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

Players told to 'sit it out' under new concussion guidance

Anyone with suspected concussion must be immediately removed from football, rugby and other sports and rest for at least 24 hours, under new guidance for grassroots clubs.
It says the NHS 111 help-line should be called and players should not return to competitive sport for at least 21 days.
The UK-wide guidelines are aimed at parents, coaches, referees and players.
Its authors say a "culture change" in the way head injuries are dealt with is needed.
"We know that exercise is good for both mental and physical health, so we don't want to put people off sport," Prof James Calder, the surgeon who led the work for the government, said.
"But we need to recognise that if you've got a head injury, it must be managed and you need to be protected, so that it doesn't get worse."
Read full story
Source: BBC News, 2 May 2023
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Watchdog repeatedly told about private NHS medicines courier

The watchdog responsible for investigating unresolved healthcare complaints has been warned repeatedly for nine months about problems with Sciensus, a private company paid millions to deliver vital medicines to NHS patients, the Guardian can reveal.
The Parliamentary and Health Service Ombudsman (PHSO) has received 18 official requests to examine grievances against Sciensus since August last year, but has not begun any investigations, according to a person familiar with the matter.
The revelation comes after a Guardian investigation exposed serious and significant concerns raised by patients, clinicians and health groups about Sciensus.
The investigation revealed that the company has struggled to provide a safe or reliable service. Patients persistently complain about delayed or missed home deliveries of medication, the Guardian found, with clinicians warning that the health of some has deteriorated as a result.
The investigation also uncovered how some NHS staff experience “daily issues” with Sciensus. Others reported an increase in patients “flaring” as a result of missed or delayed medication. Some have seen a rise in hospital admissions.
In the wake of the investigation, the Care Quality Commission, the care regulator, said it was “aware of concerns raised” about Sciensus, and was reviewing them.
Read full story
Source: The Guardian, 1 May 2023
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Failure to recognise ectopic pregnancy causing women’s deaths, says expert

Women are dying or suffering avoidable harm because of a failure to recognise ectopic pregnancy, one of the country’s leading experts on maternal health has said.
Speaking to the Guardian, Prof Marian Knight of the University of Oxford, who leads a national research programme on maternal deaths, called for action to improve diagnosis of the acute, life-threatening condition, in which a fertilised egg implants itself outside the womb, normally in the fallopian tube. Ectopic pregnancies are never viable and if left untreated can result in the tube rupturing, causing potentially fatal internal bleeding.
“We could prevent more women from dying from ectopic pregnancy because of lacking of basic recognition and management of the condition,” said Knight.
The warning comes as new data obtained by freedom of information request suggests that dozens of women have experienced “severe harm” after being admitted to hospital with ectopic pregnancies in the past five years.
The Mbrrace report, published last year, said eight women died from ectopic pregnancies between 2018 and 2020, all but one of whom had received suboptimal treatment. In three instances, better care might have saved their lives, the report concluded.
“There’s no doubt that in the [maternal deaths] inquiry we are still seeing the same messages of ectopic pregnancy not being recognised,” said Knight. “That people either don’t pick up on the fact that they’re pregnant or get single-minded about one diagnosis.”
Read full story
Source: The Guardian, 1 May 2023
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UK study highlights heart disease risk from older types of hip replacement

Patients who have had older types of hip replacement may be at greater risk of heart damage than previously thought, researchers have said, because of cobalt leaching out of so-called metal-on-metal implants.
Tens of thousands of UK patients were fitted with these devices during the 2000s, when they were marketed as a solution for young, active patients who needed a hip replacement that would last a lifetime.
The issue is that tiny metal ions made up of cobalt and chromium are thought to break off from the implants and leak into the blood, and there are fears this could cause muscle, bone and organ damage.
Surgeons began to voice concerns about the implants in 2008, and in 2012 the Medicines and Healthcare products Regulatory Agency (MHRA) issued guidance recommending annual blood or MRI checks for patients who had received them. Since then, mounting evidence has suggested that such individuals may be at greater risk of heart disease.
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Source: The Guardian, 26 April 2023
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Six systems pulled up by NHSE over poor cancer diagnosis performance

NHS England has demanded recovery plans from six systems with a poor record on delivering urgent cancer checks. 
NHS England has told the chief executives of the six integrated care boards they must “present and deliver a plan” to make more use of their diagnostic facilities for patients who need urgent cancer checks. The “facilities” referred to are all community diagnostic centres.
The six were selected because they diagnosed or ruled out fewer than 70% of urgent cancer referrals within 28 days during February. This benchmark is known as the “faster diagnostic standard”. 
A letter to the chief executives said: “improving waiting times for patients referred for urgent suspected cancer will be a critical priority for the NHS over the coming year”. It adds: “it is essential… our national investments in diagnostic capacity are more clearly prioritised for patients being investigated for urgent suspected cancer”.
Read full story (paywalled)
Source: HSJ, 28 April 2023
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‘More than half of my paycheck goes to rent’: young US doctors push to unionise

Young doctors just out of medical school working as resident physicians, fellows and interns at major US hospitals are organising unions at an increasing rate, citing long-running problems highlighted by the Covid-19 pandemic and a need to rethink the struggles young doctors face in the profession.
The Committee of Interns and Residents, an affiliate of SEIU, added five unionised sites in 2022 compared with about one a year before the pandemic and the surge has continued in 2023 with multiple union election filings. It currently represents over 25,000 residents, fellows and interns across the US, comprising about 15% of all resident and fellow physicians.
Hospital management has opposed the unionisation effort, declining to voluntarily recognise the union, encouraging residents not to sign union authorisation cards ahead of the election filing and writing local op-eds in opposition to unionisation.
Since going public with their union plans, staff have been sent emails and been invited to meetings to try to dissuade residents from unionising, “often counting on myths around what unionizing would mean”, said Dr Sascha Murillo, a third-year internal medicine resident at Massachusetts general hospital.
The unionising campaign took off after vulnerabilities in the healthcare system were exposed by the Covid-19 pandemic, she said, with residents working on the frontlines and bearing the brunt of staffing shortages, an influx of Covid-19 patients, and patients who deferred medical care.
Read full story
Source: The Guardian, 27 April 2023
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Use of antibiotics in farming ‘endangering human immune system’

The blanket use of antibiotics in farming has led to the emergence of bacteria that are more resistant to the human immune system, scientists have warned.
The research suggests that the antimicrobial colistin, which was used for decades as a growth promoter on pig and chicken farms in China, resulted in the emergence of E. coli strains that are more likely to evade our immune system’s first line of defence.
Although colistin is now banned as a livestock food additive in China and many other countries, the findings sound an alarm over a new and significant threat posed by the overuse of antibiotic drugs.
“This is potentially much more dangerous than resistance to antibiotics,” said Prof Craig MacLean, who led the research at the University of Oxford. “It highlights the danger of indiscriminate use of antimicrobials in agriculture. We’ve accidentally ended up compromising our own immune system to get fatter chickens.”
Read full story
Source: The Guardian, 25 April 2023
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Discrimination ‘biggest cause of staff leaving’

Discrimination and inequality are bigger factors for staff wanting to leave acute trusts than burnout, new analysis of this year’s NHS staff survey has found. 
Researchers at LCP compared 12 summary indicators within the survey to answers on intention to leave, to build a “relative importance model” to explain “nearly 85% of the variation in intention to leave”.
LCP said: “Approximately 30 per cent of that explained variance is attributable to the diversity and equality score (compared to less than 10 per cent attributable to the burnout summary indicator score).”
Natalie Tikhonovsky, an analyst in LCP’s Health Analytics team, said: “Our analysis reveals a grim picture of low satisfaction levels and higher staff turnover rates currently facing the NHS acute sector. Understanding what is driving this will be key to the success of the government’s new workforce plan and to the overall aim of reducing steadily increasing wait lists.”
Read full story (paywalled)
Source: HSJ, 28 April 2023
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Staff get ‘aggressive verbal abuse’ over strike cancellations

A hospital trust has said its staff have been verbally abused when contacting some patients to postpone their appointments because of next week’s nursing strike.
Oxford University Hospitals Foundation Trust posted a statement to its website yesterday, which said: “It is very regrettable that we have to report that our staff have been verbally abused when contacting some patients to postpone their appointments. We fully understand and appreciate how disappointing and frustrating any postponement is, and we only do this if we absolutely have to in order to provide safe care for all our patients.
“Our staff are doing their best in challenging circumstances to make sure you are informed as soon as possible. We do not tolerate abuse of our staff and abuse will be noted and further action may be taken.”
Read full story (paywalled)
Source: HSJ, 27 April 2023
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Almost one in three doctors investigated by GMC ‘have suicidal thoughts’

Almost one in three UK doctors investigated by the General Medical Council (GMC) think about taking their own life, a survey has found.
Many doctors under investigation feel they are treated as “guilty until proven innocent” and face “devastating” consequences, the Medical Protection Society (MPS) said.
Its survey of 197 doctors investigated by the GMC over the last five years found:
31% said they had suicidal thoughts. 8% had quit medicine and another 29% had thought about doing so. 78% said the investigation damaged their mental health. 91% said it triggered stress and anxiety. The MPS, which represents doctors accused of wrongdoing, accused the GMC of lacking compassion, being heavy-handed and failing to appreciate its impact on doctors.
Read full story
Source: The Guardian, 27 April 2023
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Hospital to send hundreds of births elsewhere

The trust at the centre of a maternity scandal is trying to reduce the number of births at its main maternity units by 650 a year following a highly critical Care Quality Commission (CQC) visit.
East Kent Hospitals University Foundation Trust is looking at ways to reduce pressure on staff at the William Harvey Hospital in Ashford, including stopping bookings from women who are “out of area”. The unit currently has around 3,600 births a year, of which 200 are out-of-area bookings. The trust is also seeking to send more births to its other site, in Thanet.
It comes after the CQC used enforcement powers to order immediate improvements at the unit, following a visit in January, when it had “significant concerns about the ongoing wider risk of harm to patients”. 
Earlier this year, the trust’s new chief executive, Tracey Fletcher, held what board papers describe as an “emotional” meeting with 135 midwives, other staff and senior Royal College of Midwives representatives. She was told by staff that the service at the WHH was not felt to be safe due to a lack of substantive staff, high acuity of patients and the level of activity.
Read full story (paywalled)
Source: HSJ, 28 April 2023
Patient Safety Learning

Nurses' strike in England to be cut short after court ruling

A 48-hour strike by nurses in England over the Bank Holiday weekend will be cut short by a day after a High Court judge ruled it was partly unlawful.
The walkout in a row over pay by the Royal College of Nursing, due to start on Sunday, will now end on Monday.
RCN chief Pat Cullen said this was "the darkest day" of the dispute so far and the government needed to negotiate.
Downing Street said it was "regrettable" the government had to go to court and it had tried to avoid it.
Health Secretary Steve Barclay took legal action after NHS Employers said the last day of the planned strike was not covered by the mandate as the ballots closed on 2 November at midday.
The judge Mr Justice Linden ordered the RCN to pay the costs of the hearing, saying the union had showed "a high degree of unreasonableness", the outcome was "inevitable" and "instead of grasping the nettle and conceding" it had forced the case to court.
Read full story
Source: BBC News, 27 April 2023
 
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Whorlton Hall: Four guilty of ill-treating hospital patients

Four carers have been found guilty of ill-treating patients at a secure hospital, following a BBC Panorama investigation.
Nine former staff at Whorlton Hall, near Barnard Castle, County Durham, had faced a total of 27 charges. Five of those on trial have been cleared.
Jurors heard vulnerable patients were mocked and treated with "contempt".
Lawyers for the defendants argued their clients had been doing their best in very challenging circumstances.
The men found guilty have been bailed and will be sentenced at Teesside Crown Court in July.
Speaking after the verdicts, Christopher Atkinson, of the Crown Prosecution Service, said the four men had a "duty of care for patients who, due to significant mental health issues, were wholly dependent on their support every day of their lives".
He said it was "clear" there were times when the care provided was "not only devoid of the appropriate respect and kindness required but also crossed the line into criminal offending".
Read full story
Source: BBC News, 27 April 2023
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UK on verge of new dawn for dementia treatments, says taskforce chair

Today’s generation of elderly people could be the last to face the spectre of untreatable Alzheimer’s disease, according to the co-chair of the government’s new dementia mission.
Hilary Evans, the chief executive of Alzheimer’s Research UK, appointed by ministers last month, said the world was “on the cusp of a new dawn” for dementia treatments that meant devastating neurodegenerative illness would no longer be regarded as an inevitable part of old age.
However, she warned that an overhaul of NHS dementia care was required to ensure that patients could access the first effective Alzheimer’s drugs, which could be approved in the UK as soon as next year.
Evans was appointed last month to co-chair the UK government’s national dementia initiative, which aims to draw lessons from the Covid vaccine taskforce to accelerate dementia research and comes with a commitment to double funding for dementia research to £160m a year by 2024–2025.
Read full story
Source: The Guardian, 26 April 2023
Patient Safety Learning

NHS warned over writing to patients in English after child dies

Patient safety investigators have issued a warning to the NHS over writing to patients only in English after a Romanian child died following missed cancer scans.
The three-year-old, of Romanian ethnicity, had an MRI scan delayed after they were found to have eaten food beforehand.
When the appointment for the child’s MRI scan was made by the radiology booking team, a standard letter was produced by the NHS booking system in English asking the child not to eat before the scan, despite the family’s first language being Romanian. Staff at the trust had hand-written on the patient’s MRI request sheet that an interpreter was required.
“The family recognised key details in the written information, including the time, date and location of the scan,” the report said.
“However, they were not able to understand the instructions about the child not eating or drinking (fasting) for a certain amount of time before the scan.”
The Healthcare Safety Investigation Branch (HSIB) has urged NHS England to develop and implement new rules on supplying written appointment information in languages other than English.
Read full story
Source: The Independent, 27 April 2023
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Outcome of the expert review of the safety of isotretinoin

Following an in-depth expert safety review of the acne drug isotretinoin (commonly known by brand names Roaccutane and Reticutan), the Commission on Human Medicines (CHM) has agreed to a number of recommendations to strengthen the safe use of the treatment.
Isotretinoin is used to treat severe forms of acne, especially if there is a risk of permanent scarring. This medicine is an extremely effective last-line treatment for severe acne. However, patients and members of the public have raised concerns about suspected side effects associated with isotretinoin, including psychiatric (mental health) and sexual side effects that sometimes continue after treatment with isotretinoin has been stopped.
Key recommendations include:
Better information for patients and their families about the risks of isotretinoin so that they can make an informed decision before using this medicine. Consistent monitoring of a patient’s psychiatric and sexual health so that any problems are spotted earlier and there are defined routes for patients to receive help. Tighter controls on first prescribing isotretinoin to young people (aged 12 to 18) so that it is only started when doctors agree the acne is severe enough to justify it and that other standard treatments have been sufficiently tried and haven’t worked. Patient Safety Commissioner, Henrietta Hughes tweeted last night: "I welcome the new recommendations from @MHRAgovuk to strengthen the safe use of isotretinoin. Courageous patients and families have shared their experience with the review. It’s only by listening and acting that we can meet patients’ needs."
Read MHRA press release, 26 April 2023
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