Skip to content

News

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

Thousands unaware they have diabetes could be diagnosed at A&E, says study

Thousands of people unaware they have type 2 diabetes could be diagnosed and avoid serious complications if screening was introduced in emergency departments, a study suggests.
The prevalence of the disease has risen dramatically in countries of all income levels in the last three decades, according to the World Health Organization. More than 400 million people have been diagnosed, but millions more are estimated to be in the dark about the fact they have the condition.
A study that took place in an NHS trust in England suggests 10% more cases could be picked up with the use of a simple blood test. Screening could also pick up 30% more cases of pre-diabetes – a serious condition where blood sugar levels are higher than normal.
The findings are being presented at the annual meeting of the European Association for the Study of Diabetes (EASD) in Hamburg, Germany.
“Early diagnosis is the best way to avoid the devastating complications of type 2 diabetes, and offers the best chance of living a long and healthy life,” said Prof Edward Jude, of Tameside and Glossop integrated care NHS foundation trust.
Read full story
Source: The Guardian, 3 October 2023
Patient Safety Learning

Trusts’ row over stroke services sparks ‘significant safety’ concerns

A district general hospital has accused a major teaching trust of ‘failing to adhere to arrangements’ made around the provision of acute stroke services, sparking patient safety warnings in a local integrated care board’s (ICB) risk register.
Harrogate and District Foundation Trust’s accusation that its neighbour, Leeds Teaching Hospitals Trust, is failing to comply with protocol around acute stroke pathways was published in West Yorkshire ICB’s risk register.
The ICB’s September risk register also said the “risk to patient safety is significant and probable if the situation remains unresolved”.
The issues centre on the provision of hyper-acute stroke unit beds, which provide the first two to three days of care for patients with newly diagnosed strokes, and what happens to patients requiring acute stroke care following their initial HASU stay.
West Yorkshire ICB said in its September’s performance report that the problem had “grown due to two recent clinical incidents,” but added “there is no quick solution to this problem”.
Harrogate has raised concerns with the ICB in recent months that “a number of patients are not receiving HASU level care at Leeds”.
Read full story (paywalled)
Source: HSJ, 3 October 2023
Patient Safety Learning

GP mistakes led to patient suffering a stroke and going blind

Doctors missed a man’s stroke which led him to suffer another one and go temporarily blind.
The man said that the experience had changed him from ‘an outgoing social person, to a sheltered man living in fear that he is not being looked after competently’.
The 75-year-old visited his GP in Darlington complaining of dizziness, light-headedness, and a numb foot. 
He had experienced a stroke and should have been immediately sent to hospital. But doctors missed the signs, diagnosed him with a ‘dropped foot’ and requested an urgent MRI scan. However, due to an administrative error the referral wasn’t made and the scan never happened.
A month after visiting the GP, the man suffered a blinding headache and diminished vision. He saw an ophthalmologist who referred him to a specialist team.
He had suffered another stroke. He also paid for a private scan which confirmed the first stroke happened a month earlier.
Distressingly, the man lost vision in his right eye, which he was told could be permanent. Fortunately, his sight returned eight weeks later.
His daughter, who described the experience as ‘horrendous’, complained to the Parliamentary and Health Service Ombudsman (PHSO) about her father’s care.
The PHSO found that the initial symptoms were signs of a problem with nerve, spinal cord, or brain function. Doctors should have suspected a stroke and immediately sent him to hospital. If that had happened, the second stroke and sight loss would likely have been avoided.
Ombudsman Rob Behrens said:
“Having a stroke and then being told you could be permanently blind must have been incredibly frightening. The impact on the man, and his family who supported him through the ordeal, will have been deep and long-lasting.
“Mistakes like these need to be recognised and acted upon so that they are not repeated.”
Read full press release
Read case file
Source: PHSO, 4 October 2023
Patient Safety Learning

NHS can’t prepare for pandemic surge due to lack of staff, NHSE warns

The NHS has too few staff to prepare for a pandemic surge, while its ageing buildings and social care’s weak ‘resilience and capacity’ would also undermine its response, NHS England has warned.
A new NHSE submission to the Covid-19 public inquiry says funding pressure from 2010 has undermined the health service’s “resilience” and that “resilience and capacity issues in social care are national issues which must be addressed from the centre”.
The document was posted unnoticed on the inquiry website last month. No current or former NHSE leaders have so far given evidence to the inquiry. It is the first time NHSE has clearly set out that understaffing and underinvestment compromised the service’s readiness to deal with the pandemic.
Referring to the NHS’s ability to create “surge capacity [with] flexible staff and equipment which can be pivoted into different roles”, it goes on: “It is only possible to train staff to work more flexibly into different roles/environments if they can be freed up to attend training and refreshers. 
“This requires ‘surplus’ staff numbers on rotas, which is not currently possible in relation to many staffing groups across the NHS.”
Read full story (paywalled)
Source: HSJ, 3 October 2023
Patient Safety Learning

Transgender women may be banned from women's NHS wards

Transgender people may be banned from single-sex hospital wards under plans to restore "common sense" in the NHS, the health secretary says.
Speaking at the Conservative party conference, Steve Barclay announced a consultation on strengthening the protections in place for women.
NHS guidance issued in 2021 said trans people may be placed on wards according to the gender they identify as. 
The change would stop that with trans people given their own rooms and areas. But doctors have questioned whether there are the facilities available to achieve that.
And the move would have to meet the legal threshold set by the Equality Act, which allows trans people to be excluded from single-sex spaces if there is a proportionate means of achieving a legitimate aim, such as privacy or safety.
Mr Barclay said he wanted to make sure the "dignity, safety and privacy" of all patients was respected, while the rights of women are protected.
Read full story
Source: BBC News, 3 October 2023
Patient Safety Learning

Strikes now endangering heart and cancer patients, NHSE warns BMA

The impact of successive doctors’ strikes is now ‘causing significant disruption and risk to patients’, including to those needing urgent heart and cancer treatment, NHS England leaders have told the BMA in their strongest warnings yet.
A letter to the union’s council chair on Tuesday evening, leaked to HSJ, said: “We are increasingly concerned that the cumulative impact of this action is causing significant disruption and risk to patients…
“We are extremely concerned that Christmas Day cover is insufficient to ensure appropriate levels of patient safety are being maintained across local health systems. This is particularly the case in the current period of industrial action, with three consecutive Christmas Day levels of service.”
Although Christmas Day includes cover for emergency care, the officials said that in practice – with demand above Christmas Day levels, and with successive days and repeated strikes – it was not protecting patients needing urgent care.
The letter, signed by NHSE leaders including chief medical officer Sir Steve Powis, and chief nurse Dame Ruth May, goes on: “Secondly, we are becoming increasingly concerned that combined periods of industrial action are impacting on our ability to manage individuals who require time-sensitive urgent treatment, for example cardiac, cancer or cardiovascular patients, or women needing urgent caesarean sections.”
Read full story (paywalled)
Source: HSJ, 3 October 2023
Patient Safety Learning

Greenland women seek compensation over involuntary birth control

A group of 67 women from Greenland are seeking compensation from the Danish government over a campaign of involuntary birth control in the 1960s.
At least 4,500 women, some of them teenagers, were fitted with coils under a programme intended to limit birth rates among the indigenous population.
An inquiry is due to conclude in 2025, but the women, some of whom are in their 70s, want compensation now.
They are seeking 300,000 kroner (£34,880; $42,150) each.
Records from the national archives showed that, between 1966 and 1970 alone, intrauterine devices (IUDs) were fitted into the women, some as young as 13, without their knowledge or consent.
A commission set up by the Danish and Greenlandic governments to investigate the programme is not due to deliver its findings until May 2025.
"We don't want to wait for the results of the inquiry," said psychologist Naja Lyberth, who initiated the compensation claim.
"We are getting older. The oldest of us, who had IUDs inserted in the 1960s, were born in the 1940s and are approaching 80. We want to act now."
Ms Lyberth said that, in some cases, the devices fitted had been too big for the girls' bodies, causing serious health complications or even infertility, while in others the women had been unaware of the devices until they were discovered recently by gynaecologists.
She accused the Danish government of the time of wanting to control the size of Greenland's population in order to save money on welfare.
"It's already 100% clear that the government has broken the law by violating our human rights and causing us serious harm," she said.
Read full story
Source: BBC News, 3 October 2023
Patient Safety Learning

Trust sent domestic abuse victim’s address to ex-partner, says regulator

A trust has been reprimanded by the Information Commissioner’s Office (ICO) for exposing a domestic abuse victim to risk by disclosing their address to an ex-partner.
University Hospitals Dorset Foundation Trust is one of only seven organisations in the UK – and the only NHS organisation – to have received a reprimand since July 2022 for a data breach involving a victim of domestic abuse.
According to new details released by the ICO, University Hospitals Dorset received a reprimand in April this year over a procedure it had in place that, when sending correspondence by letter, would include the full addresses of all recipients of that letter without their consent to do so.
In the case that was referred to the ICO, the subject of the data breach had their full address revealed to their ex-partner despite previous allegations of abuse, which has created a “risk of unwanted contact which will remain”.
The ICO concluded that, while the subject did not request their address be withheld, it would not be a reasonable expectation that personal information would be shared without prior consent.
The report raised concerns that UHD did not have a clear policy in place for managing situations where there are parental disputes and that no formal training was provided to administrative staff for dealing with such circumstances.
Read full story (paywalled)
Source: HSJ, 2 October 2023
Patient Safety Learning

Mum fears her son could die waiting for life changing surgery

The mother of a four-year-old boy with complex needs said she fears he could die waiting for life-changing surgery.
Collette Mullan made the claim to BBC Spotlight as it examined the scale of hospital waiting lists.
Northern Ireland has the worst waiting times in the UK, with more than half a million cases queued for an outpatient or inpatient appointment.
The Department of Health has described current waiting lists as "entirely unacceptable".
Óisín, from County Londonderry, has a number of health conditions including cerebral palsy, and is currently waiting for two procedures.
He is fed with a tube that carries his food through his nose into his stomach, but since it was inserted six months ago, his mum Collette said he has struggled to breathe.
Óisín is now waiting to have the nasogastric tube removed and replaced by a different feeding system which goes directly to his stomach.
Collette said she was told it could be a three-year wait for the procedure.
She is concerned that Óisín's cerebral palsy puts him at a greater risk of complications, saying she had been warned there was a danger he could aspirate.
"He could die. Anything going into his lung really, it could be very dangerous," she said.
Read full story
Source: BBC News, 3 October 2023
 
Patient Safety Learning

Murder detective among ex-police hired by NHS trust in move that could deter whistleblowers

Former police officers, including a murder detective, have been hired by NHS hospitals in a move that campaigners have warned risks discouraging whistleblowers.
The Sunday Telegraph has revealted that retired officers have been employed by a trust currently under scrutiny for its treatment of doctors who raise patient safety concerns.
One of them has taken up a patient safety incident investigator role worth up to £57,349 a year. Meanwhile a senior detective has been called into multiple trusts on an ad hoc basis to conduct investigations.
Last night a leading patient group called on the NHS to be transparent about exactly how such personnel are being used, “given the ongoing concerns about how such roles interact with whistleblowers”.
Paul Whiteing, chief executive of the charity Action Against Medical Accidents (AvMA), said: “We at AvMA welcome any steps taken by Trusts to professionalise the investigation of patient safety incidents. This is long overdue. 
“But given the on-going concerns about how such roles interact with whistleblowers, to maintain trust and confidence of all of the staff, trusts need to be clear, open and transparent about why they are making such appointments and the role and duties of those they employ to fulfil them, whatever their backgrounds.”
Campaigners have warned that some NHS trusts deliberately seek to conflate patient safety issues with staff workplace investigations.
Read full story (paywalled)
Source: The Telegraph, 30 September 2023
Patient Safety Learning

Trusts and ICBs asked to give ‘honest’ assessment of their ‘improvement culture’

Trust leaders have been asked to “self-assess” the quality of their “improvement culture” as part of an initiative launched by NHS England chief executive Amanda Pritchard in the spring to lead the service's new improvement drive.
The call came from NHS Impact, led by former Modernisation Agency chief David Fillingham, who along with NHS Impact’s deputy chair – University Hospitals Coventry and Warwickshire Foundation Trust CEO Andy Hardy – has written to service leaders, setting out the first stage in the improvement drive.
They have asked the boards and CEOs of trusts and integerated care boards to “engage directly” with a new self-assessment tool and maturity matrix created by NHS Impact. This is designed to gauge their progress on adopting the five practices that NHS IMPACT claim “form the DNA of an improvement culture”.
Those five practices are:
A shared purpose and vision which are widely spread and guide all improvement effort. Investment in people and in building an improvement focused culture. Leaders at every level who understand improvement and practise it in their daily work. The consistent use of an appropriate suite of improvement methods. The embedding of improvement into management processes so that it becomes the way in which we lead and run our organisations and systems. Read full story (paywalled)
Source: HSJ, 29 September 2023
.
Sam

Historical sexual harassment claims not acted on by doctors’ watchdog

More than 1 in 10 sexual harassment complaints against doctors are not investigated by the General Medical Council because of an “arbitary” rule, the Observer has revealed.
According to data obtained under the Freedom of Information Act, 13% of sexual misconduct complaints made between the years 2017-18 and 2021-22 were closed without investigation because the GMC is prevented from considering alleged incidents more than five years after the event.
As part of the council’s remit to protect patient safety and improve medical education and practice across the UK it investigates any kind of complaint against doctors.
The figures show the GMC refused to investigate 170 complaints relating to sexual assault, attempted rape, and rape in the period analysed. In 22 of those cases the five-year rule was cited. It received 566 sexual harassment complaints in the same period.
Anthony Omo, the GMC’s general counsel and director of fitness to practise, told the Observer: “We can and do waive the five-year rule where there are grave allegations involving sexual assault or rape. In many cases involving sexual allegations, the GMC’s position will be that such serious misconduct is incompatible with continued registration.”
A government consultation in February heard that the five-year-rule was “arbitrary” and “a barrier to public protection” as it allowed doctors who may be guilty of inappropriate behaviour to continue practising. However, despite commitments from the Department of Health and Social Care to scrap the limitation as a “top priority”, no date has been set.
Read full story
Source: The Guardian, 30 September 2023
Sam

Doctors used to diagnosing men may not spot 35,000 women with diabetes

Thousands of women may be missing out on a diagnosis of type 2 diabetes because the thresholds are geared towards men, research suggests.
Scientists assessed test results from more than one million patients across the country and concluded that the bar for diagnosis might be set too high for women. They calculated that, if thresholds were lowered slightly, an extra 35,000 women under the age of 50 in England would be diagnosed with type 2 diabetes — increasing the number in this age group with the condition by 17%.
Under the present guidelines, those 35,000 women would be given the all-clear and would miss out on the chance of earlier treatment and lifestyle advice, increasing their risk of complications in later life.
The team, led by doctors at the University of Manchester and including researchers from hospitals nationwide, stressed that their findings were preliminary, and needed further assessment before their hypothesis was confirmed. But, if proved correct, they believe that about 65 young women may be dying of diabetes each year without a diagnosis.
Read full story (paywalled)
Source: The Times, 1 October 2023
 
Patient Safety Learning

Nottingham University Hospitals Trust failed to send 400,000 letters

An NHS hospital trust in Nottingham failed to send more than 400,000 digital letters and documents to GPs and patients, BBC News can reveal.
A former employee has told of "a lack of responsibility" over a new computer system.
Patient body Healthwatch said it was "deeply concerned" by the scale of the incident and the impact on care.
The trust says a full investigation took place in 2017 and found no significant harm to patients.
But it has now said it will carry out a review of that investigation and take any further action needed.
The healthcare regulator the Care Quality Commission (CQC) said it was not aware of the incident and would be following up with the trust.
This is the second major incident in England involving unsent NHS letters uncovered by the BBC recently.
Read full story
Source: BBC News, 30 September 2023
Patient Safety Learning

NHS data breach: trusts shared patient details with Facebook without consent

NHS trusts are sharing intimate details about patients’ medical conditions, appointments and treatments with Facebook without consent and despite promising never to do so.
An Observer investigation has uncovered a covert tracking tool in the websites of 20 NHS trusts which has for years collected browsing information and shared it with the tech giant in a major breach of privacy.
The data includes granular details of pages viewed, buttons clicked and keywords searched. It is matched to the user’s IP address – an identifier linked to an individual or household – and in many cases details of their Facebook account.
Information extracted by Meta Pixel can be used by Facebook’s parent company, Meta, for its own business purposes – including improving its targeted advertising services.
Records of information sent to the firm by NHS websites reveal it includes data which – when linked to an individual – could reveal personal medical details.
It was collected from patients who visited hundreds of NHS webpages about HIV, self-harm, gender identity services, sexual health, cancer, children’s treatment and more.
It also includes details of when web users clicked buttons to book an appointment, order a repeat prescription, request a referral or to complete an online counselling course. Millions of patients are potentially affected.
Read full story
Source: The Guardian, 27 May 2023
Patient Safety Learning

GPs asked to contact ADHD patients to discuss medicines shortage

Prescribers should not start any new patients on some ADHD medicines because of a national shortage, the Department for Health and Social Care has warned.
GPs are also being asked to identify and contact all patients currently prescribed the medicines to ensure they have supplies to last.
A national patient safety alert said there were ‘supply disruptions’ of various strengths of methylphenidate, lisdexamfetamine and guanfacine.
It follows a previous alert about shortages of atomoxetine capsules in August which is set to resolve next month, DHSC said.
The shortages are due to a combination of manufacturing issues and an increased global demand, the alert explained.
With the latest issues expected to continue to December for some medicines, new patients should not be started on the products affected by shortages until the supply issue resolves, the guidance sent to healthcare professionals said.
Where patients do not have enough to last until the re-supply date – which differs depending on the medicine in question – GPs are being asked to contact pharmacies to find out about stocks and reach out to the patient’s specialist team for advice if a product cannot be sourced.
Read full story
Source: Pulse, 28 September 2023
Patient Safety Learning
Registered address: Patient Safety Learning, China Works SB203, 100 Black Prince Road Vauxhall, London, SE1 7SJ

Account

Navigation

Search

Search

Configure browser push notifications
Chrome (Android)
  1. Tap the lock icon next to the address bar.
  2. Tap Permissions → Notifications.
  3. Adjust your preference.
Chrome (Desktop)
  1. Click the padlock icon in the address bar.
  2. Select Site settings.
  3. Find Notifications and adjust your preference.