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

Government backs reduction in police response to mental health incidents despite safety warnings

Ministers are backing a potentially “dangerous” new model allowing police to reduce their response to mental health incidents after failing to formally assess the risk of harm or death.
Officials are monitoring any “adverse incomes” from the National Partnership Agreement, which will see police forces stop attending health calls unless there is a safety risk or a crime being committed.
Policing minister Chris Philp said a pilot by Humberside Police gave him confidence in national roll-out, which aims to “make sure that people suffering mental health crisis get a health response and not a police response”.
Mental health charities and experts have warned the plans could be “dangerous”, and a coroner raised the alarm following a woman’s suicide after police failed to respond to her disappearance.
A report published last month said action was needed to prevent future deaths, warning that the new model could “allow each agency to regard such a situation as the other’s responsibility, whilst nobody is on the ground attempting to retrieve a seriously ill patient”.
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Source: The Independent, 26 July 2023
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CQC names worst trusts for experience in A&E

The Care Quality Commission has named the trusts which have performed ‘worse than expected’ on patient experience in urgent and emergency care.
Data from the CQC survey of more than 36,000 people who used urgent and emergency care services in September 2022 shows a total of 10 trusts performed poorly on patients’ overall experience.
Patients reported longer wait times, while only around half felt staff “definitely” did everything they could to help control their pain in the latest survey.
Sean O’Kelly, the CQC’s chief inspector of healthcare, said it “remains extremely concerning that for some people care is falling short”.
“These latest survey responses demonstrate how escalating demand for urgent and emergency care is both impacting on patients’ experience and increasing staff pressures to unsustainable levels."
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Source: HSJ, 26 July 2023
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Faulty concrete fears at 250 NHS Scotland sites

More than 250 NHS buildings in Scotland could contain a potentially dangerous type of concrete that can collapse without warning.
NHS Scotland issued a Safety Action Notice in February and completed a "desktop survey" of its estate in June.
Reinforced autoclaved aerated concrete (RAAC) was used to build roofs, walls and floors from the 1960s to the 1990s.
NHS Scotland has warned the material is potentially vulnerable to "catastrophic failure without warning".
But a Scottish government spokesperson said there was "no evidence to suggest that these buildings are not safe."
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Source: BBC News, 25 July 2023
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Sciensus’s licence partly suspended after death of cancer patient

Britain’s health regulator has partly suspended the manufacturing licence of Sciensus, a private company paid millions by the NHS to provide vital medicines, after the death of a cancer patient who was given the wrong dose of chemotherapy.
The Medicines and Healthcare products Regulatory Agency (MHRA) said it had taken “immediate” action under regulation 28 of the Human Medicines Regulations 2012 law “where it appears to the MHRA that in the interests of safety the licence should be suspended”.
The MHRA found “significant deficiencies” in standards at Sciensus during an investigation triggered by the death of one patient and the hospitalisation of three others. 
All four patients were administered “incorrect” doses of an unlicensed version of cabazitaxel, a licensed chemotherapy used to treat prostate cancer, according to people familiar with the matter.
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Source: The Guardian, 25 July 2023
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Surgeon who exposed safety failings ‘driven out of NHS’ after 43 years

An award-winning hospital consultant says he has been “hunted” out of the NHS after 43 years for flagging patient safety failings.
Peter Duffy, 61, performed his final surgical procedure, supervising a bladder cancer removal, earlier this month at Noble’s Hospital on the Isle of Man.
He said he had “been looking forward to a good few more years of full-time work — another five, at least”. But the cumulative toll of a long-running whistleblowing dispute with his former employer, Morecambe Bay NHS Trust (UHMBT), instead pushed him into “an abrupt, even savage termination of my calling”.
The General Medical Council watchdog recently dropped a 30-month probe into Duffy prompted by emails that he alleges were falsified. The emails, which were apparently sent by Duffy in December 2014 but did not surface until 2020, appeared to implicate him in the string of clinical errors that led to the death of Peter Read, a 76-year-old man from Morecambe.
The GMC concluded that it could not attach weight to the emails as evidence. However, Duffy says the ordeal of “having the responsibility for an avoidable death I’d reported being flipped and of having the finger pointed back at me” drove him to contemplate suicide.
Read full story (paywalled)
Source: The Times, 24 July 2023
Sam

Bisexual people ‘experience worse health outcomes than other adults’

Bisexual people experience worse health outcomes than other adults in England, a study has found.
Data from lesbian, gay or bisexual (LGB) patients indicates these groups have poorer health outcomes compared to those who identify as heterosexual.
The new findings indicate that bisexual people face additional health disparities within an already marginalised community.
Experts from the Brighton and Sussex Medical School, and Anglia Ruskin University who led the analysis of more than 835,000 adults in England, suggest the differences could result from unique prejudice and discrimination that can come from both mainstream society and LGBTQ+ communities.
Read full story
Source: The Independent, 25 July 2023
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NHS trust to review all suicides since 2017

The deaths of dozens of people who took their own lives while patients of an NHS trust will be reviewed after concerns were raised.
Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) will review all 63 suicides since 2017.
It comes after the trust was accused of adding to the records of a patient the day after he took his own life to "correct their mistakes".
The patient, who was diagnosed with paranoid schizophrenia and substance misuse, had been under CPFT's care for two months when he died in Ely in 2017.
Last month, his mother Angelina Pattison, from Newmarket, Suffolk, told the BBC his care plan "was done when he died - when they were running around to correct their mistakes, which they have done".
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Source: BBC News, 25 July 2023
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Ministers reject Hunt’s plans for general practice

The Government has rejected several policy proposals to promote “continuity of care” in general practice which were put forward by Jeremy Hunt. 
The now chancellor championed significant policy changes to strengthen the link between patients and an individual, named GP, when he was Commons health and social care committee chair.
However, the government’s response to the report rejects several of the key proposals.
The committee under Jeremy Hunt said “NHS England should champion the personal list model” – under which each patient is linked to a particular GP – “rather than dismiss it as unachievable”.
The Department of Health and Social Care response said: “The department does not accept this recommendation. We agree that continuity of care is important within general practice but do not agree that requiring a return to the personal list model is the correct approach.
Government also rejected recommendations from Mr Hunt’s committee to introduce a new national measure to track continuity of care by practice; and to fund primary care networks to appoint a GP “continuity lead” for a session a week.
Read full story (paywalled)
Source: HSJ, 24 July 2023
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Digitising all trusts by 2025 ‘unachievable’ after £700m cut, government admits

NHS England’s target for all trusts to have a working electronic patient record (EPR) system by March 2025 is now ‘unachievable’’ and a new date has been set a year later, government has admitted.
A new report of the Infrastructure and Projects Authority – the government body which scrutinises and supports major projects – states: “Delivery confidence is [rated] red as a number of NHS trusts are reporting they are unlikely to be able to fully implement an electronic patient record by March 2025.”
The document, published quietly last week, downgrades the rating from “amber” to “red” – and also reveals £700m was cut from the programme’s budget last year. 
The “frontline digitisation” programme was launched by government and NHSE in 2021 with the aim of getting all trusts to a minimum level of capability, including 90% to have an EPR of an acceptable standard by the end of 2023, and 100 per cent by March 2025. 
But the IPA report states that a revised business case is now being prepared to reflect a new “end date” of March 2026.
Read full story (paywalled)
Source: HSJ, 24 July 2023
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‘A critical emergency’: America’s Black maternal mortality crisis

America is facing an intensified push to pass stalled federal legislation to address the US’s alarming maternal mortality rates and glaring racial disparities which have led to especially soaring death rates among Black women giving birth.
Maternal mortality rates in the US far outpace rates in other industrialised nations, with rates more than double those of countries such as France, Canada, the UK, Australia, Germany. Moms in the US are dying at the highest rates in the developed world.
Overall maternal mortality rates in the US spiked during the pandemic. Maternal deaths in the US rose 40% from 861 in 2020 to 1,205 in 2021, a rate of 32.9 deaths per 100,000 live births. For Black women, these maternal mortality rates were significantly higher, at 69.9 deaths per 100,000 live births in 2021.
These racial disparities in maternal health outcomes have persisted and worsened for years as the number of women who die giving birth in the US has more than doubled in the last two decades.
The CDC noted in a review of maternal mortalities in the US from 2017 to 2019, that 84% of the recorded maternal deaths were preventable.
Read full story
Source: The Guardian, 23 July 2023
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Nurse pioneers new device to reduce NG tube insertion errors

A nurse-led trial has found that a new electronic tool could reduce the number of preventable injuries and deaths caused by wrongly inserting nasogastric tubes.
The study, led by Tracy Earley, a consultant nutrition nurse at Royal Preston Hospital, tested a new fibre-optic device which can tell clinicians definitively if a nasogastric tube – which is inserted through the nose and delivers food, hydration and medicine into the stomach – has been placed correctly.
Currently, to check if nasogastric tubes – also referred to as NG tubes – are in the right place, nurses have to extract bodily fluid from the patient through the tube. Clinicians then test this fluid on a pH strip to judge whether the placement is correct.
Studies show that interpreting the pH level results in mistakes 12-30% of the time, and that in 46% of cases nurses are unable to draw aspirate at all. This means patients have to undergo x-rays, leaving them without nutrition or treatment for longer.
The study tested a device called NGPod, which uses a fibre-optic sensor to retrieve the pH reading from the tip of the NG tube leading to a definitive 'yes' or 'no' result in terms of whether it has been placed correctly – removing the need for aspirate or interpretation from the health professional.
It found that the device was as accurate as pH strip testing, and removed all of the risks associated with making subjective pH strip judgements.
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Source: Nursing Times, 18 July 2023
Sam

NHS trust accused of cover-up is refusing to release report into deaths

An ambulance trust accused of hiding information from a coroner about patients that died is keeping a damning internal report about the deaths secret, the Guardian can reveal. A consultant paramedic implicated in the alleged cover-ups continues to be involved in decisions to keep the report from the public.
Earlier this month, North East Ambulance Service (NEAS) apologised to relatives after a review into claims it covered up errors by paramedics and withheld evidence from the local coroner about the deceased patients. But a bereaved family left in the dark about mistakes made before their daughter’s death have rejected the apology.
Now, it has emerged that a 2020 internal interim report on the alleged cover-up continues to be kept secret by the trust. The damning report by consultants AuditOne has been leaked to the Guardian after first being exposed by the Sunday Times. 
Paul Aitken-Fell, a consultant paramedic blamed in the report for amending information sent to the coroner and removing crucial passages about mistakes by the trust’s paramedics, remains in post. He also holds the gatekeeper role of FoI review officer, and as such has endorsed decisions to refuse to release the report to members of the public who ask for it.
Read full story
Source: The Guardian, 24 July 2023
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Two-thirds of people administering cosmetic surgery injections are not qualified medical doctors, survey finds

More than two-thirds of people who are administering cosmetic surgery injections such as Botox in the UK are not qualified medical doctors, a new study suggests.
The study is the first survey of who is providing cosmetic injectable services, including botulinum toxin (Botox) and dermal fillers, in the country.
Dr David Zargaran, UCL Plastic Surgery, an author of the study, said: “There are well-documented, yet to-date unaddressed challenges in the UK cosmetic injectables market.
“Without knowledge of the professional backgrounds of practitioners, we cannot adequately regulate the industry.
“Our research highlights that the majority of practitioners are not doctors and include other healthcare professionals, as well as non-healthcare professionals such as beauticians.
“The range of backgrounds opens a broader question relating to competence and consent.
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Source: The Independent, 24 July 2023
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Government pledges better support for women who lose babies during pregnancy

Women who lose babies during pregnancy will be able to get a certificate as an official recognition of their loss as well as better collection and storage of remains under new government plans.
The government will make sure the certificate is available to anyone who requests one after experiencing any loss pre-24 weeks’ gestation.
The NHS will develop and deliver a sensitive receptacle to collect baby loss remains when a person miscarries. A&Es will also have to ensure that cold storage facilities are available to receive and store remains or pregnancy tissue 24/7 so that women don’t have to resort to storing them in their home refrigerators.
The new recommendations are part of the government’s response to the independent Pregnancy Loss Review.
Read full story
Source: The Independent, 23 July 2023
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Most NHS staff say they don’t have enough time to spend with patients

Most NHS staff think they have too little time to help patients and the quality of care the service provides is falling, a survey reveals.
Medical and nursing groups said the “very worrying” findings showed that hard-pressed staff cannot give patients as much attention as they would like because they are so busy.
In polling YouGov carried out for the Guardian, 71% of NHS staff who have direct contact with patients said they did not have the amount of time they would like to have to help them. A third (34%) felt they had “somewhat less than enough time” and 37% “far less than enough time” than they wanted. Almost a quarter (23%) felt they had the right amount of time while just 3% said they had “more time” than they wanted.
The survey presents a worrying picture of the intense pressures being felt at the NHS frontline. Those same personnel were asked if they thought the quality of care the service is able to offer has got better or worse over the last five years. Three-quarters (75%) said “worse”, including a third (34%) who answered “much worse”, while 17% said “about the same” and only 6% replied “better”.
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Source: The Guardian, 24 July 2023
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Managers wrongly dismissed doctor with PTSD, tribunal rules

A trust breached its own internal illness policy when managers sacked a doctor who had PTSD and had been drunk at work, an employment tribunal has ruled.
Judges criticised the move as a “complete failure” by East and North Hertfordshire Trust when Vladimir Filipovich was dismissed in July 2019.
Dr Filipovich was summoned to a hearing following allegations he had been drunk at work, did not disclose a diagnosis of post-traumatic stress disorder to his employer, and failed to take a recommended prescription of Citalopram.
In a decision published this month, the tribunal sharply criticised how the trust’s investigator handled the Citalopram claim, concluding he “did nothing to investigate the matter whatsoever”, and found ENHT had “appeared to simply take legal advice” on how to dismiss Dr Filipovich.
The tribunal also concluded ENHT “stopped following” its own illness policy, which aimed to get practitioners to return to work, and “abandoned” its requirement to obtain the latest occupational advice.
Read full story (paywalled)
Source: HSJ, 21 July 2023
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