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

Cybersecurity strategy among dozens of tech promises missed by government

The government has failed to meet most of its own deadlines for commitments to improve how the NHS uses data, including developing a cybersecurity strategy, HSJ can reveal.
The delays include work to store and analyse patient data more securely, building public trust in the NHS’ use of patient data, and agreeing national strategies on cybersecurity and cloud technology.
The strategy and its commitments were published following the Goldacre Review, which called for an overhaul of how NHS patient data is collected, stored and used.
It came after the government was forced to indefinitely halt a controversial plan to collect all GP-held patient data in 2021, which resembled the fate of a similar data scheme in 2016.
Several data projects have also come under scrutiny from doctors and campaigners in recent years, such as NHS England’s procurement of a new Federated Data Platform and a much-criticised trust’s data-sharing scheme with a credit rating company.
Read full story (paywalled)
Source: HSJ, 28 February 2023
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Woman died after breathing tube put in food pipe

A mother-of-one died after a breathing tube was put into her food pipe, despite staff raising concerns it was inserted incorrectly, an inquest heard.
Emma Currell, 32, had just received dialysis and was heading home to Hatfield, Hertfordshire, in an ambulance when she had a seizure. 
An anaesthetic team was called to sedate her as her tongue had swelled and she was bleeding from the mouth.
Dr Sabu Syed, who was a trainee anaesthetist, told the hearing: "I used suction to remove blood and I was able to push the tongue to the side and got a partial view."
She said she believed she inserted the tube into the trachea - the windpipe - and had asked her senior colleague Dr Prasun Mukherjee to check the position of the tube.
"Dr Mukherjee was busy doing other tasks," she added.
Technician Nicholas Healey said he flagged his concerns when there was no carbon dioxide reading on the ventilator, which was not faulty.
He said that both he and Dr Syed had raised concerns about the tube being in the wrong place.
The court heard the hospital had drawn up a guideline checklist for trachea procedures since Ms Currell's death and staff were due to have "no trace = wrong place" training on the warning signs of incorrect insertion.
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Source: BBC News, 27 February 2023
 
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Northampton: Maternity unit needs 37 more midwives

A criticised maternity service needs 37 more midwives, about a fifth of its total midwifery workforce.
The Care Quality Commission has said Northampton General Hospital did not always have enough qualified and experienced staff to keep women safe from avoidable harm.
Figures obtained by the BBC show that 49 serious incidents have occurred in its maternity services in four years.
The hospital said it had undertaken "a lot of work" in the past 18 months and a recruitment process was under way.
According to a Freedom of Information Act response, between November 2018 and November 2022, the hospital had 278 serious incidents, with the highest level coming across maternity services, including gynaecology and obstetrics.
There are currently 37 vacancies for midwives but the trust said it manages staffing levels "closely and ensure that all shifts are covered by bank or midwives working altered shift patterns, to ensure that we are able to provide a safe maternity experience".
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Source: BBC News, 27 February 2023
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Eating disorder patients ‘repeatedly failed’, says England watchdog

Urgent action is needed to prevent people dying from eating disorders, the parliamentary and health service ombudsman for England has warned, as he said those affected are being “repeatedly failed”.
The NHS needs a “complete culture change” in how it approaches the condition, while ministers must make it a “key priority”, according to Rob Behrens.
Little progress has been made since the publication of a devastating report by his office in 2017, which highlighted “serious failings” in eating disorder services, he said.
Lives continue to be lost because of “the lack of parity between child and adult services”, and “poor coordination” between NHS staff involved in treating patients. There remain issues with the training of medical professionals, Behrens added.
“We raised concerns six years ago in our ignoring the alarms report, so it’s extremely disappointing to see the same issues still occurring,” he said. “Small steps in improvements have been taken, but progress has been slow, and we need to see a much bigger shift in the way eating disorder services are delivered."
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Source: The Guardian, 27 February 2023
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UK spent only £15m on brain tumour research after promising £40m

Ministers have spent only £15m in five years on research into tackling brain tumours, the biggest killer of adults and children under 40, while boasting about delivering £40m, MPs have found.
The revelation emerged in a damning report seen by the Guardian that is due to be published this week by the all-party parliamentary group (APPG) on brain tumours after a two-year inquiry.
The research system is “unfit for purpose”, patients are being denied access to clinical trials, and families have been let down by promises of “millions of pounds of investment which hasn’t materialised”, the report says.
The APPG report also highlights a “valley of death” in which potential new treatments developed in the laboratory “fail to reach patients” because of unnecessary red tape. Some children are being denied access to clinical trials, and the national brain tumour research database is “not reliable”.
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Source: The Guardian, 27 February 2023
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60% of US patients uncomfortable with AI in healthcare settings, survey finds

The adoption of AI tools to simplify processes and workflows is slowly occurring across all industries, including healthcare — though patients largely disagree with clinicians using those tools when providing care, the Pew Research Center survey found.
The potential for AI tools to diminish personal connections between patients and providers is a key concern, according to the survey, which included responses from over 11,000 adults in the USA collected in December. Patients also fear their health records could become less secure.
Respondents, however, acknowledged potential benefits, including that AI could reduce the number of mistakes providers make.
They also expressed optimism about AI’s potential impact on racial and ethnic biases in healthcare settings, even as the technology has been criticised for exacerbating those issues.
Among respondents who believe racial biases are an issue in healthcare, about half said they think the tools would reduce the problem, while 15% said it would make it worse and about 30% said it would stay the same.
Read full story
Source: Healthcare Dive, 23 February 2023
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Lateral flow tests being prepared for UK outbreaks of avian flu

British health officials are preparing plans to deploy lateral flow tests if signs emerge that avian flu has begun to spread from one person to another.
The programme would provide rapid information about the dangers posed by the disease.
The UK Health Security Agency (UKHSA) is also working on blood tests to detect antibodies against the virus and officials will analyse the disease’s genetic mutations to reveal data about the increased risk to human health from avian flu.
The moves follow last week’s news that an 11-year-old girl in Cambodia has died from H5N1, the flu strain that is being spread around the globe by migrating birds and is infecting poultry farms.
At present, evidence suggests the H5N1 virus does not pass easily to people although scientists have urged care and caution. “The risk to humans is still very low, but it’s important that we continue to monitor circulation of flu in both bird and mammal populations", said Prof Jonathan Ball, of Nottingham University.
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Source: The Guardian, 26 February 2023
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O2 Academy Brixton crush: Claims of not enough medical cover

Only half the recommended number of medical staff were on duty at the O2 Brixton Academy on the night of a crush at the south-west London venue.
Industry guidelines suggest there should have been medical cover of at least 10 people, including a paramedic and a nurse, but no paramedics or nurses were present.
Rebecca Ikumelo, 33, and security guard Gaby Hutchinson, 23, died in hospital following the crowd surge on 15 December 2022 at the concert.
The medical provider, Collingwood Services Ltd, said it was "fully confident" its team had "responded speedily, efficiently and with best practice".
Two whistleblowers who regularly work for Collingwood Services Ltd at Brixton told BBC Radio 4's File on 4 programme that medical cover at the south London gig had been "inadequate".
Neither of them was there when the crush happened, but one said he had spoken to colleagues who were.
"[They] had two student paramedics, so they're basically unqualified," said one whistleblower. "They have to be supervised by a paramedic, not by anybody of a lower grade. They didn't have appropriate supervision."
Read full story
Source: BBC News, 23 February 2023
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Nasal decongestants safety review due to rare brain risk

Experts are assessing a very rare but potentially serious brain side effect of nasal decongestants bought on the High Street.
Ones containing pseudoephedrine are being reviewed because they may cause vessels supplying the brain to contract or spasm, reducing blood flow.
The concern is this could lead to seizures and even a stroke. However, drug regulators stress the likelihood of this happening is extremely low.
The UK-wide review for pseudoephedrine was initiated after regulators in France alerted European drugs regulator the EMA, which is also conducting a review, about some recent, rare cases.
Experts say anyone with concerns about medication should speak to a doctor or pharmacist. 
Read full story
Source: BBC News, 23 February 2023
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Prostate cancer screening breakthrough as harms linked to testing reduced

Prostate cancer screening may be a step closer after a study suggested that harms linked to testing have reduced thanks to advances in medical technology.
Screening for prostate cancer has been heavily debated in medical circles due to potential harms including side effects from biopsies and unnecessary testing for those with no clinically significant cancer.
A new study set out to examine whether the “seesaw has been tipped” in favour of screening.
Researchers from Prostate Cancer UK combined the results of the latest clinical trials and real-world data on the “prostate cancer screening pathway” to examine the risk-to-harm benefit.
Prostate Cancer UK said that on average 67%t fewer men experienced harm during the diagnostic process with the newer techniques compared with older methods.
Prostate Cancer UK said the UK National Screening Committee, which makes recommendations to the Government, is to re-examine prostate cancer screening.
Dr Matthew Hobbs, lead researcher on the analysis and director of research at Prostate Cancer UK, said: “We’ve known for some time now that testing more men reduces prostate cancer deaths, but there have always been concerns about how many men would be harmed to achieve this.
“However, our evidence shows that screening may now be a lot safer than previously thought. That’s why we are so pleased that the committee is going to review the evidence once more.
Read full story
Source: The Independent, 23 February 2023
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Wearable fitness trackers could interfere with cardiac devices, study finds

Wearable fitness and wellness trackers could interfere with some implanted cardiac devices such as pacemakers, according to a study.
Devices such as smartwatches, smart rings and smart scales used to monitor fitness-related activities could interfere with the functioning of cardiac implantable electronic devices (CIEDs) such as pacemakers, implantable cardioverter defibrillators (ICDs), and cardiac resynchronisation therapy (CRT) devices, the study published in the Heart Rhythm journal found.
Researchers found that the electrical current used in wearable smart gadgets during “bioimpedance sensing” interfered with proper functioning of some implanted cardiac devices from three leading manufacturers.
 Lead researcher, Dr Benjamin Sanchez Terrones, of the University of Utah. said the results did not convey any immediate or clear risks to patients who wear the trackers. However, the different levels of electrical current emitted by the wearable devices could result in pacing interruptions or unnecessary shocks to the heart. Further research was needed to determine the actual level of risk".
“Our research is the first to study devices that employ bioimpedance-sensing technology as well as discover potential interference problems with CIEDs such as CRT devices. We need to test across a broader cohort of devices and in patients with these devices. Collaborative investigation between researchers and industry would be helpful for keeping patients safe,” Sanchez said.
Read full story
Source: The Guardian, 22 February 2023
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Derby maternity deaths may have been prevented

Three women who died under the care of a hospital's maternity unit may have survived if earlier recommendations had been implemented, a report has said.
The cases occurred at University Hospitals of Derby and Burton (UHDB) NHS Foundation Trust over 16 months.
A review by the Healthcare Safety Investigation Branch (HSIB) also found a culture of intimidation and bullying.
The report found that although there was no common theme to the deaths - and four other life-threatening cases that occurred in the same period - processes and leadership had been inconsistent and fragmented.
HSIB said "robust action planning and prompt addressing of the learning" from previous recommendations from other investigations "may have had an impact on the outcome for the women who received care during the seven events included in this thematic review".
Read full story
Source: BBC News, 22 February 2023
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NHSE wrongly dismissed discrimination claim from black nurse, tribunal finds

NHS England has lost an employment tribunal case against a senior black nurse on grounds of race discrimination and whistleblowing, and has been criticised for serious flaws in its own investigations.
A judgement published today found Michelle Cox, a black woman who was an NHS continuing healthcare manager based in NHSE’s North West regional team, was excluded by her manager “at every opportunity”.
The case centres on problems between Ms Cox and her line manager, then regional head of continuing healthcare, which took place from around April 2019 to November 2020.
The tribunal ruled Ms Cox's line manager– who is now an associate director of nursing in the West Yorkshire integrated care system – had created an “intimidating and hostile and humiliating environment” for Ms Cox, which had the purpose and effect of unlawful harassment.
The tribunal also upheld Ms Cox’s complaint of detriment for whistleblowing, including for raising concerns that members of her team were sitting on continuing healthcare “independent review panels”, which she pointed out was a breach of independence and legal obligations.
Read full story
Source: HSJ, 22 February 2023
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USA: Investigation spotlights rise of for-profit ethics boards in research

A US government watchdog called for greater federal oversight of ethics boards that sign off on scientific studies, finding that for-profit companies have taken an outsize role in approving certain research and questioning whether financial motivations could put human subjects at risk.
Federal regulations require that certain research on human subjects — including those testing the safety of new drugs — first get approval from a registered institutional research board. These boards, which are made up of at least five members and can include researchers and academics, are designed to make sure that a study poses as little risk as possible and that participants have enough information to give consent.
While the majority of these boards are affiliated with universities, a small number have no affiliation with institutions conducting research. But according to a new report from the U.S. Government Accountability Office (GAO), these independent boards now account for the largest share of reviews of studies involving new drugs and biologics.
The GAO found that federal agencies overseeing the ethics panels inspect relatively few of them and lack ways to evaluate how well they protect people participating in research.
Read full story (paywalled)
Source: The Washington Post, 16 February 2023
 
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HRT: Around 400,000 women to receive cheaper menopause treatment

Hundreds of thousands of women could benefit from cheaper hormone replacement therapy (HRT) as part of a scheme to cut prescription costs.
The Department of Health said that from April, women prescribed HRT as part of menopause treatment will be able to access a new scheme to enable access to a year’s worth of treatment for just under £20.
The announcement follows the publication of the government’s women’s health strategy for England last summer.
Minister for Women Maria Caulfield said: “Around three-quarters of women will experience menopause symptoms, with one-quarter experiencing severe symptoms, which can seriously impact their quality of life.
“Reducing the cost of HRT is a huge moment for improving women’s health in this country, and I am proud to be announcing this momentous step forward.
“In our Women’s Health Strategy, we made menopause a top priority – by making HRT more accessible, we’re delivering on our commitment to women.”
Read full story
Source: The Independent, 21 February 2023
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‘One in five’ patient referrals bounced back to GPs, warns watchdog

A new report has condemned ‘serious issues’ with NHS referral processes, amid findings that one in five patient referrals made by GPs went into a ‘black hole’.
Healthwatch England said that 21% of people they spoke to with a GP referral to another NHS service were rejected, not followed up on or sent back to general practice.
The watchdog said that more support should be given to help GP and hospital teams to reduce the numbers of people returning to general practice due to ‘communication failures’ following a referral.
According to the findings, the failures were due to GP teams not sending referrals, referrals going missing between services, or being either booked or rejected by hospitals without any communication.
Louise Ansari, Healthwatch England’s national director, said that thousands of people told the watchdog that the process is ‘far from straightforward.’
She said: "Falling into this “referrals black hole” is not just frustrating for patients but ultimately means people end up going back to their GP or visiting crowded A&E departments to get the help they need.
"This adds more burden to already stretched services, making things even harder for the doctors and nurses trying to provide care."
Read full story
Source: Pulse, 20 February 2023
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