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

The moment I knew something was wrong at the Tavistock

A damning report last year from Dr Hilary Cass into the Tavistock Gender Identity Development Service (GIDS) found that it was putting children at “considerable risk”. Her full report is due to be published later this year.
Whistleblower Dr Anna Hutchinson, a senior clinical psychologist at GIDS, describes when she realised something was very wrong.
“I just couldn’t comfortably keep being part of a process that was, I felt, putting children — but also my colleagues — at risk,” Hutchinson explains. Faced with no discernible action from the executive, staff began to look for other ways to raise their concerns, to other people who might listen — and act. Hutchinson approached the Tavistock’s Freedom to Speak Up guardian. At least four other colleagues did the same in 2017. That same year, another four clinicians took their concerns outside GIDS to the children’s safeguarding lead for the Tavistock trust."
Read full story (paywalled)
Source: The Times, 13 February 2023
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First patient in UK fitted with sensor to give early heart failure alert

A heart failure patient has become the first in the UK to be fitted with an early warning sensor the size of a pen lid which gives off an alert if their condition deteriorates.
Consultant cardiologists Dr Andrew Flett and Dr Peter Cowburn have pioneered the procedure to fit the FIRE1 System during trials at University Hospital Southampton (UHS), Hampshire.
Dr Flett said: “This innovative new device has the potential to improve patient safety and outcomes in the management of patients with chronic heart failure and we are delighted to be the first site in the UK to implant as part of this ground-breaking study".
Read full story
Source: The Independent, 12 February 2023
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USA: Patients needing home IV nutrition fear dangerous shortages

CVS Health confirmed last year it was closing half its Coram home infusion branches and firing about 2,000 nurses, dietitians and pharmacists.
Their patients with life-threatening digestive disorders depend on parenteral nutrition, or PN — in which amino acids, sugars, fats, vitamins and electrolytes typically are pumped through a catheter into a large vein near the heart.
A day later Optum Rx, another big supplier, announced its own consolidation. Suddenly, thousands were scrambling for their complex essential drugs and nutrients.
“With this kind of disruption, patients can’t get through on the phones. They panic,” said Cynthia Reddick, a senior nutritionist laid off last summer in the CVS restructuring.
“It was very difficult. Many emails, many phone calls, acting as a liaison between my doctor and the company,” said Elizabeth Fisher Smith, a 32-year-old public health instructor in New York, whose Coram branch closed. A rare medical disorder has forced her to rely on PN for survival since 2017. “It added to my mental burden,” she said
Home and outpatient infusions in the USA are a growing business, as new drugs for chronic illness expand treatment options and enable patients, providers and insurers to avoid hospitalisation. 
But while reimbursement for expensive new drugs has attracted corporations and private equity, the industry is constrained by a lack of nurses and pharmacists. The less profitable parts of the business — and the vulnerable patients they serve — are at risk. This includes the 30,000-plus Americans who rely on parenteral nutrition — including premature infants, post-surgery patients and those with damaged bowels because of genetic defects.
Read full story (paywalled)
Source: The Washington Post, 6 February 2023
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Workers fighting America’s overdose crisis are ‘hanging by a thread’

President Biden has endorsed “harm reduction,” which aims to cut down on overdoses by encouraging safer drug use. But the organizations carrying out that strategy are severely underfunded.
In his State of the Union address on Tuesday, Mr Biden, the first president to endorse the strategy, highlighted the federal government’s attention to some of the core features of harm reduction work, including a provision in a recently enacted spending package that makes it easier for doctors to prescribe buprenorphine, an effective addiction medication that Ms Krauss works to get to drug users. During his speech, Mr Biden recognised the father of a 20-year-old from New Hampshire who died from a fentanyl overdose, citing the more than 70,000 Americans dying each year from the potent synthetic opioid.
But two years after Mr Biden took office, with the nation’s drug supply increasingly complex and deadly, the practice of harm reduction remains underfunded and partially outlawed in many states.
Read full story (paywalled)
Source: New York Times, 10 February 2023
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‘Underhand’ formula milk ads stop millions from breastfeeding, experts say

Exploitative and “underhand” marketing of formula milk is preventing millions of women from breastfeeding, according to a series of reports published in the Lancet.
The reports, by 25 experts from 12 countries, including paediatricians, public health specialists, scientists, economists and midwives, finds that the commercial milk formula companies “exploit parents’ emotions and manipulate scientific information to generate sales at the expense of the health and rights of families, women and children”.
Breastfeeding promotes brain development, protects infants against malnutrition, infectious diseases and death, while also reducing risks of obesity and chronic diseases in later life. It also helps protect mothers against breast and ovarian cancers. The World Health Organization (WHO) recommends exclusively breastfeeding babies for the first six months and giving breast milk alongside solid food until the age of two or beyond.
Over three reports, the series reveals how, more than 40 years since the World Health Assembly developed a voluntary international code prohibiting the marketing of infant formula, widespread violation of the code persists, with promotion of infant formula milk continuing in about 100 countries in every region of the world since the code was adopted.
Read full story
Source: The Guardian, 7 February 2023
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More failings discovered at maternity scandal trust

East Kent Hospital University Foundation Trust has been criticised for failures in services by the Care Quality Commission, after an unannounced inspection last month, years after major problems began to come to light.
The Care Quality Commission has highlighted:
Issues with processes for fetal monitoring and escalation at the William Harvey Hospital, Ashford. There had been “incidents highlighting fetal heart monitoring” problems in September and October, and the trust’s measures to improve processes were not “embedded and understood by the clinical team”; Slow maternity triage, due to staffing problems, and infection control problems at the William Harvey. The trust is reviewing how issues with infection prevention and control and cleanliness were not identified or escalated; and  Fire safety issues at the Queen Elizabeth, the Queen Mother Hospital, in Thanet with problems linked to fire doors and an easily accessible secondary fire escape route. Three years ago issues with reading and acting on fetal monitoring were highlighted at the inquest into baby Harry Richford, whose poor care by the trust led to an independent inquiry into widespread failings in its maternity services, led by Bill Kirkup.
Read full story (paywalled)
Source: HSJ, 6 February 2023
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Government delays regulation for non-surgical cosmetic procedures

The government has rejected an urgent call by MPs to bring in a new licensing regime for non-surgical procedures such as Botox injections, chemical peels, microdermabrasion and non-surgical laser interventions.
Ministers also rejected recommendations by the House of Commons Health and Social Care Committee to make dermal fillers available as prescription only substances—as Botox is—and to bring in specific standards for premises that provide non-surgical cosmetic procedures.
The government also rejected several recommendations aimed at tackling obesity—including a dedicated eating disorder strategy, annual health and wellbeing checks for every child and young person, and restrictions on buy-one-get-one free deals for foods and drinks high in fat, salt, or sugar.
Read full story
Source: BMJ, 2 February 2023
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Chronic shortage of sickle cell nurses putting patients at risk, damning report warns

Sickle cell patients are being put at risk because of a chronic shortage of specialist nurses to treat them, a damning new report has found.
'The Difference Between Life and Death', a new study by the Sickle Cell Society, found that there are not enough sickle cell workers to deliver a good standard of care.
One patient called Abi Adeturinmo told researchers that previous traumatic experiences caused by delays in receiving pain relief medication and poor care meant she “tries not to go to the hospital when in sickle cell crisis unless it is life-threatening”.
Another patient, Araba Mensah, whose daughter has sickle cell disorder, said there was a lack of “hands-on” nursing, and said patients who have difficulties feeding themselves or with personal hygiene were “left to suffer unattended”.
John James, CEO of the Sickle Cell Society, said: “While there are undoubtedly workforce challenges across all parts of the health system, the evidence in this report suggests that sickle cell is disproportionately impacted as a result of the legacy of neglect of sickle cell care.
“On behalf of everyone affected by sickle cell, we are urging NHS England to take action now to ensure all sickle cell patients have access to the specialist care they are entitled to.”
Read full story
Source: The Independent, 24 November 2023
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Two in three UK doctors suffer ‘moral distress’ due to overstretched NHS, study finds

Two in three UK doctors are suffering “moral distress” caused by the enfeebled state of the NHS and the damage the cost of living crisis is inflicting on patients’ health, research has found.
Large numbers are ending up psychologically damaged by feeling they cannot give patients the best possible care because of problems they cannot overcome, such as long waits for treatment or lack of drugs or the fact that poverty or bad housing is making them ill.
A new survey found that 65% of doctors overall, including nearly four in five (78%) GPs and more than half (56%) of hospital doctors, have experienced “moral distress” as a direct result of situations they have encountered working in the NHS.
Seeing patients with malnutrition or hypothermia, or stuck on trolleys in A&E corridors asking for help or forced to choose between heating their home or getting a prescription dispensed are among the events triggering their distress, medics said.
“There’s barely a doctor at work in the NHS today who doesn’t see or experience this distress on a daily basis,” said Prof Philip Banfield, the leader of the British Medical Association.
The NHS is “impossibly overstretched”, has thousands of vacancies for doctors and has a quarter fewer doctors a head of population than Germany, he added.
“In practice that means we can almost never give the standard of care we would want, only ever the care we can manage. That takes its toll, as we see here,” Banfield said.
Read full story
Source: The Guardian, 28 December 2023
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Overheating and flooding at hospitals in England ‘pose threat to patient safety’

Record levels of overheating and a sharp rise in flooding at England’s hospitals are putting vulnerable patients at risk, figures show.
Analysis of NHS data by the Liberal Democrats found that the number of health trusts reporting overheating in clinical areas had doubled compared with six years ago, and floods had increased by nearly 60% from last year.
An overheating incident is logged when an occupied ward or clinical area’s daily maximum temperature exceeds 26C, the temperature at which some patients become unable to cool themselves effectively.
The latest government figures show that in the summer of 2022 there were an estimated 2,985 excess deaths due to heatwaves, the highest number on record. Heatwaves also forced a fifth of UK hospitals to cancel operations.
The number of serious flooding incidents, where water caused disruption such as by breaching a building or flooding a road, rose from 176 to 279.
The climate crisis is expected to increase these risks to hospitals and patients. Helen Buckingham, the director of strategy at the Nuffield Trust, said: “These figures are a cause for real concern about the resilience of the NHS’s estate to the growing threat from extreme weather in the UK. As temperatures have climbed, so too have the number of overheating incidents in NHS hospitals.”
Read full story
Source: The Guardian, 27 November 2023
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People in UK turning to DIY health treatment amid shortage of GP appointments

Almost one in four people have bought medicine online or at a pharmacy to treat their illness after failing to see a GP face to face, according to a UK survey underlining the rise of do-it-yourself treatment.
Nearly one in five (19%) have gone to A&E seeking urgent medical treatment for the same reason, the research commissioned by the Liberal Democrats shows.
One in six (16%) people agreed when asked by the pollsters Savanta ComRes if the difficulty of getting an in-person family doctor appointment meant they had “carried out medical treatment on yourself or asked somebody else who is not a medical professional to do so”.
Ed Davey, the leader of the Liberal Democrats, said delays and difficulty in accessing GP appointments constituted a national scandal, and face-to-face GP appointments had become “almost extinct” in some areas of the country.
He said: “We now have the devastating situation where people are left treating themselves or even self-prescribing medication because they can’t see their local GP.”
Dr Richard Van Mellaerts, the deputy chair of the British Medical Association’s GP committee in England, said: “While self-care and consulting other services such as pharmacies and NHS 111 will often be the right thing to do for many minor health conditions, it is worrying if patients feel forced into inappropriate courses of action because they are struggling to book an appointment for an issue that requires the attention of a GP or a member of practice staff.”
Read full story
Source: The Guardian, 2 January 2024
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Measles now an 'imminent' global threat due to pandemic, say WHO and CDC

There is now an "imminent threat" of measles spreading in every region of the world, the World Health Organisation and the US public health agency has said.
In a joint report, the health organisations said there had been a fall in vaccines against measles and less surveillance of the disease during the COVID pandemic.
Measles is one of the most contagious human viruses but is almost entirely preventable through vaccination, though it requires 95% vaccine coverage to prevent outbreaks.
A record high of nearly 40 million children missed a dose last year because of hurdles created by the pandemic, according to the report by the WHO and the US Centers for Disease Control and Prevention.
This has left millions of children susceptible to the disease.
"We are at a crossroads," Patrick O'Connor, the WHO's measles lead, said.
"It is going to be a very challenging 12-24 months trying to mitigate this."
Read full story
Source: Sky News, 24 November 2022
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Bottoms up: Surgeons say no to BBL (Brazilian Butt Lift) but yes to SGL (Superficial Gluteal Lipofilling)

In 2018 the British Association of Aesthetic Plastic Surgeons (www.baaps.org.uk)  dissuaded all its members from performing Brazilian Buttock Lift (BBL) surgery, until more data could be collated. The decision was taken due to the high death rate associated with the procedure. Now, following an extensive four-year review of clinical data, new technology and techniques, BAAPS has published its Gluteal Fat Grafting (GFG) guidelines.
Gluteal fat grafting is currently the procedure with the biggest growth rate in plastic surgery worldwide, with an increase of around 20% year-on-year). It has become the most popular means of buttock volume augmentation, overtaking gluteal augmentation with implants.  In 2020, The Aesthetic Society statistics recorded 40,320 buttock augmentation procedures, which included both fat grafting and buttock implants.
In 2015, there were reports of intraoperative mortality related to pulmonary fat emboli associated with BBL surgery and in 2018 with growing concern about the high mortality rate associated with this procedure BAAPS recommended it was not performed by its members.
The development of the present guidelines and recommendations has been stimulated by the evidence that has emerged since 2018, based on scientific review and analysis. BAAPS guidelines now recommend that Gluteal Fat Grafting is safe to perform under two key conditions:
Injection into the subcutaneous plane only - there is a plethora of evidence to suggest this significantly reduces mortality related to the procedure perhaps this needs to be changed to – the evidence shows that the only deaths from the procedure have been when fat has been injected into the deeper muscle layer. Intraoperative ultrasound must be used during the placement of fat in the gluteal area to ensure that the cannula remains in the subcutaneous plane – this is the only way that surgeons can be confident they are not in the muscle layer. Read full story
Source: BAAPS, 17 October 2022
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Brazilian Butt Lift can be made safer say surgeons

UK plastic surgeons have released new guidelines to try to make Brazilian Butt Lift (BBL) procedures safer for people who desire a bigger bottom.
Some women have died from the operation, which involves sucking out fat from elsewhere - such as the belly - and injecting it into butt cheeks.
The British Association of Plastic Surgeons (BAAPS) says the injections should not go very deep to help avoid complications such as dangerous clots.
According to the NHS, it has the highest death rate of all cosmetic procedures, and the risk of death from BBL surgery is at least 10 times higher than many other procedures.
A major concern is that the injected fat can cause a blockage in a blood vessel in the lungs - called a pulmonary embolism - which can be fatal.
This happened to Leah Cambridge, a beautician and mother of three from Leeds.
She suffered a massive pulmonary embolism during the operation at a private hospital in Turkey in 2018, a coroner found.
BAAPS president Marc Pacifico told the BBC: "Unfortunately we don't know how many people have been going for these risky BBL procedures. We have been recommending against it for a number of years after seeing quite a frightening death rate associated with it. But people have been going abroad to get it done."
"Make sure you ask if the surgeon will be using ultrasound for gluteal fat grafting. We are recommending that surgeons should only perform this with real time ultrasound guidance as the only way to ensure the procedure is performed superficially and safely."
Read full story
Source: BBC News, 10 October 2022
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Thousands of children at risk as vaccination rates fall in England

Thousands of children face an increased risk of catching deadly diseases in England, and significant outbreaks are likely, child health experts have warned, as “alarming” figures show vaccination levels have plunged across virtually all jabs.
The UK Health Security Agency (UKHSA) is urging parents and guardians to ensure their children have received the routine jabs against potentially serious diseases, such as polio and measles, after official data revealed a drop in vaccination rates.
NHS Digital data published Thursday showed vaccine coverage fell in 13 out of the 14 routine programmes for children up to five years old in England in 2021-22, compared with the year before.
“Today’s publication of the childhood vaccination statistics in England is extremely worrying,” said Dr Doug Brown, the chief executive of the British Society for Immunology. “Immediate action to reverse this alarming multi-year downward trend and protect our communities from preventable diseases is urgently needed.”
Helen Bedford, a professor of child public health at UCL’s Institute of Child Health, said the country was now facing “the concerning double whammy of many children being unprotected and the inevitability of disease rates increasing”.
“In this situation, as night follows day, significant outbreaks of disease are likely. Measles disease is a particular concern as it is so highly infectious that any small decline in vaccine uptake results in outbreaks.
Read full story
Source: The Guardian, 29 September 2022
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GMC shares doctors frustration at delays to its reform

The GMC has responded to senior medical leaders’ frustration at news that the Government is again delaying long-promised plans for its reform which would ease the strain felt by doctors. 
Its chief executive said its Council shared widespread disappointment at the hold-up in changing the legislation – which was expected this year, but will not now happen until 2024-25.
Charlie Massey told Independent Practitioner Today: "Physician associates and anaesthesia associates are an important part of the health workforce and we welcome progress to bring them into regulation, which we will do within 12 months of legislation being laid by Government.
"But we are disappointed that the outdated legislation for doctors will not be replaced at the same time. 
"The current framework stops us from being responsive and flexible in how we address patient safety concerns and register doctors to join the UK workforce. That isn’t good for patients and puts unnecessary strain on doctors.
"The Government has said that it expects to deliver reforms for doctors as a priority following its work on physician associates and anaesthesia associates."
Mr Massey called for a clearer commitment on the specific timing of that work, adding that the GMC wanted to progress better regulation for both doctors and medical associate professionals (MAPs) as soon as the Department of Health and Social Care laid the necessary legislation.
"It is now the department’s decision when and how to implement these changes. When the department does implement these changes, we will be ready to start the process to put the reform changes into practice," he said.
Read full story
Source: Independent Practitioner Today, 9 August 2022
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