It was created with the very best of intentions – to help hospitals learn lessons when a baby or mother is harmed or dies.
But a Channel 4 News investigation has been hearing that the maternity programme of the Healthcare Safety Investigation Branch – or HSIB – was riddled with flaws.
One former senior staff member spoke to Channel 4 about bullying within the organisation and failings which could have led to harm.
In a previous report, Channel 4 heard from the mothers of Beatrice and Marnie, who were stillborn and other parents have come forward with their experience.
Watch the story
Source: Channel 4 News, 16 May 2023
As excitement builds throughout health and information systems worldwide over the rich potential benefits of new tools generated by artificial intelligence (AI), the World Health Organization (WHO) has called for action to ensure that patients are properly protected.
Cautionary measures normally applied to any new technology are not being exercised consistently with regard to large language model (LLM) tools, which use AI for crunching data, creating content, and answering questions, WHO warned.
“Precipitous adoption of untested systems could lead to errors by healthcare workers, cause harm to patients, erode trust in AI, and thereby undermine or delay the potential long-term benefits and uses of such technologies around the world,” the agency said.
As such, WHO proposed that these concerns are addressed and clear evidence of benefits are measured before their widespread use in routine health care and medicine.
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Source: United Nations News, 16 May 2023
Hospitals are deploying staff with less training than nurses – wearing the same uniforms – a conference has heard.
Nurses said trusts trying to make “cost savings” were using cheaper nursing associates, and treating student nurses as free labour, to try to plug gaps that should be filled by more qualified staff.
They are trained in similar basic skills to nurses, but have two years of training and a foundation degree qualification, compared to three years studying and a university degree for registered nurses.
Nurses at the RCN annual congress in Brighton said the associate workers are frequently being given equally complex tasks, as pressures mounted.
In some cases, they were even being given the same uniforms, meaning patients cannot distinguish between nurses and less-qualified staff, nurses said.
Meanwhile, student nurses, who should be shadowing trained staff to learn new skills, were increasingly being asked to fill in for healthcare assistants, the conference heard.
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Source: The Telegraph, 16 May 2023
More than 26,000 adults with severe mental illness die prematurely each year from preventable physical illnesses, analysis by the Royal College of Psychiatrists suggests.
New data from the Office for Health Improvement & Disparities shows 120,273 adults in England with severe mental illness, including psychosis, post-traumatic stress disorder and schizophrenia, died before the age of 75 between 2018 and 2020.
Of these, the College estimates 80,182 deaths (two in three) were potentially preventable, which is an average of 26,727 people each year.
Preventable deaths include deaths from diseases like cancer and heart disease which could have been prevented with earlier detection and treatment or lifestyle changes. While adults with severe mental illness are more likely to engage in unhealthy behaviours like smoking and drinking alcohol excessively, they are also less likely to access screening and treatment for a range of reasons including stigma associated with having a mental illness.
While cancer is the leading cause of premature death among those with a severe mental illness, it also significantly increases the risk of dying before the age of 75 across a range of physical health conditions. Adults with severe mental illness are on average:
6.6 times more likely to die prematurely from respiratory disease
6.5 times more likely to die prematurely from liver disease
4.1 times more likely to die prematurely from cardiovascular disease
2.3 times more likely to die prematurely from cancer.
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Source: Royal College of Psychiatrists, 17 May 2023
Experts are calling for "do not resuscitate" orders to be scrapped, saying they are being misused and putting people's lives at risk. One woman told BBC News that her elderly father might still be alive if the DNR in his medical file had been properly checked.
When Robert Murray began choking on a piece of fruit at breakfast, staff at his care home called 999. He'd stopped breathing and the ambulance service operator immediately sent paramedics to attend.
But seconds later, the care home told the dispatcher that the 80-year-old had a do not resuscitate form (DNR) in his medical records. The paramedics were stood down. Mr Murray died minutes later.
However, it was all a terrible mistake. It hadn't been made clear to the ambulance service that Mr Murray was choking - the DNR was only meant to apply should he have a cardiac arrest.
Mr Murray's death, at a nursing home in Eastbourne in June 2021, is an example of what experts call "mission creep" in the use of DNR - also known as DNACPR (Do Not Attempt Cardiac Pulmonary Resuscitation) - decisions.
Researchers from Essex University say some care home residents are "being inappropriately denied transfer to hospital or access to certain medicines" due to the recommendations.
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Source: BBC News, 16 May 2023
Trainee medics in a troubled maternity department have flagged concerns with national regulators over the safety of patients, it has emerged.
Last year the General Medical Council said it had concerns about the treatment of obstetric and gynaecology trainees at University Hospitals Birmingham and placed medics at Good Hope Hospital and Heartlands Hospital under intensive support known as “enhanced monitoring”.
The GMC’s review flagged serious concerns about emergency gynaecology cover arrangements and said there was a real risk trainees would become hesitant and reluctant to call on consultant support. In September it placed additional restrictions on training, due to “ongoing significant concerns about the learning environment and patient safety”.
Now it has emerged in board papers for Birmingham and Solihull integrated care board that Health Education England, now part of NHS England, and the GMC carried out a follow-up visit to UHB in late March to review progress.
Board documents state that “several patient safety concerns [were] reported by postgraduate doctors in training to the visiting team”, with a subsequent feedback letter from HEE urging immediate changes to dedicated consultant time and job plans.
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Source: HSJ, 17 May 2023
Blind people are being put “at risk” when the NHS provides them with “inaccessible” information about their health, a charity has warned.
People with sight loss have missed appointments, cancer screenings or been unable to use home test kits because of a lack of clear instructions in an accessible format, according to the sight loss charity RNIB.
It warned that denying people access to their information can also “cause embarrassment and loss of dignity”.
Linda Hansen, from Bradford, who is severely sight-impaired, said that she needed to get her daughter to read her the results of a medical exam which was sent to her in print format.
Ms Hansen, 62, said: “I can get my bank statement or a gas bill in accessible formats, but yet I still receive health information that I can’t read. What could be more personal than your health status?”
A new RNIB campaign – My Info My Way – has been launched calling for all blind and partially sighted people to be given accessible information.
The charity said that a failure to provide information in an accessible format is putting blind and partially sighted people “at risk”.
Read full story
Source: The Independent, 16 May 2023
Trusts must start submitting full data on surgeries which include a high-risk medical device into a new national registry by December as part of a national push to increase accountability and safety around surgery.
NHS England is launching the new mandatory medical device outcome registry this month. The new registry was created in response to Baroness Cumberlege’s “First Do No Harm” review and initial data submissions about surgeries that include a high-risk medical device will begin in June.
Details of the launch arrangements have been set out in a draft letter which HSJ has seen and understands is set to be sent to medical directors and other system leaders imminently.
Relevant procedures include those, for example, involving either a Class III device, like an implant, or a Class IIb therapeutic device, such as drug-eluting balloon catheter.
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Source: HSJ, 16 May 2023
More than half of £2.7bn awarded to NHS organisations for capital projects in 2017 and 2018 has yet to be delivered, research by HSJ has discovered.
The government announced almost £3bn in capital funding to upgrade NHS estates and services in four waves during 2017 and 2018. This was before the pledge to build 40 “new hospitals” by 2030, which has since largely dominated decisions about NHS capital investment.
HSJ looked at the progress of the 143 schemes, worth a total of £2.7bn, known to have been included in the “sustainability and transformation partnership” capital funding programmes.
Only £1.2bn has been given to the organisations involved, and over a fifth of live schemes – which range from emergency department upgrades to new primary care hubs – have not received any allocated funds to date.
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Source: HSJ, 15 May 2023
The UK medical regulator has launched an investigation into a “stalker” doctor who accessed intimate details of the health history of a woman who had begun dating the doctor’s ex-boyfriend.
The General Medical Council (GMC) is investigating whether the doctor – a consultant at Addenbrooke’s hospital in Cambridge – breached their professional, ethical and legal duties to protect the woman’s personal information.
The victim has given the watchdog a statement detailing the consultant’s repeated violations of her medical records and documentation that shows what she did.
The GMC declined to comment because it has not yet decided to open a formal disciplinary case against the consultant, who could face serious sanctions including a ban on working as a doctor. One of the GMC’s investigative officers is examining the victim’s claims and collecting evidence.
The Guardian revealed how the doctor had looked at the victim’s hospital and GP records seven times last August and September, in the early stages of the woman’s relationship with a man the consultant had been involved with for several years.
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Source: The Guardian, 15 May 2023
UK ministers must set out how to recruit and retain thousands more mental health nurses to plug the profession’s biggest staff shortage, healthcare leaders are warning.
Mental health nurses account for nearly a third of all nursing vacancies across England, resulting in overstretched services that are struggling to deliver timely care, according to research carried out by the NHS Confederation’s mental health network.
Sean Duggan, the network’s chief executive, said: “Mental health leaders and their teams are pulling out all the stops in what are very constrained circumstances, but they cannot be expected to solve this staffing crisis alone.
“The knock-on effect means that the mental health crisis the nation is facing will in turn become a crisis for the whole healthcare system and the country. This relentless pressure on mental health staff cannot be allowed to continue with the ultimate impact being on the patients who most need that care.”
Read full story
Source: The Guardian, 16 May 2023
An ‘outstanding’ trust’s Care Quality Commission rating has been dropped to ‘requires improvement’, after inspectors found potential safety risks and a disconnect between board and ward.
A highly critical report on University Hospitals Sussex Foundation Trust also downgraded its well-led rating to “inadequate” and recommended the trust be placed in segment four – the bottom tier – of NHS England’s system oversight framework. Its main tertiary centre – the Royal Sussex County Hospital – was also rated “inadequate”, including for safety.
Deanna Westwood, Care Quality Commission’s director of operations in the South, said “staff and patients were being let down by senior leaders, especially the board, who often appeared out of touch with what was happening on the wards and clinical areas and it was affecting people’s care and treatment”.
Read full story (paywalled)
Source: HSJ,12 May 2023
A hospital trust, which has already implemented a series of safety measures to protect employees, has reported a 17% rise in incidents of abuse against staff by patients and the public in the last year.
Data from the Oxford University Hospital’s clinical incident system, shared with HSJ, shows there were 1,181 cases of violence and aggression against staff in 2022, up from 1,003 in 2021.
Before late 2021, the monthly incident rate very rarely hit 100, while since January 2022 it has topped 100 in seven months, including 162 and 131 incidents respectively in January and February this year.
The ongoing growth is despite the trust launching a campaign, called “No Excuses”, in January 2022,. Measures include bodyworn cameras, and safety devices with alarms and positioning technology for lone workers.
Read full story (paywalled)
Source: HSJ, 16 May 2023
Nine online talking-therapy treatments for anxiety or depression have been given the green light to be used by the NHS in England.
They offer faster access to help but less time with a therapist, which may not suit everyone, the health body recommending them said.
There is huge demand for face-to-face services, with people waiting several weeks to see a therapist.
The new digital therapies, delivered via a website or an app using cognitive-behavioural therapy (CBT), provide an alternative way of accessing support, which may be more convenient for some, the National Institute for Health and Care Excellence (NICE) says.
They could also free up resources and help reduce the wait for care. However, psychiatrists said digital therapies were not a long-term solution.
Mental-health charity Sane said they were no substitute for a one-to-one relationship and could leave people feeling even more isolated than before.
Read full story
Source: BBC News, 16 May 2023
Hundreds of babies are dying unnecessarily because overstretched maternity services are delivering substandard care and struggling to overcome entrenched poverty and racial inequalities, a report has warned.
The report by baby loss charities Sands and Tommy’s says the government’s aim to halve the number of stillbirths and neonatal deaths in England by 2025 is stalling, while there is no target in Scotland, Wales or Northern Ireland.
Stillbirths are creeping up in England after falling in the past decade. Babies dying before and during delivery rose to just over four in every 1,000 births in 2021. Similarly, long-falling rates of neonatal deaths, where newborns die within the first four weeks of birth, are also rising. There were 1.4 deaths of newborn babies for every 1,000 births in 2021, compared with 1.3 in 2020.
Robert Wilson, head of the charities’ joint policy unit, said the government and NHS need to make fundamental changes. “The UK is not making enough progress to reduce rates of pregnancy loss and baby death, and there are worrying signs that these rates are now heading in the wrong direction,” he said.
Read full story
Source: The Guardian, 14 May 2023
Two mothers have renewed calls for a government allergy tsar following their daughters' deaths from severe allergic reactions.
In a letter to Health Secretary Steve Barclay, Tanya Ednan-Laperouse and Emma Turay, from London, said the deaths were "entirely preventable".
MPs are set to debate two allergy petitions on Monday, including one calling for the introduction of an allergy tsar.
In the letter, Mrs Ednan-Laperouse, from Fulham in west London, and Ms Turay, from Wood Green in north London, tell Mr Barclay: "As mothers, we have come together for change so that our tragedies never happen again.
"There are no clear lines of accountability in relation to overall NHS provision of allergy care, nor for the many other areas where policy change is required.
"This lack of national leadership has been raised time and again by coroners at the inquests of those who died following severe allergic reactions."
Ms Turay explained the issue was raised at the inquest into the death of her daughter, Shante.
"The coroner highlighted the fact that 'there is no person with named accountability for allergy services and allergy provision at NHS England or the Department of Health as a whole'," she said.
Read full story
Source: BBC News, 15 May 2023
Further reading:
Prevention of future deaths report: Alexandra Briess (6 April 2023)
Why allergies are the Cinderella service of the NHS – a blog by Tim McLachlan
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