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More than 3,000 patients have died following incidents in Irish health service since 2018

More than 3,000 patients have died following incidents in the Irish health service since 2018, new data shows.
New HSE data shows more than 480,000 incidents potentially causing harm were recorded across hospitals and community healthcare groups since 2018. These include falls, attacks on patients or staff, problems with medication, treating the wrong limb, or reactions to medical devices, among other issues.
Last year’s total of 106,967 was the highest of five years recorded, up from 94,422 in 2018.
While around half the incidents annually led to no injury, last year 0.65% or 556 led to a death. That stood at 0.59% or 557 deaths in 2018.
A spokesperson for the Irish Nurses and Midwives Organisation (INMO) said the figures are very high, but not surprising.
“Hospitals are not supposed to be dangerous places," she said.
"No matter how highly skilled your staff are, patient safety issues and the risk of missed care incidents are inevitable in a situation where patients are lining corridors on trolleys and there aren’t enough staff to care for them."
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Source: Irish Examiner, 18 August 2023
Sam

Nurse Lucy Letby guilty of murdering seven babies on neonatal unit

Nurse Lucy Letby has been found guilty of murdering seven babies on a neonatal unit, making her the UK's most prolific child serial killer in modern times.
The 33-year-old has also been convicted of trying to kill six other infants at the Countess of Chester Hospital between June 2015 and June 2016.
Letby deliberately injected babies with air, force fed others milk and poisoned two of the infants with insulin.
Commenting on the verdict, Parliamentary and Health Service Ombudsman Rob Behrens said:
“We know that, in general, people work in the health service because they want to help and that when things go wrong it is not intentional. At the same time, and too often we see the commitment to public safety in the NHS undone by a defensive leadership culture across the NHS.
“The Lucy Letby story is different and almost without parallel, because it reveals an intent to harm by one individual. As such, it is one of the darkest crimes ever committed in our health service. Our first thoughts are with the families of the children who died. 
“However, we also heard throughout the trial, evidence from clinicians that they repeatedly raised concerns and called for action. It seems that nobody listened and nothing happened. More babies were harmed and more babies were killed. Those who lost their children deserve to know whether Letby could have been stopped and how it was that doctors were not listened to and their concerns not addressed for so long. Patients and staff alike deserve an NHS that values accountability, transparency, and a willingness to learn.  
“Good leadership always listens, especially when it’s about patient safety. Poor leadership makes it difficult for people to raise concerns when things go wrong, even though complaints are vital for patient safety and to stop mistakes being repeated. We need to see significant improvements to culture and leadership across the NHS so that the voices of staff and patients can be heard, both with regard to everyday pressures and mistakes and, very exceptionally, when there are warnings of real evil.”
Sam

The huge growth in long-term prescription of strong painkillers

Almost 180,000 patients have been prescribed strong painkillers every month for two years, a rise of over a third compared to levels recorded just before the pandemic, data obtained by HSJ shows.
The figures collected by the NHS Business Services Authority showed 179,353 patients had been prescribed an opioid analgesic every month between April 2021 and March 2023, a 36% increase compared with 131,876 receiving the same prescription between April 2017 and March 2019. 
Guidelines issued by the National Institute for Health and Care Excellence in 2021 advised clinicians not to prescribe opioids to manage chronic pain. A statement published alongside an earlier draft of these guidelines explained: “While there was little or no evidence that they made any difference to people’s quality of life, pain or psychological distress, there was evidence that they can cause harm, including possible addiction.”
In 2020, the Medicines and Healthcare Products Regulatory Agency asked healthcare professionals to discuss the risks of dependency and addiction with any patient taking or planning to take an opioid-containing medicine and made sure such warnings were reinforced in the patient information leaflet. The regulator at the time defined long-term use as longer than three months.
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Source: HSJ, 18 August 2023
Patient Safety Learning

Medical neglect by London NHS trust contributed to suicide of girl, 12, rules coroner

Medical neglect and “gross failures” by a mental health trust contributed to the suicide of a 12-year-old girl in a case that has highlighted national concerns about underfunding, a coroner has ruled.
Allison Aules from Redbridge, in north-east London, died in July last year after her mood changed completely during the Covid lockdown, her family told the inquest at an east London coroner’s court.
At the conclusion of the inquest, the area coroner Nadia Persaud highlighted a series of failures by North East London NHS foundation trust (NELFT) that contributed to her death. In a narrative verdict she ruled it was a “suicide contributed to by neglect”.
Persaud also said failures in Allison’s care raised wider national issues about under-resourcing and “outstanding concerns” about the lack of consultant psychiatrists.
These will be addressed later in a prevention of future deaths report. Persaud told the court: “There are national concerns around children and adolescent mental health services … and I’m also going to write a report at the national level to reduce the risk of this happening again.”
Persaud said Allison’s case showed “both operational failures of individual practitioners and systemic failings on behalf of the trust”. She added: “This was on a backdrop of a very under-resourced service.”
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Source: The Guardian, 17 August 2023
Patient Safety Learning

Mesh bowel patients call for publication of Bristol Spire Hospital report

Patients whose lives were damaged by surgery for bowel problems are calling for a long-awaited report to be published.
More than 200 patients underwent mesh bowel operations in Bristol that they might not have needed.
The surgery was carried out by Tony Dixon at Southmead Hospital and the private Spire Hospital, in Redland.
A review by North Bristol NHS Trust was published in May 2022, but patients are still waiting to hear from Spire.
Jill Smith, 69, from Westbury-on-Trym, paid privately to go to Spire. She said she is still in severe pain following her surgery.
"Emotionally it has affected me big time. It is just horrible," she said. "The stress and panic I get going anywhere, is, 'will I have an accident or something?'."
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Source: BBC News, 18 August 2023
Patient Safety Learning

Met wins battle with NHS over not attending mental health calls

The Metropolitan police has won its battle to stop attending most of the mental health calls it receives after a tense behind-the-scenes row with the health service, the Guardian has learned.
From 31 October the Met will start implementing a scheme that aims to stop officers being diverted from crime fighting to do work health staff are better trained for.
In May, the Guardian revealed that the Met commissioner, Sir Mark Rowley, had written to health and social care leaders setting a deadline of 31 August – leading to furious reaction from health chiefs who wrote to the commissioner protesting that it would put vulnerable people at risk.
The agreement means Rowley will push his deadline for the start of the changes back by two months, before a phased introduction. Health services will not publicly criticise the police decision, and will race to put measures in place to pick up the work.
The scheme is called Right Care Right Person (RCRP), and has been agreed nationally by government departments and national police and health bodies.
The letter sent on Thursday says: “In practice, this means that police call handlers will receive a new prompt relating to welfare checks or when a patient goes absent from health partner inpatient care. The prompt will ask call handlers to check that a police response is required or whether the person’s needs may be better met by a health or care professional.”
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Source: The Guardian, 17 August 2023
 
Patient Safety Learning

Covid vaccines should be available to buy privately in UK, scientists say

Covid vaccines should be made available for people to buy privately in Britain, leading scientists have urged, amid concerns over a new wave of the virus which could worsen in autumn and winter.
Unlike flu jabs, which individuals or employers can buy for about £15 from high street pharmacies, Covid jabs are only available on the NHS in the UK.
This month the UK government announced that the Covid autumn booster programme would cover a smaller pool of the population than earlier vaccination drives. The age limit has been raised from 50 to 65 and above, with some younger vulnerable groups also eligible.
Covid is on the rise, according to the UK Health Security Agency (UKHSA). Experts raised concerns the wave could continue to grow and add to winter pressures on the NHS.
Prof Adam Finn, of the University of Bristol, a member of the UK’s Joint Committee on Vaccination and Immunisation (JCVI), said Covid jabs should be available commercially. Some employers might want to offer the vaccines to their staff, he added.
Speaking in a personal capacity, Finn said: “I think it will be a good idea for vaccines to be made available to those that want them on the private market. I don’t really see any reason why that shouldn’t be happening.”
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Source: The Guardian, 17 August 2023
Patient Safety Learning

NHS cancer standards reform to speed up diagnosis for patients

Thousands of people referred for urgent cancer checks every month are set to be diagnosed and treated sooner, as the NHS reforms its cancer standards to reflect what matters most to patients and to align with modern clinical practice.
Developed by clinical experts and supported by leading cancer charities, there will be three cancer standards, which combine all of the previous standards and cover additional patients:
the 28-Day Faster Diagnosis Standard (FDS) which means patients with suspected cancer who are referred for urgent cancer checks from a GP, screening programme or other route should be diagnosed or have cancer ruled out within 28 days. the 62-day referral to treatment standard which means patients who have been referred for suspected cancer from any source and go on to receive a diagnosis should start treatment within 62 days of their referral. the 31-day decision to treat to treatment standard which means patients who have a cancer diagnosis, and who have had a decision made on their first or subsequent treatment, should then start that treatment within 31 days. GPs will still refer people with suspected cancer in the same way, but the focus will rightly be on getting people diagnosed or cancer ruled out within 28 days, rather than simply getting a first appointment.
The three agreed standards will come into effect from October.
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Source: NHS England, 17 August 2023
Patient Safety Learning

Staff ‘let down by leaders’ as ‘chaotic’ service gets double downgrade

A teaching trust has had its maternity services downgraded to ‘inadequate’ after inspectors found stillbirths and massive haemorrhages were not being treated as ‘serious incidents’.
Maternity services at St George’s University Hospitals Foundation Trust in south London were previously inspected in 2016, when they were assessed as “good”.
The Care Quality Commission (CQC) said serious incident declaration meetings at St George’s were regularly classing serious incidents as “adverse incidents”, meaning executives were not informed and there were missed opportunities for learning and development.
Inspectors also found incidents such as severe perineal tears, emergency hysterectomy, and birth injuries were rated as causing low or no harm when a higher level would have been appropriate, or and sometimes downgraded from a higher rating.
Carolyn Jenkinson, CQC’s deputy director of secondary and specialist healthcare, said: “We saw areas where significant and urgent improvements are needed to ensure safe care is provided to women, people using this service, and their babies.
“Both staff and people using the service were being let down by leaders who failed to respond quickly, resulting in care that was unsafe, and in the delivery suite, also chaotic.”
Read full story (paywalled)
Source: HSJ, 17 August 2023
Patient Safety Learning

‘Warts and all’ references for NHS leaders ‘may be attacked’

NHS England could have gone further to insist that errors and failures by senior NHS leaders are disclosed to future employers, according to the leading barrister who reviewed the NHS’s fit and proper person test (FPPT).
Tom Kark KC’s review of the FPPT was delivered to government five years ago and made public the following year, and changes were finally proposed by NHSE earlier this month. 
In an interview with HSJ, Mr Kark said he broadly welcomed the plans, and that the revised framework should provide greater consistency across NHS boards “if applied correctly”; and could “strengthen the hand” of chairs and chief executives.
Part of the purpose of the regime is to prevent senior managers and other board members who make big errors in one role, from keeping this secret from a future employer.
Mr Kark told HSJ he had heard evidence that when “someone leaves under a cloud, they pop up somewhere else, and the information is lost.”
Read full story (paywalled)
Source: HSJ, 16 August 2023
Patient-Safety-Learning

Government reports on 'overdue' major conditions strategy

The Government must provide the health service with more support to fulfil its ambition of extending healthy life expectancy and reducing premature death, an expert has warned.
It comes after the Department for Health and Social Care (DHSC) published an interim report on its Major Conditions Strategy, a 5-year blueprint to help manage six disease groups more effectively and tackle health inequality.
The groups are cancer, cardiovascular disease – including stroke and diabetes – musculoskeletal conditions, chronic respiratory diseases, mental health conditions and dementia. The Government said the illnesses "account for over 60% of ill health and early death in England", while patients with two or more conditions account for about 50% of hospital admissions, outpatient visits, and primary care consultations. By 2035, two-thirds of adults over 65 are expected to be living with two or more conditions, while 17% could have four or more.
Sally Gainsbury, Nuffield Trust senior policy analyst, said the Government is right to focus on the six conditions, but "will need to shift more of its focus towards primary prevention, early diagnosis, and symptom management". She added: "What's less clear is how Government will support health and care systems to do this in the context of severe pressures on staff and other resources, as well as a political culture that tends to place far more focus on what happens inside hospitals than what happens in community healthcare services, GP practices and pharmacies. This initiative is both long overdue and its emphasis has shifted over time. The Major Conditions Strategy is being developed in place of a White Paper on health inequalities originally promised over 18 months ago."
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Source: Medscape, 16 August 2023
Patient-Safety-Learning

Addiction treatment eludes more than half of Americans in need

Roughly three in 10 adults have been addicted to opioids or have a family member who has been, and less than half of those with a substance use disorder have received treatment, according to a new survey conducted by KFF, a health policy research group.
The survey, which polled more than 1,300 adults in July, underscores the broad and often harmful influence of opioid addiction across the nation, which recorded around 110,000 fatal drug overdoses last year alone.
And the findings suggest that some proven medications for helping curb drug cravings, such as buprenorphine and methadone, are still not getting to those who need them. Only 25 percent of participants in the poll who said they or someone in their family had an opioid addiction reported receiving medication for themselves or family members.
Mollyann Brodie, the executive director of KFF’s polling program, said that the numbers might be an undercount, as some survey participants might have been hesitant to share histories of opioid addiction.
Addiction cuts across class, race and geography, the KFF researchers found. Rural and white Americans were the likeliest to report personal or family opioid addiction, but significant percentages of Black, Hispanic, urban and suburban families did, as well. White families were more likely than Black or Hispanic families to say that they had received treatment. Overdose fatality rates among Black Americans have climbed substantially in recent years, the Centers for Disease Control and Prevention found in a study last year.
Dr. David Fiellin, an addiction physician at the Yale School of Medicine, said the survey showed the need for a stronger federal response to substance use disorders, akin to the one for AIDS. He said, “There’s often a misunderstanding of what treatment actually looks like and what it is—people often look to a quick fix,” he said, referring to a detox strategy. “Effective treatment tends to be much more long term and requires addressing the denial that can be part of the condition.”
Read full story (paywalled)
Source: New York Times, 15 August 2023
Patient-Safety-Learning

Study links lung conditions to young people who vape

Young people who vape are more at risk of bronchitis and shortness of breath, research has suggested, even if they also smoke cigarettes.
Researchers from the US tracked the respiratory health of young people in the Southern California Children’s Health Study between 2014 and 2018.
They conducted surveys which asked about people’s vape and cigarette use in the last 30 days. Researchers also included questions on bronchitic symptoms, such as a daily cough for three months in a row, as well as wheezing and shortness of breath.
The study found the odds of wheezing were 81 per cent more likely among past 30-day e-cigarette users than among “never users”. The odds of bronchitic symptoms were twice as likely, while those of shortness of breath were 78 per cent more likely after accounting for survey wave, age, sex, race and parental education.
The researchers said their findings contribute to “emerging evidence from human and toxicological studies that e-cigarettes cause respiratory symptoms that warrant consideration in regulation of e-cigarettes.”
Jon Foster, policy manager at Asthma + Lung UK, said it is “interesting” the study found a link between vaping and lung conditions in young people, but pointed out the regulation around the amount of nicotine and chemicals used in e-cigarettes is “much tighter” in the UK than the US. “More research would be needed to find out if the situation in the UK is the same,” he added. “However, given that we still know little about long-term effects, the growing popularity of vaping among children and young people is concerning.”
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Source: Independent, 16 August 2023
Patient-Safety-Learning

Updated Covid vaccines are nearly ready as alarm grows over new variant’s rapid spread

Updated Covid vaccines are expected to become available in the US next month as alarm grows over a new variant dubbed Eris.
Healthcare providers are grappling with a rise in hospitalisations stemming from Covid infections. Eris or EG.5.1, a subvariant of Omicron that originally emerged in late 2021, now accounts for around 17per cent of current COVID cases, according to the CDC.
Symptoms of the new variant include a runny nose, headache, fatigue, sneezing and a sore throat. In the week of 30 July to 5 August, the latest period that data is available for, hospitalisations spiked by more than 14per cent, while deaths rose 10per cent compared to the previous week.
It comes as providers and pharmacies prepare to roll out an updated vaccine designed to combat Omicron — but experts are not very optimistic that the greater majority of Americans will opt to be vaccinated.
Fewer than 50 million people in the US got the shot last fall, compared to 250 million, or 73 per cent of the country’s population, when the vaccine was first made available in 2021, according to the agency.
Read full story
Source: Independent, 16 August 2023
Patient-Safety-Learning

Heart attacks at record level after pandemic

Record numbers of people have been hospitalised with heart attacks in the wake of the pandemic, official figures show.
On Tuesday, health chiefs will launch a campaign urging those with symptoms to seek help, with fears that too many cases are being detected too late. The new figures for England show that more than 84,000 patients were admitted to hospital because of a heart attack in 2021/22 – a rise of more than 7,000 in a year. It follows warnings that heart deaths have risen by more than 500 a week since the first lockdown, with a fall in the numbers prescribed vital medication amid struggles to access GP care.
Health officials are afraid that people are still failing to come forward, adding to the collateral damage caused by the pandemic.
From this week, an NHS advert will encourage people to call 999 as soon as they experience symptoms of a heart attack, such as squeezing across the chest, sweating and a feeling of uneasiness, so people have the best chance of survival.
Prof Nick Linker, a cardiologist and NHS national clinical director for heart disease, said: “Cardiovascular disease causes one in four deaths across the country, so it is vital that people are aware of the early signs of a heart attack. Every moment that passes during a heart attack increases heart muscle damage, and nearly all of the damage takes place within the first few hours, so if you experience symptoms such as a sensation of squeezing or tightness across the chest alongside sweating, nausea, or a sense of unease, please call 999 so you have the best chance of a full recovery”.
Read full story (paywalled)
Source: The Telegraph, 15 August 2023
Patient-Safety-Learning

Patients could get cancer scans without GP referral, says Steve Barclay

Patients with cancer symptoms could bypass their GP in the future and go straight for a scan, the health secretary has suggested, in the latest “radical” attempt by the government to cut huge NHS waiting lists.
The suggestion, which comes as the government is expected to reduce the number of NHS cancer waiting time targets, could form part of proposals to “design out bottlenecks” in the NHS system, Steve Barclay said in an interview.
Health department officials are reportedly working on proposals that would mean some patients experiencing cancer symptoms could go straight to an NHS diagnostic centre – or “one-stop shop” – without a GP referral.
“We are very much looking at those patient pathways,” Barclay told the Daily Telegraph. “Where there are bottlenecks in the system of referral from the GP, is there scope to go direct to the relevant diagnostic test or to the clinician? Breast cancer is a good example because almost always the GP refers on … and therefore there’s an opportunity to design out bottlenecks in the system.”
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Source: Guardian, 16 August 2023
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