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

Man dies after A&E sent him home and ‘told him to drink Lucozade’ despite vomiting 100 times

A man died after A&E doctors sent him home from hospital and “told him to drink Lucozade” despite him vomiting 100 times in 24 hours.
Nick Rousseau died from an undiagnosed blocked bowel in 2019 after doctors at Milton Keynes Hospital failed to spot that he had the life-threatening condition.
The 47-year-old was sent home twice in three days and reassured he “would be alright” as doctors believed he had gastroenteritis, his “devastated” wife Kimberly White said.
But Mr Rousseau was actually suffering from an ischaemic bowel, a condition which blocks the arteries to the bowel. He had been to see his doctors several times and had lost three stones in weight over two years due to vomiting and diarrhoea but was never diagnosed.
His family, represented by Osbornes Law, received a six-figure payout in June from Milton Keynes University Hospital NHS Foundation Trust. While it did not admit negligence, it accepted that there were features of Mr Rousseau’s illness which could have justified admission, inpatient observation, and further tests, which could have given a definitive diagnosis.
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Source: The Independent, 4 August 2023
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Babies born very premature can have brain development disrupted in intensive care unit, review finds

While most babies born more than two months prematurely now survive thanks to medical advances, little progress has been made in the past two decades in preventing associated developmental problems, an expert review has found.
The review also found that very preterm babies can have their brain development disrupted by environmental factors in the neonatal intensive care unit (NICU), including nutrition, pain, stress and parenting behaviours.
A review conducted by experts from the Children’s Hospital of Orange County in the US and the Turner Institute for Brain and Mental Health at Monash University in Australia found that while these neurodevelopmental problems can be related to brain injury during gestation or due to cardiac and respiratory issues in the first week of life, the environment of the NICU is also critical.
To improve outcomes for very preterm babies, the review recommended family based interventions that reduce parental stress during gestation, more research into rehabilitation in intensive care and in the early months of life, and greater understanding of the role of environment and parenting after birth.
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Source: The Guardian, 3 August 2023
Patient Safety Learning

Trust given warning notice over rapid tranquillisation

A mental health trust has been served with a warning notice ordering improvements in its processes around rapid tranquillisation of patients.
The Care Quality Commission said the trust needed to ensure all staff at Kent and Medway NHS and Social Care Partnership Trust followed local and national recommendations to monitor and record a patient’s physical health when rapid tranquillisation was administered. Inspectors were concerned staff were not always aware of the potential impact of these medications.
Serena Coleman, CQC deputy director of operations in the south, said: “We found some staff weren’t always using the least restrictive options to make sure that people’s behaviour wasn’t controlled by an excessive use of medicines.
“As required medication, such as lorazepam and promethazine, was being used quite frequently but we couldn’t always find records to explain why these medications were necessary. There were examples where reviews hadn’t happened for long periods, meaning staff couldn’t be sure it was still appropriate to administer to people."
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Source: HSJ, 3 August 2023
Patient Safety Learning

NHS to expand use of private sector to tackle waits

The use of the private sector to tackle the NHS backlog in England is to be expanded, the government says.
Ministers say they want to unlock spare capacity to get more people the treatment and operations they need.
This includes opening eight privately-run diagnostic centres and using new rules to make it easier for the NHS to purchase care in the private sector.
It comes as a record 7.5 million people are waiting for treatment - three million more than before the pandemic.
The private sector already carries out hundreds of thousands of treatments and appointments for the NHS every year. But it has said it has the capacity to carry out about 30% more than it is.
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Source: BBC News, 4 August 2023
Patient Safety Learning

Trusts warned to check helipad safety after death

Trusts have been told to check the safety of their helipads after an accident in a hospital car park left a pensioner dead.
Jean Langan, 87, was blown over by the “downwash” of air from a helicopter at Derriford Hospital last year. She was walking through a car park at the hospital after an appointment when she fell and hit her head as an HM Coastguard helicopter landed on the hospital’s helipad. Another elderly woman broke her pelvis.
Now the Health and Safety Executive has written to trust chief executives reminding them of their duty to manage health and safety risks around helipads. These risks include downwash from helicopters, the moving parts of helicopters, and the design and location of helipads.
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Source: HSJ, 2 August 2023
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Negligence at Lancashire hospital caused boy permanent brain damage, court rules

An 11-year-old boy suffered permanent brain damage after birth because of negligence by hospital midwives who then fabricated notes, a high court judge has ruled.
Jayden Astley’s challenges in life include deafness, motor impairments, cognitive difficulties and behavioural difficulties, his lawyers said.
After a five-day trial at the high court in Liverpool, Mr Justice Spencer ruled that staff at the Royal Preston hospital in Lancashire were negligent in their treatment of Jayden in 2012.
The brain injury was caused by prolonged umbilical cord compression that resulted in acute profound hypoxia – lack of oxygen – sustained during the management of the birth, the court found.
Midwives failed to accurately monitor Jayden’s heart rate when he was born and failed to identify his bradycardic, or slow, heart rate during delivery. The judge also found that some entries in notes were fabricated.
In his judgment Spencer said it was agreed that all permanent damage to Jayden’s brain would have been avoided if he had been delivered three minutes earlier.
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Source: The Guardian, 2 August 2023
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GPs given freedom to order heart checks direct

GP practices in England will be able to order a host of checks directly to help speed up the diagnosis of a range of heart and respiratory conditions.
Traditionally GPs refer to specialists when conditions like heart failure and lung problems are suspected.
But the ability to direct refer, which was rolled out for cancer last year, is now being extended.
GPs welcomed the move, but questioned whether there was sufficient testing capacity to cope.
Royal College of GPs chair Prof Kamila Hawthorne said: "Any initiative to accelerate the process by which patients can be diagnosed and begin to receive any necessary treatment should be seen as positive."
She said GPs had "long been calling" for better access to diagnostic tests.
But she added: "For this initiative to be successful, it is vital that diagnostic capacity - both in terms of testing and people to conduct and interpret tests - is sufficient."
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Source: BBC News, 3 August 2023
Patient Safety Learning

Directors to be judged on their ability to create ‘compassionate’ cultures

NHS England has announced the first details of its ‘Leadership Competency Framework’, and revealed it will be launched this September.
The LCF will underpin the annual appraisal of NHS board directors and, in turn, adherence to the revamped Fit and Proper Person Test.
NHSE also revealed that leaders, including senior clinicians, who hold “significant roles” but are not board members may be subject to the FPPT in the near future.
The new FPPT framework said the LCF would contain “six competency domains which should be incorporated into all senior leader job descriptions and recruitment processes”.
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Source: HSJ, 3 August 2023
Patient Safety Learning

Warning over medical clinics using fake Google reviews

Medical clinics are using fake Google reviews to boost their profiles online, a BBC investigation has found.
Consumer groups say fake reviews are a "significant and persistent problem" and have called on internet firms to do more to remove them and fine companies.
Which? has warned it could be a serious issue if someone chooses a treatment clinic based on reading a fake review.
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Source: BBC 2 August 2023
Patient_Safety_Learning

Should the acne drug that 'cost Annabel Wright and Jon Medland their lives' be banned for under-18s?

Jonathan Medland's voice crackles with anger and emotion when he talks about his beloved son Jon, who tragically took his own life aged just 22.
'He was the most exuberant, engaging, funny and amazing young man you could ever wish to meet — nobody had a bad word to say about him — he was really going places,' says Jonathan, 66, a retired driving instructor from Barnstaple in Devon. 'But that drug did something terrible to his brain.'
The drug he's referring to is isotretinoin — brand name Roaccutane — a pill first licensed in the UK for the treatment of severe acne in 1983 and since taken by hundreds of thousands of patients.
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Source: Mail Online 31 July 2023
Patient_Safety_Learning

Should Ozempic come with a warning about a risk of suicidal thoughts?

In the U.S., the prescribing label of Ozempic's sister drug, Wegovy, already warns of possible suicidal ideation because of similar side effects linked to other weight loss drugs.
Following reports of self-injury and suicidal thoughts among a small number of people who’ve taken Ozempic or Wegovy in Europe and the United Kingdom, health regulators there are investigating whether the drugs carry a risk of these side effects.
The European Medicines Agency said last month that it was reviewing 150 such reports from people who took drugs in this class, called GLP-1 receptor agonists, which lower blood sugar and suppress appetite by mimicking a hormone in the gut.
Then last week, the U.K.'s Medicines and Healthcare products Regulatory Agency told Reuters that it was reviewing safety data about the drugs following similar reports.
Neither Ozempic nor Wegovy, which are both versions of a drug called semaglutide at different dosages, carry warnings about suicidal ideation in Europe or the U.K., since clinical trials have not shown evidence of an increased risk.
But in the United States, the Food and Drug Administration requires that medications for weight management that work on the central nervous system carry a warning about suicidal thoughts. Because the agency approved Wegovy as a weight loss treatment, its prescribing label asks medical professionals to monitor for these symptoms and to discontinue the medication if people develop them. Ozempic, which is only FDA-approved to treat diabetes, does not come with that warning.
But some patients think it should.
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Source: NBC 1 August 2023
Patient_Safety_Learning

AI use in breast cancer screening as good as two radiologists, study finds

The use of artificial intelligence in breast cancer screening is safe and can almost halve the workload of radiologists, according to the world’s most comprehensive trial of its kind.
Breast cancer is the most prevalent cancer globally, according to the World Health Organization, with more than 2.3 million women developing the disease every year.
Screening can improve prognosis and reduce mortality by spotting breast cancer at an earlier, more treatable stage. Preliminary results from a large study suggest AI screening is as good as two radiologists working together, does not increase false positives and almost halves the workload.
The interim safety analysis results of the first randomised controlled trial of its kind involving more than 80,000 women were published in the Lancet Oncology journal.
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Source: Guardian 2 August 2023
Patient_Safety_Learning

Trust apologises to dozens of families after harm to children

A hospital trust has apologised to families after dozens of children suffered hearing loss following failures in their care.
Croydon Health Services Trust had already revealed three children “may have been at risk of serious hearing loss or a delay to their speech development”, but it has now confirmed to HSJ that a further 49 “incurred mild to moderate hearing loss or impairment”.
The south London trust would not disclose the results of its internal review that begun after it declared a serious incident in March 2021, saying it was “ongoing”, but said it had acted on all the “immediate recommendations”.
The incident was declared after more than 1,400 children were found not to have been followed up by the trust. 
There was also an external review carried out by an audiologist from Guy’s and St Thomas’ Foundation Trust. It is unclear which review uncovered the incidents of harm. 
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Source: HSJ 1 August 2023
Patient_Safety_Learning

Promising new Alzheimer’s drugs may be less effective for Black patients

Groundbreaking treatments for Alzheimer’s disease that work by removing a toxic protein called beta amyloid from the brain may benefit whites more than Black Americans, whose disease may be driven by other factors, leading Alzheimer’s experts told Reuters.
The two drugs - Leqembi, from partner biotech firms Eisai (4523.T) and Biogen (BIIB.O), and an experimental treatment developed by Eli Lilly (LLY.N), donanemab — are the first to offer real hope of slowing the fatal disease for the 6.5 million Americans living with Alzheimer’s.
Although older Black Americans have twice the rate of dementia as their white peers, they were screened out of clinical trials of these drugs at a higher rate, according to interviews with 10 researchers as well as four Eisai and Lilly executives.
Prospective Black volunteers with early disease symptoms did not have enough amyloid in their brain to qualify for the trials, the 10 researchers explained.
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Source: NBC 31 July 2023
Patient_Safety_Learning

Patients ‘not thin enough’ for help as NHS battles eating disorder crisis

Desperately ill people with eating disorders are being refused NHS treatment for “not being thin enough”, as new figures reveal the health service is in the grips of a growing eating disorder crisis.
Shocking figures obtained by The Independent show at least 5,385 patients – the overwhelming majority, 3,896, of whom are children – were admitted to general wards for conditions such as anorexia and bulimia in 2021-22, more than double the number in 2017-18.
It comes as separate analysis of NHS figures suggests the number of children being treated for eating disorders more than doubled from 5,240 in 2016-17 to 11,800 in 2022-23.
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Source: Independent 1 August 2023
Patient_Safety_Learning

Coroners issue 24 warnings over emergency care crisis

Coroners have warned of increasing numbers of deaths caused by problems in the emergency pathway, with some citing ‘severe’ staffing shortages.
HSJ has identified that at least 24 “prevention of future death” reports were sent to NHS organisations in England and Wales in the first half of 2023, which noted shortcomings within emergency services.
In six of the 24 cases, coroners found ambulance, emergency room and other delays caused or contributed to patient deaths.
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Source: HSJ 1 August 2023
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