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

NHS staff to be asked about sexual harassment for the first time

NHS staff will be asked if they have experienced sexual harassment or inappropriate behaviour in the workplace for the first time.
In a letter, NHS England chief delivery officer Steve Russell said the upcoming annual staff survey would include the following question: “In the last 12 months, how many times have you been the target of unwanted behaviour of a sexual nature in the workplace? This may include offensive or inappropriate sexualised conversation (including jokes), touching or assault.”
Mr Russell said the anonymous answers to the new question would “help us understand the potential prevalence of sexual misconduct in your organisation and inform further action to protect and support staff across the NHS”. 
It comes as NHSE launches the health service’s first sexual safety charter to help protect staff from harassment and inappropriate behaviour.
The charter is an agreement comprising 10 pledges, including commitments to provide staff with clear reporting mechanisms, training, and support from managers.
Read full story (paywalled)
Source: HSJ, 6 September 2023
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The agony of women suffering with topical steroid withdrawal

Rhiannon Kennedy-Chapman’s early twenties could hardly be described as the best years of her life. Covered in grazes, open sores and dry skin, she was at a loss as to why her body was continuously failing her, despite her efforts to follow medical advice and take her steroid medication.
Having used both steroid cream and oral tablets since suffering from eczema as a child, she had little concern about the medication when she was once again prescribed it for small patches of eczema.
“It worked for a bit and then it would stop working. The GP would give me a higher dose and the pattern went on for many months. I went through four different strengths – it would work for a short period of time and when I stopped using it, it would come back even fiercer.
Little did she know that she was suffering from topical steroid withdrawal (TSW), a rare skin condition caused by the repeated use and cessation of steroid creams.
A 2021 report by the Medicines and Healthcare Products Regulatory Agency (MHRA) gave guidance on the risks of TSW and it is now included as patient information for all prescribed topical steroids.
Patients can now also report their suspected reactions to topical steroids via the MHRA’s “yellow card scheme” and eczema charities have called for further research into the causes and long-term effects of TSW.
Andrew Proctor, chief executive of the National Eczema Society, said it was calling on the UK medicines regulator, the MHRA, to introduce clearer strength and potency labelling of topical steroids to support their safe and effective use.
“This change needs to happen and is supported by patients and healthcare professional bodies,” he said.
Read full story
Source: The Independent, 5 September 2023
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Trust told it ‘lacks skills or integrity’ to carry out suicides review

A senior clinician has raised fundamental concerns about a trust’s probe into dozens of suicide cases, which was sparked by his allegations that staff had tampered with the notes of a patient.
Cambridgeshire and Peterborough Foundation Trust announced in July there would be an internal review of 60 suicide cases dating back to 2017.
But a key whistleblower told HSJ he fears it could be a “whitewash” and it should be carried by an external, independent investigator rather than led by the trust.
The suicides review was prompted by allegations staff had added a care plan into the patient record of a patient a day after the 33-year-old had died by suicide in 2017.
The allegations, not contested by the trust, were based on the findings of an internal investigation in 2021 of the trust’s conduct around the patient's case.
Read full story (paywalled)
Source: HSJ, 6 September 2023
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NHS ombudsman calls for Martha's rule to give power to patients

Top boss of NHS complaints in England has told the BBC he wants Martha's rule to be introduced to give patients the power to get an automatic second medical opinion about hospital care, when they think things are going wrong.
Rob Behrens said he had been moved by the plea of Merope Mills, who shared the story of her daughter's death.
Martha was 13 when she died from sepsis. 
Merope Mills wants hospitals around the country to bring in Martha's rule, which would give parents, carers and patients the right to call for an urgent second clinical opinion from other experts at the same hospital, if they have concerns about their current care.
It is something that Parliamentary and Health Service Ombudsman Rob Behrens fully supports.
He told BBC Radio 4's Today programme: "Along with many others, I was moved and in great admiration for what Merope has said and done and I give unambiguous support.
"Unfortunately, as tragic as this case is, it's not the first and there have been many cases where patients have been failed by their doctors because they haven't been listened to."
Read full story
Source: BBC News, 5 September 2023
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Hospitals to review concrete risks to ‘maintain safety and confidence’

NHS boards have been told to obtain extra assurance around the risks to unsafe concrete beams in their estate, following the sudden closure of school buildings.
HSJ understands there was a call between national leaders and trust bosses yesterday, to ensure there are additional assessments of the risks around “reinforced autoclaved aerated concrete” in the NHS estate.
As part of this, trusts which have already identified the beams in their buildings have been told to plan for potential “RAAC failure, including the decant of patients and services where RAAC panels are present in clinical areas”, and to note the learnings from an “evacuation plan” that was tested in the East of England.
Around 40 hospital buildings across 23 trusts are currently understood to be affected by these lightweight panels, which can be on roofs, floors and walls.
Trust estates’ teams will already have undertaken assessments and have plans to mitigate the risks, with the government already providing a £700m fund to mitigate immediate safety risks until 2025.
But in light of fresh concerns around RAAC planks in school buildings, national leaders have asked for additional assurances to be obtained.
Read full story (paywalled)
Source: HSJ, 5 September 2023
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Why are so many elderly patients abandoned by the NHS the minute they leave hospital?

Hospitals are sending frail, vulnerable patients home before they are better and without vital medical care, leaving them unable to fend for themselves.
Over the past fortnight, The Mail on Sunday has received an alarming number of letters from readers who have told of their anger, frustration and sheer desperation at being denied support they were promised. Many have been left bed-bound and unable to wash, dress or use the bathroom for weeks on end.
The daughter of an 87-year-old stroke survivor had to put a hospital bed in her living room and provide 24/7 care for her mother after the local health team failed to provide adequate support. Within a year, the woman was dead, having been treated with little more than paracetamol.
In another case, a 70-year-old woman had to take her immobile 84-year-old husband to the hospital in a taxi every day for several weeks to have vital injections, because carers refused to come to their home.
And the disabled wife of one 74-year-old man, who fell off a roof and broke his pelvis and ribs, told of the heartbreak at not being able to look after her husband due to her own poor health.
Campaigners say a Government scheme designed address the ‘problem’ of bed-blockers – the somewhat derogatory term used to describe patients, most of them elderly, who are occupying a hospital bed that they don’t strictly need – is to blame.
The protocol, called Discharge To Assess, launched eight years ago, aims to get patients home as quickly as possible amid reports that some elderly patients ended up stuck in wards for months on end – usually because the NHS hasn’t been able to organise the next stage of their care, so it’s not safe discharge them.
Read full story
Source: Mail Online, 2 September 2023
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Labour ward staffing shortages restrict use of beneficial drug

Staffing shortages are likely to restrict the use of a beneficial painkiller in birthing suites, even once its use has been recommended by national guidance.
Research by HSJ suggests that just over half of trusts are already offering remifentanil to women in labour, although some are having to restrict its use due to lack of staffing.
Responses to freedom of information requests from 108 trusts revealed 55 offered remifentanil during labour in 2022-23.
Recent draft National Institute for Health and Care Excellence guidance on intrapartum care, published in April, suggested healthcare professionals “consider intravenous remifentanil patient-controlled analgesia” in obstetric units. This is partly because it reduces the likelihood of forceps or ventouse being required compared to intramuscular pethidine (an opioid commonly used in labour).
However, the drug is not yet mentioned in official NICE guidelines and the opioid’s use in labour is currently off-label (its more common licenced use is alongside anaesthesia in surgery). A Royal College of Anaesthetists spokesperson said the use of drugs off-label “is extremely common in obstetrics given that drug trials do not often include pregnant women”.
Read full story (paywalled)
Source: HSJ, 1 September 2023
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Maine hospital under fire for threatening to sue family of teenager who shared patient safety concerns online

A not-for-profit health system in Maine has threatened legal action against a 15-year-old boy for shedding light on alleged patient safety issues in the paediatric ward of one of its hospitals.
Samson Cournane, a student at the University of Maine, started a petition (Patient Safety in Maine Matters) advocating for an investigation into Northern Light Eastern Maine Medical Center last year, claiming conditions at the hospital were unsafe.
Mr Cournane’s mother, Dr Anne Yered, had previously been fired from the hospital after reportedly voicing safety concerns to the hospital’s CEO and president in 2020.
In the petition, Mr Cournane said his mother was threatened by hospital staff after raising concerns, with one hospital manager going so far as to show up in her backyard to confront her. Dr Yered subsequently claimed she was wrongfully terminated.
Mr Cournane then began pushing for an investigation into the hospital, outlining problems in the petition, which was addressed to US Representative Jared Golden. He alleged that the medical director of the paediatric intensive care unit (ICU) — a former colleague of his mother’s — finished just one year of a three-year critical care fellowship, and implied other hospital employees may be scared to come forward with safety concerns.
Read full story
Source: The Independent, 4 September 2023
Sam

NHS ‘a long way’ from being ‘proactive’ on safety, watchdog warns

Integrated care systems (ICSs) should factor patient safety into all their operational and financial decisions, the Healthcare Safety Investigations Branch’s chief investigator has urged.
Rosie Benneyworth, who was appointed as interim chief investigator last summer, said other safety-critical industries made decisions on the basis of a “triad” of operations, finances and safety. She said the NHS needed to be “more proactive” to take action before things go wrong.
Dr Benneyworth said in an interview with HSJ: “I think it’s fundamental that ICSs put safety at the core of everything they do. And I don’t think operational decisions or financial decisions should be made without considering the implications for safety.”
Dr Benneyworth – a former GP and commissioner – also spoke about whistleblowing in the wake of the Lucy Letby scandal, saying national organisations should “lead the way” on being proactive over safety and supporting whistleblowers. Major cultural problems were uncovered at HSIB several years ago, while NHSE has been under the spotlight in recent weeks for implementation of the “fit and proper person” test for board members.
“I think it’s very difficult as national organisations to tell providers what they should [be] doing, if we’re not doing it ourselves,” Dr Benneyworth said.
She added: “What we need is a much more proactive approach to safety, where we actually identify those things that could go wrong and take action before they do go wrong."
Read full story (paywalled)
Source: HSJ, 5 September 2023
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Thousands of babies face hospitalisation with life-threatening virus this winter as government delays vaccine

Babies could be needlessly hospitalised this winter because the government has delayed a vaccine that protects them from a life-threatening virus, the UK’s top children’s doctor has warned.
Dr Camilla Kingdon, president of the Royal College of Paediatrics and Child Health (RCPCH), said she was “frustrated” by delays in introducing a new vaccine for respiratory syncytial virus (RSV), which drives 30,000 hospital admissions each winter and leads to dozens of deaths.
She warned the delay meant thousands of children’s operations will have to be cancelled as RSV patients fill up beds – piling further pressure on already soaring waiting lists.
It comes after the UK’s most senior A&E doctor, Dr Adrian Boyle, told The Independent that the government’s failure to prepare the NHS for winter could see thousands of people die needlessly this year.
The Joint Committee on Vaccination and Immunisation (JCVI) said in June that a rollout of two RSV vaccines, one for babies and one for pregnant women, would be “cost-effective”, while the UK Health Security Agency (UKHSA) said there was a “strong case” for a jab.
But it confirmed there was no timeframe for when vaccinations could start.
Read full story
Source: The Independent, 4 September 2023
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Hundreds of UK women can now take legal action over Essure device

Two hundred women in the UK who claim they were left in pain after having a permanent contraception device fitted, can now take group legal action through the courts, against its manufacturer.
The Essure coil "has caused irreparable damage physically and mentally", the women's lawyers say.
German maker Bayer says it will defend itself vigorously against the claims.
When Essure was withdrawn from sale, in 2017, the UK medicines regulator said there was no risk to safety.
Lawyers in England began legal action in 2020 and now have permission to bring a group claim on behalf of 200 women.
Other women wishing to join the group action have until 2024 to do so.
The Essure device is a small metal coil inserted into a woman's fallopian tubes. Scar tissue forms around the coil, creating a barrier that keeps sperm from reaching the eggs.
Launched in 2002, the device was marketed as a simpler alternative to sterilisation by surgery.
But some women say they suffered constant pain and complications, including heavy bleeding, with some ending up having hysterectomies or the device removed altogether.
Read full story
Source: BBC News, 5 September 2023
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New Zealand woman discovers surgical instrument ‘size of a dinner plate’ left in her body after operation

A woman who suffered chronic abdominal pain for 18 months after undergoing a caesarean section was found to have a surgical instrument the size of a dinner plate inside her abdomen.
The Alexis retractor, or AWR, was left inside the New Zealand mother after her baby was delivered at Auckland City Hospital in 2020.
Following initial investigations into the case, Te Whatu Ora Auckland, formerly Auckland District Health Board, claimed it had not failed to exercise reasonable skill and care towards the patient, who was in her 20s.
But on Monday, New Zealand’s Health and Disability Commissioner, Morag McDowell, found Te Whatu Ora Auckland in breach of the code of patient rights.
Read full story
Source: Guardian, 4 September 2023
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Sharp rise in wait times for perinatal mental health care in England

Campaigners have expressed alarm at new analysis showing a sharp increase in new or expectant mothers waiting for mental health care, with one woman found to have waited 319 days for a first appointment.
More than 30,000 women who are pregnant or have newly given birth are on waiting lists for mental health support, according to NHS England data analysed by Labour, with the party saying many of them were being left to “suffer in silence”.
Amid rising demand for what are known as perinatal mental health services, during the period from August 2022 to March 2023 the numbers of women waiting rose by 40%. Over that same period, the numbers who accessed support also rose, but only by 8%.
Read full story
Source: Guardian, 4 September 2023
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Botox providers in England facing stricter rules

The government could ban unlicensed providers of cosmetic treatments in England, in what industry bodies say would be the biggest shake-up in a generation.
Under the plans, anyone carrying out Botox, breast or butt lift injections would have to be trained and licensed, with their premises also inspected.
The proposals have been have been opened up for public consultation.
At present, healthcare professionals such as doctors, nurses and dentists carrying out non-surgical cosmetic procedures have to be trained and insured to do them as part of the requirements laid down by their regulatory bodies.
But there is no set training for beauty therapists and other non-professionals.
Read full story
Source: BBC News, 3 September 2023
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Martha's rule: Call for right to second opinion after tragic teen death

The parents of a teenager who died in hospital two years ago are calling for patients to be given the right to an urgent second opinion, if they feel their concerns are not being taken seriously by medical staff.
Martha Mills, who would have been 16 on Monday, died after failures in treating her sepsis at King's College Hospital. An inquest said she could have survived had her care been better.
Martha's mother, Merope, has helped the think tank Demos write a report which is calling on NHS England to urgently put in place Martha's rule.
This would "effectively formalise the idea of asking for a second opinion, from a different team outside the team currently looking after you if you feel you are not being listened to", she said.
She added that asking for a second opinion when there is a deterioration "shouldn't be a problem and it shouldn't involve confrontation".
It might be that a patient or family could escalate to another team over the phone to get an urgent critical care review.
Read full story
Source: BBC News, 4 September 2023
 
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USA: Dangers and deaths around black pregnancies seen as a ‘completely preventable’ health crisis

Tonjanic Hill was overjoyed in 2017 when she learned she was 14 weeks pregnant. Despite a history of uterine fibroids, she never lost faith that she would someday have a child.

But, just five weeks after confirming her pregnancy she seemed unable to stop urinating. She didn’t realize her amniotic fluid was leaking. Then came the excruciating pain.
“I ended up going to the emergency room,” said Hill, now 35. “That’s where I had the most traumatic, horrible experience ever.”
An ultrasound showed she had lost 90% of her amniotic fluid. Yet, over the angry protestations of her nurse, Hill said, the attending doctor insisted Hill be discharged and see her own OB-GYN the next day. The doctor brushed off her concerns, she said. The next morning, her OB-GYN’s office rushed her back to the hospital. But she lost her baby.
Black women are less likely than women from other racial groups to carry a pregnancy to term — and in Harris County, where Houston is located, when they do, their infants are about twice as likely to die before their 1st birthday as those from other racial groups. Black fetal and infant deaths are part of a continuum of systemic failures that contribute to disproportionately high Black maternal mortality rates.
“This is a public health crisis as it relates to Black moms and babies that is completely preventable,” said Barbie Robinson, who took over as executive director of Harris County Public Health in March 2021. “When you look at the breakdown demographically — who’s disproportionately impacted by the lack of access — we have a situation where we can expect these horrible outcomes.”
Read full story
Source: KFF Health News, 24 August 2023
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