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

"There is a level of complacency": trial exposes UK’s vulnerability to organ harvesting

The UK is supposed to have one of the best systems in the world for preventing vulnerable people being exploited for their organs. How then did one of its biggest hospitals become embroiled in the macabre trade of kidney harvesting?
The UK’s first trial organ trafficking trial has exposed alarming vulnerabilities to a illegal trade that makes up 10% of transplants worldwide. The case has highlighted how poverty can tempt some people to sell their body parts to those willing to exploit an acute global shortage of organs for donation.
The case heard that doctors at a private renal unit at London’s Royal Free hospital and the regulators, the Human Tissue Authority (HTA), were fooled by Dr Obinna Obeta, into approving his kidney transplant in July 2021.
As the prosecutor, Hugh Davies, said: “If there’s a lesson to be learned here – those clinicians need to set the index of suspicion for safeguarding somewhat lower.”
Dominique Martin, a professor of health ethics at Australia’s Deakin University who studies organ trafficking, said the case highlighted the need for robust vetting by hospitals and regulators.
She said: “There is a level of complacency, including in the UK, the US and Australia regarding the risks of organ trafficking happening within our borders. Screening programmes may not be as strong as we assume or as consistently implemented as we might expect.”
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Source: The Guardian, 23 March 2023
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‘It is not right to normalise the current GP workload’, says RCGP chair

It is ‘not right to normalise’ the current workload in general practice as numbers of GPs and practices goes down, the RCGP chair told delegates at Pulse Live this week. 
Professor Kamila Hawthorne highlighted the pressure GPs are under with general practice appointments increasing most last year, compared to A&E and outpatients. 
She also said her priority from a new GP contract would be better resourcing for GPs working in deprived areas. 
Her speech looked at the challenges facing general practice and imagined what the future could look like, including what the college can do to bring about change.
Professor Hawthorne said: ‘The workload that we’re facing – it’s not right to normalise it. The sort of work days that we have in general practice, it is not right to normalise this.
‘The number of GPs is going down because they’re leaving the profession faster than they’re entering it. The number of practices in England is going down, and compared with affluent areas, GPs in deprived areas earn less but see more patients with more chronic illness.’ 
Read full story
Source: Pulse, 21 March 2023
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Stretched A&E staff ‘rarely saw exec team’, review finds

Trust executives and senior managers have been criticised by a former national director for their lack of support for an under-pressure A&E.
An independent review described York Hospital as “reluctant” to trigger internal escalation processes, and suggested it should be quicker to admit extra patients to inpatient wards during busy periods.
Professor Matthew Cooke, a former national clinical director for emergency care who conducted the review, said that during his two-day visit to the department he witnessed a 60-hour delay for a patient to be admitted: “I was surprised not to see any senior managers or executives in the ED, despite such long delays. ED staff reported they rarely saw the executive team.”
Professor Cooke also warned of uncertainty over escalation processes, including for reducing pressure in the emergency department by “boarding” patients on wards beyond normal capacity.
He said: “On the second morning, there were multiple patients on oxygen in ordinary seats in majors waiting room, cared for by a single nurse. I find it difficult to understand how this is safer than boarding one extra patient on several wards.”
“Staff perceived that the organisation was reluctant to move to higher escalation levels and I sensed this meant staff no longer pushed for such actions.”
Read full story (paywalled)
Source: HSJ, 23 March 2023
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Man died of sepsis after being sent home from Milton Keynes Hospital A&E

A father-of-two died of sepsis three days after being sent home from A&E with antibiotics for a suspected urinary tract infection, an inquest heard.
Alex Blewitt, 48, died in July 2022 after suffering a cardiac arrest caused by a perforated bowel and sepsis.
Senior coroner for Milton Keynes, Dr Sean Cummings, said Mr Blewitt's death was avoidable.
The coroner recorded a narrative conclusion and said he intended to issue a prevention of future deaths report.
Mr Cummings said: "The doctor, who saw and assessed Mr Blewitt in the emergency department, did not read the Urgent Care Centre communication that was provided and did not record important factual information in the clinical note.
"Mr Blewitt was discharged, but returned two days later when suffering with sepsis due to a previously undiagnosed bowel perforation."
Mr Blewitt's widow, Amy Blewitt, said: "Alex was in such pain and kept asking the hospital for help, but they sent him home.
"My plea to the hospital is please, please don't let this type of mistake ever happen to anyone else ever again."
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Source: BBC News, 22 March 2023
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Self-harm hospital admissions up 22% for children aged eight to 17

Self-harm hospital admissions for children aged eight to 17 in the UK jumped 22% in one year.
The age group is now the largest for self-harm admissions, with all others seeing a drop, according to NHS data.
Charities say early access to support is vital, but high thresholds and long waiting lists mean more young people are ending up in hospital.
Emily Nuttal, 29, first struggled with self-harm when she was 12. At 13, she was first admitted to A&E.
At that time, she was struggling with changes at school, bullying and troubles at home.
Over the years, she said she had had varied experiences in accident and emergency departments.
"It's been times where it's been really empathetic and passionate people, understanding, supportive. And there's been times where there's been that stigma and judgement."
She said being labelled as "attention-seeking" was really difficult and made it harder to reach out for help again.
"I would then only go if I was forced upon by the crisis service, or if somebody else noticed, and they got people involved," she said.
Read full story
Source: BBC News, 23 March 2023
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Candida auris: deadly fungal infections spreading across US at ‘worrisome’ rate

Potentially deadly fungal infections with Candida auris are spreading rapidly in US healthcare facilities, with cases nearly doubling between 2020 and 2021, the US Centers for Disease Control and Prevention has said.
The number of cases rose by 44% to 476 in 2019, up from 330 in 2018, and subsequently by 59% to 756 in 2020 and by an additional 95% to 1,471 in 2021, the agency’s researchers reported on Monday in Annals of Internal Medicine.
Also concerning was a tripling in 2021 of the number of cases that were resistant to echinocandins, the class of drugs most often recommended for treatment of the disease.
The most common Candida auris symptoms include a high fever and chills that do not improve after antibiotic treatment for suspected bacterial infections, according to guidelines from the CDC. Additional symptoms can develop if the infection spreads.
Dr Waleed Javaid – an epidemiologist, infectious disease expert and director of infection prevention and control at New York’s Mount Sinai Downtown – told NBC News that the new findings were “worrisome”.
Read full story
Source: The Guardian, 21 March 2023
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Why US mothers are more likely to die in childbirth

The United States remains one of the most dangerous wealthy nations for a woman to give birth.
Maternal mortality rose by 40% at the height of the pandemic, according to new data released by the US Centers for Disease Control and Prevention.
In 2021, 33 women died out of every 100,000 live births in the US, up from 23.8 in 2020. That rate was more than double for black women, who were nearly three times more likely to die than white women, according to the CDC.
Compared to other countries, the maternal mortality rate was twice as high in the US than in the UK, Germany and France; and three times higher than in Spain, Italy, Japan and several other countries, according to the most recent global comparison data kept by the World Bank.
"Clearly the US is an outlier," said Joan Costa-i-Font, a professor of health economics at the London School of Economics. "Covid has made [maternal mortality] worse, but it was already a major issue in the US."
Read full story
Source: BBC News, 18 March 2023
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Children getting ‘conveyor belt’ care due to waiting list pressure

The pressure to tackle long waiting lists in children’s community services is impacting care quality, clinical leaders have warned.
It comes after community health services waiting list figures were published for the first time by NHS England last week.
They revealed more than 200,000 children were waiting, of whom 12,000 had been waiting more than a year, and 65,000 more than 18 weeks. While adult community services lists have been coming down fairly steadily since the autumn, children’s services are failing to make progress.
The children’s services with the longest lists are community paediatrics (which mostly deals with neurological development issues such as autism and ADHD), speech and language therapy, and children’s occupational therapy.
Specialists in those areas told HSJ it was the result of staffing gaps, rising and more complex demand, Covid backlog, and years of underfunding.
Read full story (paywalled)
Source: HSJ, 20 March 2023
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Blindness and injuries reported after US recalls eyedrops

US health officials say that eyedrops may have killed one person and severely injured several others due to drug-resistant bacterial contamination.
The Centers for Disease Control and Prevention (CDC) have identified 68 patients across 16 states with a rare strain of Pseudomonas aeruginosa.
The strain had never been found in the US before this latest outbreak.
In addition to the one death, eight patients have suffered vision loss, and four have had eyes surgically removed.
Most of the patients diagnosed with the infection reported using eyedrops and artificial tears, according to the CDC.
Ten different brands were initially identified as possibly linked to the outbreak, the CDC said. Eyedrops that are made in India and imported to the US under two brands were subsequently pulled from shelves in January and February.
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Source: BBC News, 17 March 2023
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No significant clinical harm from Advanced cyber attack, says chief information security officer at NHS England

Following the Advanced cyber attack in August 2022, Phil Huggins has revealed to a Digital Health Rewired audience that the NHS has “seen no clinical impact or significant clinical harm”, after a review to be released in the near future.
The national chief information security officer for health and care at NHS England was speaking alongside a panel on the Cyber Security Stage on day two of Digital Health Rewired 2023 in London.
Huggins explained that although the impact of the Advanced attack was big on the system, in a clinical sense it was not particularly damaging, despite the fact that client data was confirmed to have been exfiltrated.
However, Ayesha Rahim, clinical lead for digital mental health at NHS England and chief medical information officer at Surrey and Borders Partnership Foundation Trust, was also on the panel, and spoke of the huge impact the attack had on staff.
“The date 4th August is imprinted in my brain”, Rahim said, which is when the attack first happened and was first reported. She explained that it is “quite difficult to fully convey the chaos this caused”, giving examples of staff having no idea what a patient’s background was and therefore having to do everything “blindfolded”.
Rahim said staff could not tell if it was safe to go out on visits to mental health patients due to the lack of data and information on them, and every time a person saw a staff member they were retraumatised having to explain their past over and over, including experiences of sexual abuse.
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Source: Digital Health, 15 March 2023
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‘Deliberate attempts’ to conceal racism at NHS agency, says leaked report

Deliberate attempts were made to “conceal the extent of racial discrimination” at a national NHS agency, according to a report leaked to HSJ.
A highly critical internal report at NHS Blood and Transplant (NHSBT) also said fewer than half the recommendations made in 2020 by external mediation experts, around issues of racism, had so far been actioned.
A review conducted by Globis Mediation Group in 2020 found “systemic racism” among management at the agency’s large Colindale site in north London, with ethnic minority staff being “ignored, being viewed as ineligible for promotion and enduring low levels of empathy”.
It made nine recommendations, including exploring whether similar issues existed at the other 15 NHSBT sites.
Read full story
Source: HSJ, 16 March 2023
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USA: Top 10 patient safety concerns for 2023

The US Emergency Care Research Institute (ECRI) has said the paediatric mental health crisis is the most pressing patient safety concern in 2023.
ECRI, which conducts independent medical device evaluations, annually compiles scientific literature and patient safety events, concerns reported to or investigated by the organization, and other data sources to create its top 10 list.
Here are the 10 patient safety concerns for 2023, according to the report: 
1. The pediatric mental health crisis
2. Physical and verbal violence against healthcare staff
3. Clinician needs in times of uncertainty surrounding maternal-fetal medicine
4. Impact on clinicians expected to work outside their scope of practice and competencies
5. Delayed identification and treatment of sepsis
6. Consequences of poor care coordination for patients with complex medical conditions
7. Risks of not looking beyond the "five rights" to achieve medication safety
8. Medication errors resulting from inaccurate patient medication lists
9. Accidental administration of neuromuscular blocking agents
10. Preventable harm due to omitted care or treatment
For the number one spot, ECRI said the COVID-19 pandemic raised the situation, which includes high rates of depression and anxiety among children, to crisis levels. 
ECRI President and CEO Marcus Schabacker, MD, PhD, said social media, gun violence and other socioeconomic factors were fueling the issue, but COVID-19 pushed it into a crisis.  
"We're approaching a national public health emergency," Dr. Schabacker said in a statement. 
Read full story
Source: Becker's Hospital Review, 13 March 2023
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USA: Rise in infant deaths hits Black families hardest, study finds

A new US study highlights a striking racial disparity in infant deaths: Black babies experienced the highest rate of sudden unexpected deaths (SIDS) in 2020, dying at almost three times the rate of White infants.
The findings were part of research by the Centers for Disease Control and Prevention, which also found a 15% increase in sudden infant deaths among babies of all races from 2019 to 2020, making SIDS the third leading cause of infant death in the United States after congenital abnormalities and the complications of premature birth.
“In minority communities, the rates are going in the wrong direction,” said Scott Krugman, vice chair of the department of pediatrics and an expert on SIDS at Sinai Hospital in Baltimore.
The study found that rising SIDS rates in 2020 was likely attributable to diagnostic shifting — or reclassifying the cause of death. The causes of the rise in sleep-related deaths of Black infants remain unclear but it coincided with the arrival of the coronavirus pandemic, which disproportionately affected the health and wealth of Black communities.
Read full story (paywalled)
Source: The Washington Post, 13 March 2023
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Hospitals urged to offer patients more gown sizes

Hospitals are being asked to offer a wider range of gown sizes to better protect patients' dignity.
It follows the experience of a patient from Wiltshire who said she was offered a gown that was "far too small" during a hospital stay in Bristol.
Barbara Gale said it gaped at the back and made her feel "embarrassed".
The experience sparked calls for more sizing options..
An independent study conducted by the University of Strathclyde in Glasgow in 2019 asked patients across the UK for their thoughts on the issue of hospital gowns.
Consultant clinical psychologist for the NHS, Nicola Cogan, led the research and said the findings showed Ms Gale's experience was not an isolated case.
She said: "We spoke to a 1,000 patients and found over two thirds reported they struggled to get a gown on themselves and 70% reported the gown did not fit".
"It's not cost effective for the NHS, but also it shows that the gown is currently not fit for purpose."
Read full story
Source: BBC News, 13 March 2023
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How doctors are exposed and vulnerable due to the current 'blame culture'

The patient lay slumped next to a pile of pills and a personally signed note reading: 'do not resuscitate me'. His breathing was agonal, his skin mottled, his pupils fixed, no pulse discernible. The attending doctor, in agreement with both paramedics and family member, decided to respect his wishes. Yet, this GP was placed under investigation for gross negligence manslaughter by the Crown Prosecution Service (CPS) for not resuscitating the patient, setting in motion a sequence of investigations, including by the coroner and the General Medical Council (GMC), that were triggered by the statement of one policeman at the scene. 
All investigations and allegations were eventually dismissed but not until the GP had been through years of significant physical and mental stress. Still today, questions remain unanswered – in particular, concerning the actions of the police and the CPS.
Speaking under the condition of anonymity, the GP spoke to Medscape News UK, and said that now, over 7 years after that fateful home visit, she remained resolute that she made the correct clinical decisions at the time.
"It has all been very stressful for me. What was behind this case? What was driving this potential prosecution? And throughout, the patient, the family and their concerns were completely forgotten in the pursuit of so-called justice," she pointed out.
Read full story
Source: Medscape News, 9 March 2023
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More than 500 deaths in England last year after long ambulance wait

More than 500 seriously ill patients died last year before they could get treatment in hospital after the ambulance they called for took up to 15 hours to reach them, an investigation by the Guardian reveals.
The fatalities included people who had had a stroke or heart attack or whose breathing had suddenly collapsed, or who had been involved in a road traffic collision. In every case, an ambulance crew took much longer to arrive than the NHS target times for responding to an emergency.
Bereaved relatives have spoken of how the pain of losing a loved one has been compounded by the ambulance crew having taken so long to arrive and start treatment. Coroners, senior doctors and ambulance staff say the scale of the loss of life illustrates the growing dangers to patients from the implosion of NHS urgent and emergency care services.
“These 500-plus deaths a year when an ambulance hasn’t got there in time are tragic and avoidable,” said Dr Adrian Boyle, the president of the Royal College of Emergency Medicine, which represents A&E doctors. “These numbers are deeply concerning. This is the equivalent of multiple airliners crashing.”
Read full story
Source: The Guardian, 9 March 2023
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