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

Brexit: Health leaders issue new no-deal warning

Health leaders have written to Boris Johnson issuing new warnings on the impact of a no-deal Brexit. In a letter to the Prime Minister, the heads of 17 royal colleges and health charities across the UK say clinicians are "unable to reassure patients" their health and care will not be affected. 
They go on to say they have "significant concerns about shortages of medical supplies". Government said it was working with the health sector on "robust preparations". 
The letter, co-ordinated by the Royal College of Physicians, is signed by the heads of organisations including the British Dental Association, the Royal Pharmaceutical Society, Kidney Care UK and the Royal College of Emergency Medicine. It calls for the Health and Social Care Secretary Matt Hancock to be put on the EU exit strategy committee chaired by Michael Gove, who is in charge of no-deal planning.
The signatories argue that - given the scale of the NHS - without sufficient planning, even the smallest of problems could have "huge consequences on the lives of millions of people".
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Source: BBC News, 21 August 2019
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Cardiologist who fitted wrong pacemaker and destroyed patient notes is struck off

A cardiologist has been struck off the UK medical register after he failed to check a patient’s medical notes before surgery, implanted the wrong type of pacemaker, and then destroyed the notes specifying the correct type.
Amer Chit, a locum consultant cardiologist at Royal Cornwall Hospitals NHS Trust, admitted to a trust investigation that, before implanting the pacemaker, he had looked at the operating list but not at the patient’s medical notes.
Read full story (paywalled)
Source: BMJ, 23 August 2019
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CQC closes ‘inadequate’ children’s unit

An NHS children’s mental health unit has been closed down by the Care Quality Commission after being rated “inadequate” last week.
A child and adolescent mental health ward run by Tees, Esk and Wear Valley’s Foundation Trust has been closed after the CQC took enforcement action to protect the safety of patients.
In a statement today, a CQC spokesman said: ”[We have] taken urgent enforcement action at Tees, Esk and Wear Valley’s Foundation Trust which will lead to the closure of the child and adolescent mental health service units at West Lane Hospital. The Holly unit at West Park Hospital and Baysdale Unit at Roseberry Park are unaffected. The action follows continued concerns identified at earlier inspections in June and August, and the recent inspection on 20 and 21 August 2019."
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Source: HSJ, 23 August 2019
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Hospital deep clean as baby skin infection detected

A small number of babies at a Belfast hospital have been found to have pseudomonas on their skin. The infants involved were being treated in the neonatal unit of the Royal Jubilee Maternity Service. Although the bacteria was found on their skin, it does not mean the babies were infected. Staff have put in place infection prevention measures and carried out a deep clean of the unit.
A spokesperson for the Belfast Health Trust said while the issue was unfortunate it wanted to reassure patients, their families and the public that the situation was being managed appropriately.
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Source: BBC News, 29 August 2019
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Crumbling hospitals putting lives at risk, say NHS chiefs

Hospital patients’ safety is being put at risk by fires, floods and crumbling, overcrowded buildings caused by a £4 billion government squeeze on capital funding, NHS bosses are warning.
Hospitals say they do not have the funding to replace outdated scanners, fix leaking roofs and boilers, or remove ligature points that suicidal patients may attempt to use to try to end their lives.
Four out of five (82%) chief executives and chief finance officers at NHS trusts in England fear the lack of capital funding poses a medium or high risk to patient safety.
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Source: Guardian, 30 August 2019
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Addenbrooke's surgeon suspended after performing wrong operation

An orthopaedic surgeon falsified records and lied to a patient after he performed the wrong operation on her. 
Alan Norrish admitted performing the wrong type of partial knee replacement on his patient in January 2018 at the Nuffield Hospital in Cambridge. Having realised his mistake the former Addenbrooke's consultant tried to cover it up by falsifying records and doing "revision" surgery six days later.
Mr Norrish has been suspended for a year following a medical tribunal. He told the hearing of the Medical Practitioners Tribunal Service (MPTS) he was "shocked" and "upset" when he realised his mistake. It was found he had lied in a letter to a hospital matron about the reason for the second operation, which was carried out on 25 January 2018.
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Source: BBC News, 30 August 2019
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Girl died after sepsis guidelines ignored

A five-year-old girl who died due to sepsis complications could have been saved if clinical guidelines had been followed, an inquest heard.
Ava Macfarlane died of toxic shock caused by a bacterial infection on 15 December 2017. She had presented with symptoms when she first went to hospital two days earlier but they were not picked up. Nottingham Coroner's Court heard she was given Calpol and ibuprofen before doctors allowed her to go home.
Dr Shearn admitted Ava had been showing at least two "red flags" of sepsis and if he had followed guidelines from the National Institute for Health Care and Excellence and the Sepsis Trust, then the infection would have been picked up earlier. When asked by Assistant Coroner Laurinda Bower whether the "failure to follow the Sepsis 6 Pathway contributed to her death", he replied "it probably did".
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Source: BBC News, 2 September 2019
Patient Safety Learning

High street heart checks on the NHS

Pharmacists are set to offer rapid detection and help for killer conditions like heart disease as part of a major revamp of high street pharmacy services. The high street heart checks are part of an ambitious target the NHS in England has set itself as part of its Long Term Plan to prevent tens of thousands of strokes and heart attacks over the next ten years.
Plans are underway for both GPs and community pharmacists to lead the fight against common conditions that cause cardiovascular disease (CVD) and stroke, building on successful pilots which have reduced strokes by a quarter.
From 1 October 2019, as part of their new £13 billion five-year contract, community pharmacists will start to develop and test an early detection service to identify people who may have undiagnosed high-risk conditions like high blood pressure for referral for further testing and treatment. If successful this could be rolled out to all community pharmacies in 2021-22.
Professor Stephen Powis, NHS national medical director, said: “Heart disease and strokes dramatically cut short lives, and leave thousands of people disabled every year, so rapid detection of killer conditions through High street heart checks will be a game-changer."
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Source: NHS England, 2 September 2019
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Almost half of consultant anaesthetists have had a car accident or near miss on their commute home because of fatigue

A survey of consultants in anaesthesia and paediatric intensive care working in the UK and Ireland found that most had experienced work related fatigue.
The survey, published in Anaesthesia, received 3847 responses from consultants working in the UK and the Republic of Ireland. Most (91%) said that they had experienced work related fatigue and 72% said that this had a moderate or significant negative impact on their social and family life.
Read full story (paywalled)
Source: BMJ, 3 September 2019
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First ‘digital’ baby born at West Cumberland Hospital

The first baby born using entirely digital maternity notes in north Cumbria has been born at West Cumberland Hospital in Whitehaven. The new digital system replaces the traditional paper-based system with notes being held digitally for staff and linking to a phone app so women no longer need to carry their notes to appointments.
The app which expectant and new mothers can use is called ‘Maternity Notes’. It helps women track their pregnancy journey and contains lots of information about the baby’s development as they move through their pregnancy, and up to six weeks post-birth. The new system is safer too, with women no longer needing to carry paper maternity notes.
Since going live on 1 April, 100% of women registering a new pregnancy have signed up to the app.
North Cumbria University Hospitals NHS Trust is one of only 14 Trusts across the country to implement electronic maternity notes.
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Source: Health Tech Digital, 2 September 2019
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Isle of Wight NHS Trust 'no longer inadequate or unsafe'

An NHS Trust, rated inadequate for more than two years, has been awarded an improved grade by inspectors.
Isle of Wight NHS Trust has made "improvements in most areas" and is no longer unsafe overall, the Care Quality Commission (CQC) said. Although it recommended the trust should remain in special measures, the CQC gave the trust a rating of "requires improvement".
The trust said it welcomed the change and was committed to improving further.
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Source: BBC News, 4 September 2019
Patient Safety Learning

An open letter to MPs on the impact of a no deal Brexit on health and care

In an open letter to MPs, The King's Fund, the Health Foundation and Nuffield Trust have summarised the four major areas where the impact of a no deal Brexit could be felt most sharply in health and care. 
There is a very real risk that leaving the EU without an agreement could exacerbate the workforce crisis in health and care, drive up demand for already hard-pressed services, hinder the supply of medicines and other vital supplies, and stretch the public finances which pay for healthcare.
They conclude that a no deal Brexit could cause significant harm to health and social care services and the people who rely on them.
Read full letter
Source: The King's Fund, 3 September 2019
Patient Safety Learning

Nottingham's Queen's Medical Centre failings led to girl's sepsis death

A series of hospital failings contributed to the death of a five-year-old girl who died from toxic shock syndrome, an inquest jury has found. Ava Macfarlane died on 15 December 2017 after being treated at Nottingham's Queen's Medical Centre.  
Prescribing antibiotics earlier could have "given her chances of survival", Nottingham Coroner's Court heard. Returning a narrative conclusion the jury said there had been "missed opportunities" to diagnose sepsis.
Dr Keith Girling, medical director at Nottingham University Hospitals NHS Trust, apologised for the "significant shortcomings" in its care.
He said a number of changes had been made following Ava's death and greater awareness of sepsis, in relation to children with complex medical conditions, had been raised.
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Source: BBC News, 4 September
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