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

‘We’ve got no magic fix’ admits director of trust with ‘culture of fear’

The deputy leader of a trust rated ‘inadequate’ by a health watchdog four times in the past decade has admitted the necessary changes to its culture may take a further four years.
Norfolk and Suffolk Foundation Trust staved off calls to break it up earlier this year after the Care Quality Commission raised its rating from “inadequate” to “requires improvement”.
However, it has come under increased scrutiny in recent months after a review found it lost track of patient deaths, and a subsequent BBC Newsnight investigation discovered the report was edited to remove criticism of its leadership.
The BBC found earlier drafts removed references to a “culture of fear” highlighted by some staff.
Now deputy CEO Cath Byford has addressed growing concerns about the morale of staff working at the organisation, and their ability to speak up, at a meeting of Norfolk County Council’s health overview and scrutiny committee.
During the meeting, she revealed the results of an anonymous survey which received 18,000 staff interactions. Most feedback was “not positive” admitted Ms Byford.
She said many staff reported bullying and harassment, unfairness, inequality, and nepotism. This was particularly the case in recruitment, with staff feeling jobs were being lined up for certain individuals.
Read full story (paywalled)
Source: HSJ, 15 September 2023
Patient Safety Learning

Sick children’s health worsening as record numbers wait for NHS care in England

Sick children’s health problems are getting worse as record numbers wait up to 18 months for NHS care, doctors treating them have warned.
The number of under-18s on the waiting list for paediatric care in England has soared to 423,500, the highest on record. Of those, 23,396 have been forced to wait over a year for their appointment.
Delays facing children and young people are now so common that Dr Jeanette Dickson, the chair of the Academy of Medical Royal Colleges, the body representing all UK doctors professionally, warned that children are “the forgotten casualties of the NHS’s waiting list crisis”.
“As a paediatrician, I’ve seen first hand the damaging impact that long waiting times have on children, on their education and overall wellbeing, and of course on their families,” said Dr Camilla Kingdon, the president of the Royal College of Paediatrics and Child Health (RCPCH).
The figures came from the RCPCH’s analysis of official performance data recently published by NHS England.
The health of some children was deteriorating while they languished on the waiting list because their illness and age meant they needed to have their treatment fast, Kingdon added. “Many treatments and interventions must be administered within specific age or developmental stages. No one wants to wait for treatment, but children’s care is frequently time-critical.”
Read full story
Source: The Guardian, 17 September 2023
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Unvaccinated children to face isolation for 21 days during measles surge

Children who have not been vaccinated against measles may have to enter isolation for 21 days if a classmate becomes infected.
The UK Health Security Agency (UKHSA) predict the capital alone could see 160,000 cases occur as measles, mumps and rubella (MMR) vaccination rates are at the lowest in a decade.
Both Haringey and Barnet Council wrote to parents to tell them any unvaccinated child who comes into close contact with a measles case could be asked to self-isolate for up to 21 days.
This week statistics from NHS England show that across the country more than 102,000 children aged four and five starting in reception are not protected against catching measles, mumps and rubella.
32,000 children in London alone aren’t vaccinated, reveal NHS England, and just three-quarters of children in the capital have received the two required doses of the MMR jab, which protects against measles. This is 10% lower than the national average.
Measles is highly infectious and if left unvaccinated nine out of ten children in a classroom will catch the disease if just one child is infectious.
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Source: The Independent, 15 September 2023
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Derby and Burton's maternity services among 'most challenged in England'

Derby and Burton’s maternity services are now among the “most challenged in England”, requiring national involvement to boost improvements. The University Hospitals of Derby and Burton NHS Foundation Trust joins 31 other NHS trusts across England which are now under closer scrutiny aimed at improving the quality of maternity services.
A report from the trust details that it asked to be added to the national NHS England Maternity Safety Support Programme (MSSP) "voluntarily". Midwifery and obstetric improvement advisors have now been allocated to the trust to spend two days a week on the trust’s sites and also to provide “virtual” assistance.
A letter to Stephen Posey, the trust’s chief executive, sent by Sascha Wells-Munro, the deputy chief midwifery officer for NHS England, details that the organisation’s addition to the national support programme comes after a number of concerning reports – not just its request. It references the Healthcare Safety Investigation Branch report, published in February, which highlighted the cases of seven women and their babies between January 2021 and May 2022, with three mothers and a baby dying and four mothers suffering extreme consequences.
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Source: Derbyshire Live, 13 September 2023
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Improve NHS mental health funding or more children will die by suicide, says coroner

A London coroner has warned the health secretary that preventable child suicides are likely to increase unless the government provides more funding for mental health services.
Nadia Persaud, the east London area coroner, told Steve Barclay that the suicide of Allison Aules, 12, in July 2022 highlighted the risk of similar deaths “unless action is taken”.
In a damning prevention of future deaths report addressed to Barclay, NHS England and two royal colleges, Persaud said the “under-resourcing of CAMHS [child and adolescent mental health services] contributed to delays in Allison being assessed by the mental health team”.
An inquest into Allison’s death last month found that a series of failures by North East London NHS foundation trust (NELFT) contributed to her death.
In her report, Persaud said delays and errors that emerged in the inquest exposed wider concerns about funding and recruitment problems in mental health services.
“The failings occurred with a children and adolescent mental health service which was significantly under-resourced. Under-resourcing of CAMHS services is not confined to this local trust but is a matter of national concern,” she said.
Read full story
Source: The Guardian, 14 September 2023
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Consumer genetic test results ‘causing unnecessary breast cancer alarm’

Women are being unnecessarily alarmed about their risk of breast cancer by consumer genetic test results that do not take family history into account, researchers have said.
Women who discover outside a clinical setting that they carry a disease-causing variant of the BRCA1 or BRCA2 genes may be told that their risk of breast cancer is 60-80%. But analysis of UK Biobank data suggests the risk could be less than 20% for those who do not have a close relative with the condition.
Dr Leigh Jackson, of the University of Exeter’s medical school, who is the lead author of the analysis published in the journal eClinical Medicine, said that in extreme cases this could result in women unnecessarily undergoing surgery.
“Being told you are at high genetic risk of disease can really influence levels of fear of a particular condition and the resulting action you may take,” he said. “Up to 80% risk of developing breast cancer is very different from 20%.”
Until recently, women who received BRCA results did so because they had attended clinic due to symptoms or a family history of disease. However, an increasing number are now learning of their genetic risk after paying for home DNA testing kits or taking part in genetic research, without ever having any personal link with breast cancer. 
Read full story
Source: The Guardian, 15 September 2023
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Staff feel ‘frozen out and ignored’ at ‘inadequate’ services

Leaders of two maternity services have been told to take urgent action, after inspectors found understaffing and declining levels of care, despite safety warnings from midwives. 
Maternity services at University Hospital North Durham and Darlington Memorial Hospital have been downgraded from “good” to “inadequate” in Care Quality Commission reports, published today. 
The CQC noted a “concerning deterioration” in the care the two services provided, despite midwives telling managers they felt the service was unsafe.
Sue Jacques, chief executive of County Durham and Darlington Foundation Trust, which runs the hospitals, said the CQC’s findings would be taken “extremely seriously”.
The reports also said staff reported “feeling ‘frozen out’ or that their concerns were ignored by leaders” and that staff felt “‘continuity of carer’ was the trust’s main focus, despite depleted safe staffing levels, skill mix, and staff being pulled in to cover acute areas on a frequent basis”. Last year, trusts were told not to pursue continuity of carer models – which were previously championed by NHS England – unless they had adequate staffing levels to do so safely. 
Read full story (paywalled)
Source: HSJ, 15 September 2023
Patient Safety Learning

Global stakeholders agree to a new charter on patient safety rights

The WHO-hosted global conference on patient safety and patient engagement concluded yesterday with agreement across a broad range of stakeholders on a first-ever Patient safety rights charter. It outlines the core rights of all patients in the context of safety of healthcare and seeks to assist governments and other stakeholders to ensure that the voices of patients are heard and their right to safe health care is protected. 
“Patient safety is a collective responsibility. Health systems must work hand-in-hand with patients, families, and communities, so that patients can be informed advocates in their own care, and every person can receive the safe, dignified, and compassionate care they deserve,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “Because if it’s not safe, it’s not care.”
"Our health systems are stronger, our work is empowered, and our care is safer when patients and families are alongside us,” said Sir Liam Donaldson, WHO Patient Safety Envoy. “The journey to eliminate avoidable harm in health care has been a long one, and the stories of courage and compassion from patients and families who have suffered harm are pivotal to driving change and learning to be even safer." 
The global conference on patient engagement for patient safety was the key event to mark World Patient Safety Day (WPSD) which will be observed on 17 September under the theme “Engaging patients for patient safety”. Meaningful involvement of patients, families and caregivers in the provision of health care, and their experiences and perspectives, can contribute to enhancing health care safety and quality, saving lives and reducing costs, and the WPSD aims to promote and accelerate better patient and family engagement in the design and delivery of safe health services. 
At the conference, held on 12 and 13 September, WHO unveiled two new resources to support key stakeholders in implementing involvement of patients, families and caregivers in the provision of health care. Drawing on the power of patient stories, which is one of the most effective mechanisms for driving improvements in patient safety, a storytelling toolkit will guide patients and families through the process of sharing their experiences, especially those related to harmful events within health care. The Global Knowledge Sharing Platform, created as part of a strategic partnership with SingHealth Institute for Patient Safety and Quality Singapore, supports the exchange of global resources, best practices, tools and resources related to patient safety, acknowledging the pivotal role of knowledge sharing in advancing safety.
“Patient engagement and empowerment is at the core of the Global Patient Safety Action Plan 2021–2030. It is one of the most powerful tools to improve patient safety and the quality of care, but it remains an untapped resource in many countries, and the weakest link in the implementation of patient safety measures and strategies. With this World Patient Safety Day and the focus on patient engagement, we want to change that”, said Dr Neelam Dhingra, head of the WHO Patient Safety Flagship.
Read full story
Source: WHO, 14 September 2023
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Women 'failed at every stage' of maternity care with 'many made to feel they were to blame'

Women are being "failed at every stage" when it comes to maternity care, say campaigners, as they call for more support for those experiencing traumatic births.
Mumsnet found 79% of the 1,000 women who answered their questionnaire had experienced some form of birth trauma, with 53% saying it had put them off from having more children.
And according to the snapshot of UK mothers, 44% also said healthcare professionals had used language implying they were "a failure or to blame" for what happened.
Conservative MP Theo Clarke is leading calls for more action after her own experience, where she thought she was "going to die" after suffering a third degree tear and needing emergency surgery.
Now, she has set up an all party parliamentary group on birth trauma.
She said: "[It is] clear that more compassion, education and better after-care for mothers who suffer birth trauma are desperately needed if we are to see an improvement in mums' physical wellbeing and mental health.
"It is vitally important women receive the help and support they deserve."
Chief executive of Mumsnet, Justine Roberts, said the trauma had "long-lasting effects", adding: "It's clear that women are being failed at every stage of the maternity care process - with too little information provided beforehand, a lack of compassion from staff during birth, and substandard postnatal care for mothers' physical and mental health."
Read full story
Source: Sky News, 15 September 2023
Patient Safety Learning

‘Staggering’ paper use revealed as NHS told electronic records safer

The NHS still relies heavily on paper notes, with experts warning they are not as safe or efficient as electronic records.
It comes after a survey by the British Medical Journal (BMJ) found the majority of NHS trusts are still using paper, despite 88% of all trusts in England being equipped with electronic patient record (EPR) systems.
Of 182 trusts, 4% said they only use paper notes, while 25% are fully electronic. Some 71% use both paper and an EPR system.
Of the 172 trusts that responded to questions on prescriptions, 9% said they only use paper drug charts, 27% are fully electronic, and 64% use a mixture.
Writing for the BMJ, freelance journalist and doctor Jo Best argued that the continued reliance on paper is less safe and efficient, while difficulties around sharing electronic records could be preventing even the most advanced trusts from realising their full potential.
Read full story
Source: The Independent, 14 September 2023
Patient Safety Learning

Millions of women in UK face severe period pain but symptoms dismissed

Millions of women and girls experience debilitating periods, yet nearly one-third never seek medical help, and more than half say their symptoms are not taken seriously, according to research.
A survey of 3,000 women and girls for the Wellbeing of Women charity found that they are often dismissed as “just having a period”, despite experiencing severe pain, heavy bleeding and irregular cycles that can lead to mental health problems.
Almost all of those surveyed, who were between 16 and 40 years old and based in the UK, had experienced period pain (96%), with 59% saying their pain was severe. 91% had experienced heavy periods, with 49% saying their bleeding was severe. 
Prof Dame Lesley Regan, the chair of Wellbeing of Women, said: “It’s simply unacceptable that anyone is expected to suffer with period symptoms that disrupt their lives, including taking time off school, work, or their caring responsibilities, all of which may result in avoidable mental health problems.

“Periods should not affect women’s lives in this way. If they do, it can be a sign of a gynaecological condition that requires attention and ongoing support – not dismissal.”
Wellbeing of Women has launched its “Just a Period” campaign, which Regan said aims to address “the many years of medical bias, neglect and stigma in women’s health”. This includes tips on how to get the most out of seeing your GP and what women should do if they feel they have been dismissed.
Read full story
Source: The Guardian, 14 September 2023
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NHS waiting list in England rises to record 7.7m

A record 7.68 million people are on a hospital waiting list in England, figures show.
The total at the end of July represents nearly one in seven people and is a jump of more than 100,000 in a month.
The rising number means the prime minister's pledge to bring down waiting lists is under threat. The government has blamed strikes for adding to the pressures facing the NHS.
It comes as ministers have announced an extra £200m for the NHS this winter.
Health Secretary Steve Barclay said he wanted to see "high impact" interventions to help the NHS get through winter.
Read full story
Source: BBC News, 14 September 2023
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A&E handover delays ‘still getting worse at some hospitals’

Ambulance chiefs say handover delays have got worse at some trusts in recent months, despite the picture improving nationally since last winter.
A report from the Association of Ambulance Chief Executives says there are continuing concerns about handover delays at emergency departments.
Jason Killens, the body’s lead chief executive for operations, told HSJ: “There’s been some improvement [at some sites] since February, but what we’ve also seen is a commensurate or bigger decay in other sites across that same period.”
Mr Killens said “it’s difficult to be precise” about why some trusts have struggled more than others but that challenged hospitals are often affected by “pathway issues” including delayed discharges.
“And then maybe there are challenges around stable leadership or the visibility of the leadership, the culture there about managing that risk dynamically, and so on,” he added.
Read full story (paywalled)
Source: HSJ, 14 September 2023
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Health Secretary backs Martha’s Rule giving right to second medical opinion

The government has backed Martha’s rule, a campaign to give families and patients the right to a second assessment if they feel their concerns are not being taken seriously.
Health secretary Steve Barclay said ministers are “committed” to implementing the rule, insisting the case for it is “compelling”.
Martha Mills died after developing sepsis while under the care of King’s College Hospital NHS Foundation Trust in south London.
Mr Barclay said the case set out by Ms Mills, was “compelling”.
“For everyone that has heard it, it is an absolutely heartbreaking case,” he told the BBC.
Mr Barclay said: “I’m determined that we ensure we learn the lessons from it and very keen to learn from best international practice.”
Mr Barclay said there are “international lessons”, particularly from Ryan’s Rule in Australia, giving patients a direct line to a second opinion.
“And I particularly want to give much more credence to the voice of patients,” Mr Barclay said.
He added: “I think a key part of this measure is ensuring that patients feel heard and can get a second opinion.”
Read full story
Source: The Independent, 14 September 2023
Patient Safety Learning

Launch of new centre to promote patient safety in NI

A new regional centre which promotes the reporting of suspected safety concerns associated with healthcare products has been launched in Northern Ireland.
The Yellow Card centre for Northern Ireland will bring together a dedicated team to increase awareness, educate, and promote reporting of suspected adverse events to the Medicines and Healthcare products Regulatory Agency (MHRA) Yellow Card scheme.
The Yellow Card scheme provides a mechanism for patients, care givers and healthcare staff to report suspected safety concerns associated with healthcare products.
Speaking at the launch of the new service, Northern Ireland Chief Pharmaceutical Officer Professor Cathy Harrison said: “Collecting and monitoring information on possible adverse effects of medications and healthcare products is vital to ensuring patient safety.
"It is fitting that the launch of the Yellow Card centre for Northern Ireland coincides with World Patient Safety Day on 17 September, with this year’s theme of "Engaging patients for patient safety".
"The Yellow Card scheme puts the patient voice at its heart. By voluntarily reporting issues, patients, families and care givers can play a crucial role in their own care, and the safety of healthcare as a whole. I welcome the launch of the new regional centre and would encourage anyone who has suspected safety concerns to report them.”
Read full story
Source: Department of Health (Northern Ireland), 13 September 2023
Patient Safety Learning

Trusts admit ‘severe’ harm to children

Children have suffered severe harm at two further hospital trusts as a result of failures in paediatric audiology, HSJ has revealed.
HSJ reported in July that three children at Croydon Health Service Trust may have come to “severe harm” – meaning they may have suffered permanent damage – following failures in the trust’s processes in audiology.
Now East and North Hertfordshire Trust and North West Anglia Foundation Trust have also confirmed a small number of cases of severe or serious harm; while some trusts have yet to confirm findings from case reviews they have carried out.
Major problems emerged earlier this year, initially in Scotland, of poor quality checks missing children with hearing problems who should have received support, and of a failure to inspect the services.
NHS England ordered a review of data from the national newborn screening programme which, alongside other review work, identified six English trusts as having likely failures in their service: Croydon, East and North Herts, North West Anglia, Warrington and Halton Hospitals, North Lincolnshire and Goole, and Worcestershire Acute Hospitals.
Read full story (paywalled)
Source: HSJ, 14 September 2023
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