare Financial Management Association said Ms Bennyworth’s views had “incensed” its members.
Commenting below the story, HFMA chief executive Mark Knight said: “I have been contacted by a number of finance directors who are incensed by the comments in this article. To gain a fuller picture of the views of the newly created HSSIB we will be asking for a meeting with Dr Benneyworth and [HSSIB chair Ted] Baker. The HFMA would like to understand the evidence on which the assertions in the article are based, which are completely at odds with how I know the vast majority of finance directors and their teams behave.”
Read full story (paywalled)
Source: HSJ, 23 October 2023
Patient-Safety-Learning

Reliance on private hospitals being ‘hard wired’ into NHS elective care

The drive to cut NHS waiting lists are becoming ‘disproportionately reliant’ on the private sector, experts have warned, as new data suggests rapid growth in the elective activity carried out by non-NHS providers.
Internal figures for activity commissioned by integrated care boards and NHS England, seen by HSJ, suggests the value-weighted activity carried out by private providers has increased by around 30 per cent on pre-covid levels. The value-weighted elective activity carried out by NHS providers rose by just three per cent over the same three-month period, from April to June 2023.
The figures relate to activity measured under the “elective recovery fund”, which accounts for the bulk of elective activity. NHSE said it was right to make use of “all available capacity” to treat long-waiters. However, experts said the NHS would struggle to bring down waiting lists without significantly increasing the amount of elective work it did.
Waiting list analyst Rob Findlay said independent sector outsourcing was “not genuine backlog clearance, but a way of plugging some of the recurring shortfall in core NHS capacity.”
Read full story (paywalled)
Source: HSJ, 23 October 2023
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