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

Mum alarmed at 'out-of-depth' admission

The mother of a seriously ill boy said she was "very alarmed" when a doctor at an under-fire children's ward admitted they were "out of their depth".
In October, Carys's five-year-old son Charlie was discharged from Kettering General, but she returned him the next day in a "sort of lifeless" state.
She said it seemed "quite chaotic" on Skylark ward before he was transferred to another hospital for further tests.
Since the BBC's report in February that highlighted the concerns of parents with children who died or became seriously ill at the hospital, dozens more have come forward.
In April, Care Quality Commission (CQC) inspectors rated the Northamptonshire hospital's children's and young people's services inadequate.
Among the findings, inspectors said "staff did not always effectively identify and quickly act upon patients at risk of deterioration".
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Source: BBC News, 6 June 2023
Sam

Global ‘silver tsunami’ of older cancer patients is coming, experts warn

The world must urgently prepare for a global “tsunami” of millions of older cancer patients or risk healthcare systems being unable to cope, leading doctors have warned.
With life expectancy increasing and a rapidly soaring population of older people, a looming increase in elderly patients with cancer was now a “serious public health concern”, the American Society of Clinical Oncology (ASCO) said in a report. Cancer centres must prepare for “the silver oncologic tsunami”, the experts added.
At ASCO’s annual meeting in Chicago, the world’s largest cancer conference, Dr Andrew Chapman, the director of the Sidney Kimmel Cancer Center-Jefferson Health and a specialist in geriatric oncology, said: “As the population expands and the incidence goes way up, are we really prepared to deal with those needs? I think globally, we’re not prepared.”
“We know cancer is a disease that is associated with ageing, and there are a number of biological mechanisms as to why that is,” Chapman said. “What is often times missed is that the older adults’ goals, wants, needs, preferences, and issues are much different than those of the average adult.
“Sometimes there’s a nihilism – ‘if you’re older we’re not going to bother’ – which is horrible,” he added.
Dr Julie Gralow, the chief medical officer and executive vice-president of ASCO, said healthcare systems should act immediately to avoid being overwhelmed by the dramatic rise in older cancer patients. “By 2040, the global burden is expected to grow to 27.5m new cancer cases and 16.3m cancer deaths simply due to the growth and ageing of the population.”
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Source: The Guardian, 5 June 2023
Sam

NHS hospital investigated over ‘gross negligence’ following baby’s death

One of the NHS’ largest hospital trusts is being investigated over “possible gross negligence manslaughter” after a baby died 24 hours after her birth.
Polly Lindop died at St Mary’s Hospital on 13 March and Greater Manchester Police have now launched a probe into her death.
Police said its major incident team launched the investigation into “possible Gross Negligence manslaughter” after concerns were raised to the force and local coroner.
DCI Mark Davis of GMP’s major incident team said: “First, I want to express my condolences to the parents of Polly at what is an extremely difficult time for them. Our thoughts will remain with them as we carry out our investigation.
“A number of hospital staff have been spoken to as witnesses by officers and no arrests have been made at this time.
“The hospital trust has been fully cooperative with the police and all relevant authorities have been kept informed. The investigation into Polly’s death is on-going and her family will continue to be kept updated in relation to any significant developments.”
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Source: The Independent, 5 June 2023
Sam

NHSE merger halts plan to boost district nurses

Plans to procure more district nursing courses to start this September have been paused because of the merger of Health Education England into NHS England, HSJ understands.
An email sent last month from a commissioning officer at NHSE’s workforce, training and education directorate – the new HEE – said procurement of new district nursing courses from universities would be paused “until further notice”, due to the “ongoing merger”.
Since 2009, the number of district nurses working in the English NHS has fallen drastically, from around 7,000 to around 3,900.
Steph Lawrence, executive director of nursing and allied health professionals at Leeds Community Healthcare Trust, said the decision to pause the expansion of courses was a “huge concern” as numbers of district nurses need to grow “at a much faster rate”.
“This is a major safety issue for safe and effective care in the community if we don’t have the appropriate numbers of nurses trained. We may also lose nurses as well who want to progress and expand their knowledge,” Ms Lawrence said.
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Source: HSJ, 5 June 2023
Sam

Children's doctors call for ban on disposable vapes

Children's doctors are calling for a complete ban on disposable vapes because they are likely to damage young lungs and are bad for the environment.
But an anti-smoking campaign group says a ban would make it harder for some adults to give up smoking and increase the trade in illegal vapes.
UK governments are planning steps to reduce vaping among under-18s.
Prime Minister Rishi Sunak recently said it was "ridiculous" that vapes were designed and promoted to appeal to children when they were supposed to be used by adults giving up smoking.
A BBC investigation found unsafe levels of lead, nickel and chromium in vapes confiscated from a secondary school, which could end up being inhaled into children's lungs. Scientists analysing the vapes said they were the worst lab test results of their kind they had ever seen.
The Royal College of Paediatrics and Child Health (RCPCH) now says the UK government should "without a doubt" ban disposable e-cigarettes.
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Source: BBC News, 6 June 2023
Sam

Leaked data reveals ‘distressing’ scale of ‘unacceptable’ A&E waits

One in five cases in which patients attend A&E needing mental healthcare are spending more than 12 hours in the department – at least double the rate of patients with physical health problems.
Unpublished internal NHS data seen by HSJ also suggests the proportion of mental health patients suffering long waits in accident and emergency has almost tripled when compared to the situation before the pandemic. 
According to the data, the proportion of attendances by patients with a mental health problem who waited more than 12 hours in A&E before being admitted or discharged increased from 7% (34,945 breaches) in 2019-20 to 20% (88,250 breaches) in 2022-23.
The situation has become so difficult, that some acute trusts are spot purchasing private sector mental health in order to discharge patients. 
Read full story (paywalled)
Source: HSJ, 5 June 2023
Sam

‘Axe under pillow’: paramedics urged to take police escorts to 1,200 dangerous homes

Paramedics are being told to take a police escort to more than 1,200 addresses for fear of attack, The Times has revealed.
The College of Paramedics said the figure was outrageous and called on courts to implement tougher sentences for assaults on paramedics.
Ambulance services have marked hundreds of addresses after violence towards crew. Notes on addresses include “patient keeps axe under pillow — serrated knife hidden round the house and is known to be a risk”, “shoots/throws acid”, and “patient is anti-ambulance”.
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Source: The Times, 4 June 2023
Patient Safety Learning

Doctor told cancer patient she had anorexia despite three ‘red flag’ signs

A woman was “fobbed off” by her doctors who failed to diagnose her colon cancer for a year, an investigation revealed.
In May 2019, Charlie Puplett, 45, expressed concern at her GP surgery in Yeovil, Somerset, about unexplained weight loss, lack of appetite and a change in bowel habits.
But the surgery did not test her for colon cancer – with one doctor suggesting she had anorexia and was “in denial”, she said.
She was not diagnosed until almost a year later when she was rushed to hospital after vomiting blood.
Ms Puplett’s experience was detailed in an investigation by the Parliamentary and Health Service Ombudsman (PHSO), which found that her symptoms should have been “red flags” leading to urgent testing within two weeks, and said she had been “failed” by her doctors.
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Source: The Independent, 4 June 2023
Patient Safety Learning

Complaints about non-surgical butt lifts ‘rising at alarming rate’ in UK

Complaints about non-surgical Brazilian butt lifts and breast enhancements have risen at an “alarming” rate, up from fewer than 5 to 50 in a year, an industry body has revealed.
Save Face, a national, government-approved register of accredited non-surgical treatment practitioners, is calling for the procedures to be banned, while the Local Government Association has asked Westminster to take urgent action.
Ashton Collins, the director of Save Face, said the organisation had noted an “alarming” increase in complaints about these enhancements, which she said should be banned.
Collins said: “No reputable healthcare professional would offer these treatments as they are very high risk.
“It’s a new and incredibly dangerous trend which has emerged from social media, a trend people think is a cheaper, risk-free alternative to the surgical counterparts. All the cases reported to us have been carried out by non-healthcare practitioners who have prioritised profits ahead of the safety and wellbeing of their clients.
“These treatments are incredibly risky, and we have helped people who have contracted sepsis and have had to undergo surgery to remove the filler. In 2021, we had fewer than five complaints about these treatments. That figure has increased tenfold in the past year alone and we are getting more and more complaints each week.”
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Source: The Guardian, 2 June 2023
Patient Safety Learning

Women ‘traumatised’ by invasive hysteroscopies that are often carried out with just paracetamol

Some women are being left “traumatised” following a routine gynaecological procedure that is often carried out with minimal pain relief, with one pain expert warning there is an “apathy” within the NHS in changing how it is done.
There are various pain relief options for the procedure, including general anaesthetic. However, campaigners say it is common for women to be told just to take paracetamol before they arrive at the hospital.
Doctors claim this is sufficient pain relief for most patients, however a significant number of women have reported pain so severe that it has left them feeling “traumatised” and “violated”.
Jenny Wade, 51, had a hysteroscopy carried out this year after her GP referred her to Leicester General Hospital to investigate her postmenopausal bleeding.
Ms Wade said she asked if she could have the procedure under general anaesthetic and was told she could, but there would be a wait.
She decided to go ahead with the procedure without the anaesthetic, as she was worried she could have cancer and did not want to delay a diagnosis.
“I’ve never known pain like it. I had tears flooding down my face,” she said describing the procedure.
“It was so traumatic. The only way I can describe the pain is similar to childbirth. I’d say it could have even been worse because I had an epidural during childbirth.”
According to a best practice paper published by the Royal College of Obstetricians and Gynaecologists this year, women should be given accurate written and verbal information about hysteroscopies ahead of their appointment, including the various pain control options.
Read full story
Source: iNews, 4 June 2023
Further reading on the hub:
My experience of an outpatient hysteroscopy procedure - Patient stories Hysteroscopy: 6 calls for action to prevent avoidable harm Painful hysteroscopy - hub Community thread)  
Patient Safety Learning

‘Archaic’ and risky patient records still used by most GP practices

Most GP practices in England are still using ‘archaic’ Lloyd George paper records despite a commitment to digitise them, HSJ has found.
NHS England’s 2019 GP contract included a commitment to do away with the so-called “Lloyd George envelopes” – named after the early 20th century prime minister who introduced a pre-NHS health insurance scheme – and digitise them by 2022-23. The NHS stopped issuing new envelopes for first-time registrations in January 2021.
But Freedom of Information requests submitted by HSJ have revealed that the famous brown paper records, some of them many decades old, are still widely used in England.
Where they are still used, staff typically use electronic records for new information, but have to find and consult the paper records occasionally, when they need older information. This is less efficient than if the records had been digitised, and storing the paper records takes up several rooms in many practices.
Read full story (paywalled)
Source: HSJ, 5 June 2023
Patient Safety Learning

Access to contraception has got harder in England, top doctor says

Women are finding it harder to access contraception than they did a decade ago, resulting in more unplanned pregnancies, the women’s health ambassador has said.
They have been discouraged by bad experiences, a confusingly disjointed system and long delays for procedures such as the coil or implant insertion, according to Prof Lesley Regan, a leading gynaecologist who was appointed women’s health ambassador for England last year.
She said that “destructive” changes made to the NHS commissioning system in England in 2012, which siloed GP surgeries from hospitals, were failing women. “If you’re not commissioned to deal with the problem, there’s no incentive to do a job properly … Contraception has got to be everybody’s business and up until this moment it’s been nobody’s responsibility and no one’s been accountable for it.”
She added that the NHS preoccupation with cost was counterproductive as “contraception is the single most cost-effective intervention in healthcare”. She is pushing to get the progesterone-only pill, which took a decade to become available over the counter, made free in pharmacies so fewer women “fall through the cracks”.
Read full story
Source: The Guardian, 5 June 2023
Patient Safety Learning

Error causes 800 patients to be wrongly removed from waiting list

A trust is carrying out a review after hundreds of patients were wrongly removed from the waiting list and potentially missed out on treatment.
York and Scarborough Teaching Hospitals Foundation Trust told HSJ that roughly 800 patients of its referral to treatment waiting list, were affected.
A serious incident was declared after it emerged some patients “had their referral to treat clocks stopped erroneously, resulting in patients not receiving treatment”, according to a report to the trust board.
The trust said reviews were under way but had not yet identified any cases of “moderate or significant clinical harm”, although it admitted some patients had been significantly delayed.
Read full story (paywalled)
Source: HSJ, 2 June 2023
Patient Safety Learning

Liver dialysis device safe and effective for treating liver failure

Researchers have completed the first successful in-patient trial of liver dialysis.
The DIALIVE device, invented by researchers at UCL’s Institute for Liver and Digestive Health, was found to be safe and effective, research suggests.
According to a new study, the device is associated with substantial improvement in the severity of symptoms and organ function in a greater proportion of patients with acute-on-chronic liver failure (ACLF), when compared with patients receiving standard of care.
The next step would be a larger clinical trial, which if successful could see DIALIVE approved for clinical use within the next three years.
Read full story
Source: The Independent, 1 June 2023
Sam

USA: Eating disorder group pulls chatbot sharing diet advice

A US organisation that supports people with eating disorders has suspended use of a chatbot after reports it shared harmful advice.
The National Eating Disorder Association (Neda) recently closed its live helpline and directed people seeking help to other resources, including the chatbot.
The AI bot, named "Tessa," has been taken down, the association said. It will be investigating reports about the bot's behaviour.
In recent weeks, some social media users posted screenshots of their experience with the chatbot online.
They said the bot continued to recommend behaviours like calorie restriction and dieting, even after it was told the user had an eating disorder.
For patients already struggling with stigma around their weight, further encouragement to shed pounds can lead to disordered eating behaviours like bingeing, restricting or purging, according to the American Academy of Family Physicians.
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Source: BBC News, 2 June 2023
Sam

‘Muddle, frustration and distrust’ at ‘most mature’ ICS

Multiple problems have been highlighted with the leadership and governance of a much-vaunted integrated care system, including a lack of trust between organisations which often hide information that could weaken their position.
HSJ has seen an executive summary of the review of Greater Manchester ICS, which cited widespread concerns around the allocation of resources, confusion about the role of commissioning, and “muddled” governance, including:
a lack of transparency and trust between partners, with some only sharing a “partial overview” of performance and finances which drives choices likely to “bias” some organisations;
complex architecture of system boards, committees and forums, with “muddled” governance, unclear paths for critical decisions to be made, and unclear delegations to localities;
frustration at the quantum of meetings that take place at system, locality and provider level.
Read full story (paywalled)
Source: HSJ, 2 June 2023
Sam
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