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

GPs ‘in crisis’ as one in four fear surgery is in danger of closing

GPs are facing “insurmountable pressures”, experts have said as they warned that the NHS “will not survive” without general practice.
A new report into GP pressures suggests one in four staff fear their practice is in danger of closing because of unmanageable workloads and rising demand.
The document, from the Royal College of GPs (RCGP), says general practice is “in crisis”, and makes a series of calls to help ease pressures and stop the growing number of GPs from quitting.
The report says GPs are bracing for “winter-style pressures” well into spring and summer.
“The workload pressures in general practice over this winter have been immense, and high levels of patient demand are set to continue for some time,” the report authors wrote.
“General practice is in crisis. We cannot rely on short-term emergency funding pots over winter to try and paper over the cracks."
Read full story
Source: The Independent, 10 March 2023
Patient Safety Learning

USA: Reports of squamous cell carcinoma (SCC) in the capsule around breast implants - FDA safety communication

The U.S. Food and Drug Administration (FDA) is providing an update on reports of squamous cell carcinoma (SCC) in the scar tissue (capsule) that forms around breast implants. Previously, on 8 September 2022, the FDA released a safety communication informing the public of reports of cancers, including SCC and various lymphomas, in the capsule that forms around breast implants.  The various lymphomas are not the same as the lymphomas described previously by the FDA as breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).  
This update includes information from the FDA’s review of literature and medical device reports (MDRs). The FDA is aware of 19 cases of SCC in the capsule around the breast implant from published literature. There have been reports in the literature of deaths from progression of the disease.  While the FDA continues to believe that occurrences of SCC in the capsule around the breast implant may be rare, the cause, incidence and risk factors remain unknown. 
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Source: US FDA, 8 March 2023
Patient Safety Learning

Leap in staff scared to report safety concerns

NHS staff are significantly less comfortable raising concerns and are less confident in their organisation to address them, the service’s annual staff survey has revealed.
The 2022 results, with a response rate of 46%, showed a decline on all measures relating to raising concerns about clinical safety and speaking up more generally, with the greatest deterioration seen in the percentage of staff who would feel secure raising concerns about unsafe clinical practice.
Helen Hughes, chief executive of charity Patient Safety Learning, warned an “alarmingly high” number of staff could not say they felt safe raising concerns.
Ms Hughes continued: “If we are to effectively learn from and prevent future incidents of avoidable harm, staff need to feel safe to raise and discuss patient safety incidents.
“This year’s staff survey results are a clear indication that too often this is still not the case. This is reinforced by the experiences and testimonies of many whistleblowers and the findings of numerous inquiries into major patient safety scandals.”
She added there were a lack of “tangible measures” in place to create a safety culture where staff feel safe to speak up and called for “more resources to support improvement and evaluate their impact”.
Read full story (paywalled)
Source: HSJ, 9 March 2023
Sam

Fears NHS weight loss jab could be harmful to those vulnerable to eating disorders

A newly approved weight loss jab should be used with caution as it could be harmful to those vulnerable to eating disorders, doctors have warned.
Thousands struggling with obesity could be prescribed Wegovy, or semaglutide, which scientists have described as a “game changer”, after the National Institute for Health and Care Excellence (NICE) approved its use.
However, eating disorder experts have warned the NHS to proceed with caution in prescribing the drug, with one GP accusing NICE of being “absolutely reckless” in approving it.
The drug was approved on Wednesday for use in adults who have at least one weight-related condition, such as type 2 diabetes, high blood pressure, high cholesterol sleep apnoea and heart disease, and a body mass index score of at least 35. It can only be prescribed to those undergoing weight management treatment.
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Source: The Independent, 8 March 2023
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'Unprecedented': Coroner prohibits naming of surgeon in herpes deaths inquest

A surgeon who may have infected two new mothers with herpes has been granted anonymity during the inquests into their deaths in an "unprecedented" ruling.
Coroner Catherine Wood said she made the decision because the surgeon's "apprehension" about being named when he stands as a witness would "likely impede his evidence in court" and affect his health.
Mid Kent and Medway Coroners is investigating the cases of Kimberly Sampson, 29, and Samantha Mulcahy, 32, who both died in 2018 after the same obstetrician conducted their caesareans. They were treated 6 weeks apart in hospitals run by East Kent Hospitals University NHS Trust (EKHUT).
On February 26 – the day before the inquest was due to begin and 16 months after it was first announced – EKHUT made a last-minute bid for anonymity covering the surgeon and a midwife also involved in both cases. The trust said they should not be named unless the inquest concluded they had passed on the infection, because of the "reputational damage" they would suffer, and because the surgeon's health was already being impacted by reports.
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Source: Medscape, 9 March 2023
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New government taskforce to lay foundations for preventative NHS

Patients in England are set to benefit from a radical new project that will look to identify innovative new methods of preventing cardiovascular disease, as the Department of Health and Social Care appoints the first ever Government Champion for Personalised Prevention.
John Deanfield CBE, a Professor of Cardiology at University College London, has been asked by the health secretary to explore how the potential of technology and data can be properly harnessed to allow people to better look after their health and reduce the risk of cardiovascular disease.
Professor Deanfield will spearhead a taskforce comprised of experts in everything from policy and technology to economics and behavioural science to deliver a range of recommendations that will lay the foundations for a modern, tailored cardiovascular disease prevention service.
The Government say the recommendations will:
Identify breakthroughs in predicting, preventing, diagnosing and treating risk factors for cardiovascular disease. Advise on how public services, businesses and the population can be encouraged to support prevention outside the NHS. Use personalised data to predict and manage disease more effectively. Bring care closer to homes and communities by establishing new partnerships that advance the way preventative services are delivered. Evaluate how this strategy for cardiovascular disease prevention may impact conditions with shared risk factors. Read full story
Source: NHE, 7 March 2023
Sam

Five women sue Texas over abortion access

Five women who say they were denied abortions in Texas despite facing life-threatening health risks have sued the state over its abortion ban.
Texas bars abortions except for medical emergencies, with doctors facing punishment of up to 99 years in jail.
According to the lawsuit, doctors are refusing the procedure even in extreme cases out of fear of prosecution.
The Center for Reproductive Justice has filed the legal action on behalf of the five women and two healthcare providers that are also plaintiffs.
"It is now dangerous to be pregnant in Texas," said Nancy Northup, the centre's president.
One of the women, Amanda Zurawski, said she had become pregnant after 18 months of fertility treatments. She had just entered her second trimester when she was told she had dilated prematurely and that the loss of her foetus, whom she and her husband had named Willow, was "inevitable".
"But even though we would, with complete certainty, lose Willow, my doctor could not intervene while her heart was still beating or until I was sick enough for the ethics board at the hospital to consider my life at risk," Ms Zurawski said.
For three days, trapped in a "bizarre and avoidable hell", Ms Zurawski was forced to wait until her body entered sepsis - also known as blood poisoning - and doctors were allowed to perform an abortion, according to the lawsuit.
Ms Zurawski spent three days in intensive care, leaving the hospital after a week, the legal action says. The ordeal has made it harder for her to conceive in future, she said.
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Source: BBC News, 8 March 2023
Patient Safety Learning

Trust spent £680k in failed attempt to fight whistleblower

A trust spent £460,000 on legal fees trying to fight a patient safety whistleblowing case that it lost, it can be revealed.
An employment tribunal judge rejected the idea that a consultant nephrologist had done anything to bring about her dismissal from Portsmouth Hospitals University Trust.
Jasna Macanovic was subjected to what the tribunal earlier this year called “a campaign of harassment”, after she warned colleagues that a procedure they were using was harming patients.
After relationships broke down in the Wessex Kidney Unit, she was referred to a disciplinary panel at which two board members – the former nursing director and the current medical director – offered her a good reference if she would resign. She refused and was dismissed in March 2018. The judge noted the offer was clear evidence that the disciplinary process was a foregone conclusion.
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Source: HSJ, 8 March 2023
Patient Safety Learning

‘Worse than childbirth’: women with endometriosis call for better treatments

Lisa Hague, 38, was diagnosed with endometriosis at the age of 17 after being in such severe pain that she resorted to taking a powerful painkiller, dihydrocodeine, that had been prescribed to her partner for a sports injury. She had an allergic reaction to the codeine and was taken to hospital.
After speaking to a doctor about why she had taken such a risk, she was referred for a laparoscopy and diagnosed. “I’d never heard of endometriosis before and didn’t know anyone that had it,” she says. 
The diagnosis was a relief, but there were few treatment options available and she has had to manage intense pain and very heavy bleeding for a few days each month.
At times, she has resorted to sitting against hot radiators or taking scalding baths to “as a distraction from the internal pain”. “It is very dismissed still at the doctors,” she says.
Hague says there is a “desperate need” for better treatments so that her teenage daughter’s generation do not face the same struggle. “Things have got to have changed since I was 17,” she says.
Read full story
Source: The Guardian, 8 March 2023
Patient Safety Learning

‘We are struggling’: US doctors faced with vacuum of information on Long Covid

More than three years into the Covid pandemic, there are a host of important unanswered questions about Long Covid, which significantly limit healthcare providers’ ability to treat patients with the condition, according to US physicians and scientists.
That vacuum of information remains as much of the US has moved on from the pandemic, while Covid long-haulers continue to face stigma and questions over whether their symptoms are real, providers say.
“We don’t quite have our finger on the pulse of what’s wrong, what biologically is causing it, and that’s a big problem,” said Dr Marc Sala, co-director of the Northwestern Medicine Comprehensive Covid-19 Center. “It’s hard to direct drugs or treatments without having the biological underpinnings for why someone is feeling so fatigued with exercise.”
In addition to the ambiguity around the root causes of Long Covid, there are also challenges in research because of how Covid can produce so many different symptoms. The Centers for Disease Control and Prevention list includes fatigue, respiratory issues and difficulty thinking or concentrating but also states that “post-Covid conditions may not affect everyone the same way”.
“Everyone has a different constellation of symptoms,” said Dr Steven Deeks, an infectious disease specialist at the University of California, San Francisco. “Some people get better over time, some people wax and wane, some people get worse,” and so it is difficult for researchers to determine when a study should end and compare a drug versus a placebo.
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Source: The Guardian, 6 March 2023
Patient Safety Learning

‘It’s not just about dying’: Uganda’s pioneers of palliative care undaunted by huge challenges

Morphine was first introduced in Uganda 30 years ago, but as the burden of cancer increases, thousands of people still lack access to even basic treatment or pain relief.
About 70% of the 2,000 patients on Hospice Africa Uganda (HAU)’s programme have cancer, and some are HIV positive, too. Few can afford tests or treatment for their conditions and, even when they can, it is not uncommon for doctors to misdiagnose or fail to prescribe adequate pain relief. Often, by the time a patient is referred to HAU, their condition is incurable, much to the frustration of the team, whose goal is to offer palliative care from the moment a person is diagnosed with a life-limiting condition.
“One of our biggest challenges is to remove the stigma [around palliative care]. Some people think it is about dying, but it is for anyone with a chronic illness that is not going away,” says Antonia Kamate Tukundane, programmes manager at HAU’s Mbarara site in south-west Uganda. “Palliative care focuses on holistic care: How are you? How is your family? What other things are affecting your illness? We provide something the doctors and nurses have no time for.
Dr Anne Merriman at home in Kampala. She founded Hospice Africa Uganda in 1993, with a vision to introduce “palliative care for all in need in Africa”
“Sometimes the patient comes to us very ill and passes on, but if we had known the patient earlier we could have explained what was happening to their body; agreed on realistic goals; all this is so helpful for the patient. Those who find us are glad they did.”
Read full story
Source: The Guardian, 6 March 2023
Patient Safety Learning

Medical records changed as hospitals cover up mistakes, watchdog warns

Hospitals are still covering up serious mistakes in patient care and fobbing off families that raise concerns, the head of the watchdog that investigates complaints against the NHS has warned.
Rob Behrens told The Times he had seen cases of medical records being changed after a death and spoken to doctors who were too scared to speak out about failings in their hospitals.
He called on ministers to change the law to introduce a “duty of candour” on health and other public service staff to “transform” the system and make it more accountable to patients.
He warned: “There is a deep reluctance to explain and give an account of what you do in the health service or the public service for fear of retribution. The things that really get to me are the avoidable deaths of babies in the health service — dying because there’s been poor coordination or they’d been wrongly diagnosed or the parents hadn’t been listened to. That is shocking.”
Read full story (paywalled)
Source: The Times. 6 March 2023
Patient Safety Learning

Scotland first country in the world to ban environmentally harmful anaesthetic

Scotland has become the first country in the world to stop its hospitals using the anaesthetic desflurane because of the threat it poses to the environment.
NHS data suggests the gas, used to keep people unconscious during surgery, has a global warming potential 2,500 times greater than carbon dioxide.
Banning it in Scotland - from its peak use in 2017 - would cut emissions equal to powering 1,700 homes a year.
In the last few years, more than 40 hospital trusts in England and a number of hospitals in Wales have stopped using it.
Dr Kenneth Barker, anaesthetist and clinical lead for Scotland's national green theatres programme, said he was shocked to find the anaesthetic drug he had used for more than a decade for many major and routine operations was so harmful to the environment.
"I realised in 2017 that the amount of desflurane we used in a typical day's work as an anaesthetist resulted in emissions equivalent to me driving 670 miles that day," he said.
"I decided to stop using it straight away and many fellow anaesthetists have got on board.
"When you are faced with something as obvious as this and with the significance it has to the environment - I am very glad we have got to this stage."
Read full story
Source: BBC News, 3 March 2023
Patient Safety Learning

Los Angeles hospital under investigation accused of ignoring Black woman’s pain

April Valentine planned to have a complication-free delivery and to enjoy her life as a first-time parent to a healthy baby girl. Instead, California’s department of health and human services is investigating the circumstances of the April's death during childbirth.
April, a 31-year-old Black woman, went to Centinela hospital in Inglewood on 9 January and died the next day. Her daughter Aniya was born via an emergency caesarean section. Her family and friends say that staff at the hospital ignored the pregnant woman’s complaints of pain, refused to let her doula be in the hospital room during the birth and neglected Valentine as her child’s father performed CPR on her.
“It’s hard to even sleep, to even look at my child after seeing what I saw in that hospital that night,” said Nigha Robertson, Valentine’s boyfriend and Aniya’s father, to the Los Angeles county board of supervisors during its 31 January meeting. “I’m the only one who touched her, I’m the one who did CPR. Nobody touched her, we screamed and begged for help … they just let her lay there and die.”
During the 31 January board of supervisors meeting, people who spoke in support of Valentine said that Centinela hospital is known around the community for being one of the “worst hospitals in the county” for Black and Latina mothers and their infants. 
Since 2000, the maternal mortality rate in the US has risen nearly 60%, with about 700 people dying during pregnancy or within a year of giving birth each year. More than 80% of the deaths are preventable, according to the US Centers for Disease Control and Prevention. The US has the highest maternal mortality rate among industrialized countries and Black women are three times more likely to die during childbirth than white women.
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Source: The Guardian, 3 March 2023
Patient Safety Learning

Race and deprivation set back medical trainees, GMC analysis finds

New research shared with HSJ  has ‘laid bare’ the inequalities experienced by medical trainees, with black doctors more likely to perform worse in exams than any other ethnic group.
The report published by the General Medical Council (GMC) highlights that UK medical graduates of black or black British heritage have the lowest specialty exam pass rate of all ethnic groups at 62%, which is almost 20 percentage points lower than that of white doctors (79%). It is the first time the medical regulator has split this data by ethnicity, it said. 
The GMC has pledged to “eliminate discrimination, disadvantage and unfairness” in undergraduate and postgraduate medical education by 2031 and the disproportionate number of fitness to practise complaints received about ethnic minority doctors and doctors who gained their medical qualification outside of the UK by 2026.
Read full story (paywalled)
Source: HSJ, 2 March 2023
Patient Safety Learning

Half of men with eating disorders don’t get any help: 8 warning signs somebody needs support

Over half of men with an eating disorder have never had any treatment, according to new research.
Despite typically being linked with females, males account for a quarter of all eating disorder cases – and many are not getting any support, the eating disorder charity Beat is highlighting
“Eating disorders affect 1.25 million people in the UK, and we estimate one in four of those are men,” says Tom Quinn, Beat’s director of external affairs – speaking to mark this year’s Eating Disorders Awareness Week (February 27 – March 5).
“We surveyed men across the UK about their experiences of an eating disorder and, alarmingly, we discovered over half have never had treatment for their eating disorder, and one in three have never tried to get treatment in the first place.
“There’s a harmful misconception that eating disorders are female illnesses, which creates a great deal of shame and can entrench harmful behaviours for men who are unwell,” Quinn adds.
Read full story
Source: The Independent, 27 February 2023
Further reading on the hub: Top picks: Eight resources on eating disorders
 
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