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

Trust top team was ‘least cohesive I’ve ever joined’, says new CEO

A review into how a reporting error came about has uncovered tension among an ambulance trust’s previous senior leaders, including that its new CEO felt it was ‘the least cohesive team I have ever joined’.
Management consultancy Verita was commissioned by London Ambulance Service Trust to carry out a review of how it came to be misreporting category 1 (the most serious) response times.
The report, published in board papers on Thursday, said it was caused by a contractor’s programming error going unnoticed and concluded it was “impossible to typify the events of August 2020 as other than an avoidable failure of governance and process”. 
Daniel Elkeles, who joined the trust as CEO in August 2021, told the review that when he joined the senior team it was “the least cohesive team I have ever joined” and said the organisation was not “psychologically safe” for those who wanted to speak up.
Read full story (paywalled)
Source: HSJ, 26 May 2023
Patient Safety Learning

Closing baby unit considered over safety concerns

Health inspectors considered shutting down a maternity unit earlier this year over safety concerns.
The Care Quality Commission (CQC) instead called for "immediate improvements" following a visit to the William Harvey hospital in Ashford, Kent.
Helen Gittos, whose newborn daughter died in the care of the East Kent Hospitals Trust, said there were "fundamental" problems at the trust.
The inspection of East Kent's William Harvey hospital laid bare multiple instances of inadequate practices at the unit, including staff failing to wash their hands after each patient, and life-saving equipment not being in the right place.
Days after the visit, the watchdog raised safety concerns and threatened the trust with enforcement action to ensure patients are protected.
Ms Gittos, whose baby Harriet was born at the East Kent trust's Queen Elizabeth the Queen Mother Hospital (QEQM) in 2014 and died eight days later, said: "When my daughter Harriet was born, the then head of midwifery was so concerned about safety that she thought that the William Harvey in particular should be closed down."
She told BBC Radio 4's Today programme: "Here we are, almost nine years later, in a similar kind of situation. What has been happening has not worked.
"I keep being surprised at how possible it is to keep being shocked about all of this, but I am shocked, that under so much scrutiny, and with so much external help, it's still the case that so much is not right.
"The problems that are revealed are so fundamental that we have to do things differently."
Read full story
Source: BBC News, 26 May 2023
Patient Safety Learning

MHRA and Genomics England to launch pioneering resource to better understand how genetic makeup influences the safety of medicines

A brand-new genetic research resource, known as a ‘biobank’, will be piloted by the Medicines and Healthcare products Regulatory Agency (MHRA) in a joint venture with Genomics England to better understand how a patient’s genetic makeup can impact the safety of their medicines.
The Yellow Card biobank, which will contain genetic data and patient samples, will operate alongside the MHRA’s Yellow Card reporting site for suspected side effects and adverse incidents involving medicines and medical devices. It forms part of a long-term vision for more personalised medicine approaches, as scientists will use the repository of genetic information in the biobank to determine whether a side effect from a medicine was caused by a specific genetic trait. This will in turn enable doctors to target prescriptions using rapid screening tests, so patients across the UK will receive the safest medication for them, based on their genetic makeup.
Adverse Drug Reactions (ADRs), or side effects, continue to be a significant burden on the NHS and account for one in 16 hospital admissions. Understanding the underlying mechanism of an adverse reaction would support the development of pharmacogenetic testing strategies, such as the screening tests enabled through the information provided by the Yellow Card biobank. These strategies would in turn provide the opportunity to prevent rather than react to adverse drug reactions.
The biobank pilot will officially begin on 1 June 2023 with participant recruitment commencing later this year, on 1 September.
Read full story
Source: MHRA, 25 May 2023
 
Patient Safety Learning

Shop around on NHS app to shorten wait for treatment

Patients are being urged to shop around on the NHS app and website to cut their waiting time for treatment in England.
IT systems have been updated to allow patients to more easily exercise their right to choose where they go for planned care, such as knee operations.
They will now be able to view up to five providers - filtered by distance, waiting times and quality of care.
But hospitals warned staffing shortages still needed to be tackled to make the biggest impact on waits.
The idea of choosing where to go for treatment has been in place since the early 2000s, but few use it.
Currently only1 in 10 exercises their right to choose, with patients reporting they are not always offered a choice of where to go or that it is hard to select different venues.
Ministers believe that by searching the list of different hospitals, patients will be able to reduce their waits - potentially by up to three months, research suggests.
Read full story
Source: BBC News, 25 May 2023
Sam

Government pledge to build 40 ‘new’ England hospitals likely to be delayed until after 2030

The health secretary is set to signal a major delay to one of the headline promises in the last Conservative manifesto by suggesting the delivery of 40 new hospitals in England is likely to be pushed back until after 2030.
In a move that will spark anger among MPs who wanted “spades in the ground” before the next election, government sources said Steve Barclay would make the announcement today.
The pledge to build and fund “40 new hospitals over the next 10 years” was one of the major headlines of Boris Johnson’s pitch to the electorate in 2019.
Sources indicated the government had been ready to make the announcement about the probable delay for some time, but it was repeatedly pushed back because of fears about a backlash from Tory MPs.
Rundown NHS hospitals have become a danger to patients, warn health chiefs
Read full story
Source: The Guardian, 25 May 2023
Sam

More hospital beds ‘squeezing out rehab and keeping people out of work’

Extra beds squeezed into hospitals as part of winter planning are crowding out space for rehab, pushing up length of stay and knock-on costs, and increasing the chance of readmission, NHS leaders have been warned. 
Systems and trusts were encouraged to staff thousands of additional ward beds in the run-up to last winter to try to ease emergency care pressures, and government and NHS England have since asked for many of them to be kept open through the year.
However, many of the additional beds are not in proper ward spaces, instead being located in gyms and other areas used for physiotherapy and other rehab. This followed on from some rehab areas already being lost during the pandemic, to be used for beds or storage.
NHSE has sent out a warning about the issue, following a commitment by ministers earlier this year. However, senior figures in physio and older people’s care remain concerned the spaces will not be restored without checks and enforcement, especially as acute trusts remain under pressure to increase general bed space.
Sam

‘Over a year behind’ on key maternity target, NHSE admits

Pregnant women and new mothers are facing wide variation in access to mental health support, new figures suggest, as NHS England admits national performance on a key long-term plan goal to expand services is ‘over a year behind trajectory’.
Analysis of access rates for perinatal mental health services from NHS Digital shows the rates of women accessing support within the past 12 months range from 3.7 per cent in Humber and North Yorkshire to 15 per cent in Shropshire, Telford and Wrekin ICS.
The long-term plan target is for 66,000 women per year to be accessing specialist perinatal services, which can help with conditions such as post-partum psychosis, by March 2024. NHSE admitted in its papers that “although access is increasing, performance remains over a year behind trajectory”.
Read full story (paywalled)
Source: HSJ, 25 May 2023
Sam

Young mental health patients 'at risk' in child wards

A safety investigation has warned that young people with complex mental health needs are being put at significant risk, by being placed on general children's wards in England.
The findings come from the Healthcare Safety Investigation Branch (HSIB).
BBC News recently highlighted the plight of a 16-year-old autistic girl, who spent several months in a children's ward.
Other families have since contacted the BBC describing similar situations.
The majority had faced similar difficulties getting appropriate support.
HSIB says that paediatric wards are designed to care for patients who only have physical health needs and not for those with mental health needs.
It describes the situation in 18 hospitals it visited as "challenging", and 13 were described as "not safe" for children who were suicidal or at risk of harming themselves to be on their paediatric wards.
Read full story
Source: BBC News, 25 May 2023
Patient Safety Learning

Top doctor questions need for change at gender clinic

A doctor with a key role in reforming a controversial gender identity clinic for children has been recorded questioning the need for change.
Prof Gary Butler, clinical lead for the children's gender clinic in England and Wales, also appeared to accuse the author of a report, which will underpin the new service, of "nepotism".
He was recorded making the comments in a keynote speech at a major conference.
The Gender Identity Development Service (Gids), based at London's Tavistock and Portman NHS Foundation Trust, was rated as "inadequate" by inspectors, who visited in late 2020. It was earmarked for closure in July 2022.
An independent review, led by Dr Hilary Cass, also called for a "fundamentally different" model of care for children with gender dysphoria.
Prof Butler has been awarded a key role in shaping the new service, as one of several people tasked with implementing a new training programme, underpinned by Dr Cass's recommendations.
However, BBC Newsnight has learned Prof Butler has publicly questioned the need for change and described Dr Cass's recommendations as "slightly unusual".
In the 14-minute speech at the conference, he talked about current services across the UK, the legal challenges to the situation in England, and how he felt Gids has been the subject of "lies" in the media.
Read full story
Source: BBC News, 24 May 2023
Patient Safety Learning

Northern Ireland: No shows to health appointments costing thousands

Patients who fail to turn up for surgical day case procedures are costing the health service thousands of pounds.
It is a problem across Northern Ireland's five health trusts.
Over a 10-month period in the South Eastern area 14,000 patients did not attend or cancelled review appointments on the day they were due to turn up.
Assistant Director of Elective Surgery at the South Eastern Trust Christine Allam said it was "frustrating".
The South Eastern trust review showed between April 2022 and January 2023, 7,755 people did not attend or cancelled new outpatient appointments on the day.
During the same period, 14,003 or 10% of patients didn't show for review appointments.
Ms Allam said the situation was "frustrating for those patients who are waiting to be seen".
"Those slots where people don't turn up are lost capacity because we haven't been given notice - and this only lengthens the waiting lists," she added.
It is a problem that all health trusts are experiencing.
Read full story
Source: BBC News, 24 May 2023
Patient Safety Learning

World must prepare for disease more deadlier than Covid, WHO chief warns

The head of the World Health Organisation warned on Tuesday that governments need to prepare for a disease even deadlier than Covid-19.
Dr Tedros Adhanom Ghebreyesus, director general of WHO, told its annual health assembly in Geneva that it was time to advance negotiations on preventing the next pandemic.
He warned that nation states cannot “kick this can down the road” and that the next global disease was bound to “come knocking”.
Dr Tedros said: “If we do not make the changes that must be made, then who will? And if we do not make them now, then when?”
He added: “The threat of another variant emerging that causes new surges of disease and death remains. And the threat of another pathogen emerging with even deadlier potential remains.”
Read full story
Source: The Independent, 24 May 2023
Patient Safety Learning

An exercise trial for Long Covid is being criticised by some patients

A proposed exercise trial for Long Covid is being criticised by some of the patients the government-funded researchers want to study.
The trial is part of the Researching COVID to Enhance Recovery (RECOVER) initiative, funded by the US government for $1.15 billion over four years. It aims to study Long Covid and help find treatments for the millions of people experiencing a range of long-lasting symptoms, including extreme fatigue, brain fog and shortness of breath.
The exercise study protocol has not been finalised, but it will test physical therapy at different intensity levels, tailored to the patient’s capabilities, and aim to improve endurance, said Adrian Hernandez, executive director of Duke Clinical Research Institute.
Some Long Covid advocates, however, say that any exercise trial could be potentially dangerous for long-covid patients with myalgic encephalomyelitis (ME/CFS), also known as chronic fatigue syndrome.
Studies show that people with ME/CFS don’t have the same response to physical exertion as healthy individuals, and many ME/CFS patients report a worsening of symptoms after even small amounts of activity. This crash is called post-exertional malaise.
Advocates now worry that Long Covid patients with ME/CFS could be similarly harmed if they take part in any exercise study.
Read full story (paywalled)
Source: Washington Post, 22 May 2023
Further reading on the hub:
Understanding Covid-19 as a vascular disease and its implications for exercise
 
Patient Safety Learning

Work pressures driving nurses and midwives away

Work pressures are driving thousands of nurses and midwives a year away from the profession, the Nursing and Midwifery Council  (NMC) says.
The NMC said retention was becoming a major concern despite an overall growth in the register.
Its annual report found 27,000 professionals had left the register in the UK in the year to the end of March.
While retirement appeared to be the most common reason for leaving, health and exhaustion were cited as the next.
NMC Chief Executive Andrea Sutcliffe said: "There are clear warnings workforce pressures are driving people away.
"Many are leaving earlier than planned, because of burnout and exhaustion, lack of support from colleagues, concerns about quality of care and workload and staffing levels."
Read full story
Source: BBC News, 24 May 2023
Patient Safety Learning

Approach to tackling violence raises concern among NHS England staff

There has long been an acknowledgment by ministers and NHS leaders that violence against staff by patients was an issue that needed addressing, with a strategy to tackle it announced nearly five years ago.
The health service’s 2019 long-term plan included a pilot for the use of body-worn cameras by paramedics in a bid to “de-escalate” situations. The following year the Crown Prosecution Service announced an agreement with the police and NHS England to “secure swift prosecutions” of those who assault staff, and the maximum penalty for assaulting emergency workers, including doctors and nurses, was also doubled to two years.
Despite these measures, there have been internal disagreements within NHS England about the best approach to the problem, which affected almost 15% of staff last year, according to the latest national survey of the health service workforce.
The Guardian understands that senior managers in NHS England told staff in its violence prevention and reduction (VPR) team last April that prosecutions of those who assaulted healthcare workers and dismissals of abusive staff should be a last resort. Instead, the focus should be on improving the culture of the NHS and staff wellbeing.
It is also understood that managers cautioned against using the term “zero tolerance” because they said it did not take into account that some people who abuse NHS staff might lack capacity, an apparent reference to mentally ill patients.
Read full story
Source: The Guardian, 23 May 2023
Patient Safety Learning

New treatment ‘can help people stop taking opioid painkillers for chronic pain’

A new treatment could help people to stop taking addictive opioid painkillers for chronic pain, research suggests.
Data suggests there are one million people at risk from longer-term continuous opioid prescriptions, and more than 50,000 have been taking these for six months or more.
While recent NHS initiatives have managed to reduce opioid prescribing by 8%, saving an estimated 350 lives, the new research has found evidence that could help many more people stop their opioid painkiller use.
A team of researchers and doctors has developed and successfully trialled a programme designed to guide people in coming off prescription painkillers, tapering their opioid intake and learning how to manage their pain using alternative techniques with a course which combines one-to-one and group support.
According to the findings, after one year, one in five people were able to stop taking opioids without their pain increasing.
The scientists suggest the new treatment is an alternative to opioid use and has potential to give patients a better quality of life.
Read full story
Source: The Independent, 23 May 2023
Patient Safety Learning

Essex GP struck off over 'sexually motivated' examination

A GP accused of trying to pull down a patient's gym shorts and of touching her genitalia has been struck off the medical register.
The Medical Practitioners Tribunal Service found Dr Kamran Ali's behaviour towards four women at a surgery in Essex amounted to misconduct.
The tribunal heard he had not practised since the allegations in 2016.
The 44-year-old, of Glendale Gardens, Leigh-on-Sea, was cleared of criminal charges following a trial in 2018.
Panel chairman William Hoskins said at the tribunal on Thursday that erasing him from the register was necessary to "protect public confidence in the medical profession".
A female patient - referred to as Patient C - reported his behaviour to police in the November.
She had complained of spots on her face, white coating on her tongue and wanted a repeat prescription for anxiety medication.
The panel heard Dr Ali began to pull down her gym shorts and examined her genitalia without wearing gloves and without obtaining consent.
Read full story
Source: BBC News, 23 May 2023
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