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

Significant failings in care by Great Ormond Street Hospital

The coroner looking into the death of Scottish teenager Amy Allan has found significant failings in her care by Great Ormond Street Hospital.
Amy, from Dalry in North Ayrshire, was 14 when she died in September last year following surgery on her spine. Coroner Edwyn Buckett outlined poor planning and support from the hospital. But he said he "was not able to make a firm conclusion" that those omissions "had caused or materially contributed to her death." The coroner is however likely to issue a prevention of future deaths report.
Great Ormond Street Hospital admitted Amy's care "fell short of the high standards" it should be meeting but said it had made changes to the way it worked.
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Source: BBC News, 5 September 2019
Patient Safety Learning

Postnatal checks for new mothers need to be properly funded, charity tells government

Almost half (47%) of new mothers get less than three minutes or no time to discuss their mental and physical health at the routine six week postnatal check-up, according to a survey by the National Childbirth Trust (NCT).
The charity is calling on the government to provide funding for a full postnatal check-up so that GPs have sufficient time to talk to a new mother about her health and wellbeing.
Read full story (paywalled)
Source: BMJ, 5 September 2019
Patient Safety Learning

Seven in 10 hospital trusts failing to meet safety standards

Patient safety is frequently at risk in NHS hospital trusts in England, with 70% of them failing to meet national safety standards, according to an Observer analysis of inspection reports, with staff shortages the biggest problem. 
Reports by the Care Quality Commission (CQC) reveal that managers at one trust failed to act on staff reports of abuse and violence, while a shortage of critical beds at another trust led to three serious incidents resulting in patient harm. Of 148 acute and general hospital trusts, safety standards at 96 are rated as “requires improvement” by the CQC; six are rated inadequate, the lowest category. The others are rated good, with none outstanding.
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Source: Guardian, 8 September 2019
Patient Safety Learning

AHSN's 'Patient Safety in Partnership' plan

The Academic Health Science Network (AHSN) has published their plan for a safer future: 'Patient Safety in partnership: Our plan for a safer future 2019-2025' . Their plan supports the NHS Patient Safety Strategy and sets out how England’s 15 AHSNs, and the Patient Safety Collaboratives (PSCs) they host, will work more closely with their local health and care organisations to improve safety both in hospitals and community-based services such as care homes.
AHSN's "ambition is to support the delivery of the NHS Patient Safety Strategy and therefore our vision is aligned to the national strategy: ‘for the NHS to continuously improve patient safety'.’'
Patient Safety Learning is delighted to be working with The AHSN and Patient Safety Collaboratives and welcomes their Patient Safety in Partnership plan:
"We believe that it will make a difference for patient safety and represents a step forward from the good work that AHSNs are already doing. We believe that there is opportunity for even more to be achieved with the resources, scale and capability within the AHSN networks. We absolutely applaud the statement that patient safety is a central priority and guiding principle for all AHSNs, and we recognise the AHSNs’ distinct role as orchestrators across the healthcare system. We think that AHSNs, with PSCs, can reinforce this position by taking a powerful role in bringing, enabling and supporting systems thinking for patient safety across healthcare."
Patient Safety Learning will be sharing details of the innovation and improvement programmes on the hub.
Patient Safety Learning

When parents of sick children don't get to decide

The parents of five-year-old Tafida Raqeeb, who is on life support, are going to the High Court to challenge an NHS decision which is preventing them from taking her abroad. 
Tafida Raqeeb suffered a traumatic brain injury in February as a result of a rare condition, arteriovenous malformation, where a tangle of blood vessels causes blood to bypass the brain tissue. Tafida's mother and father want to seek treatment in Italy. But the Royal London Hospital, which is caring for their daughter, says releasing her is not in her best interests.
A spokesperson for Barts Health NHS Trust, which runs the hospital, said that its clinicians and independent medical experts had found "further medical treatment would not improve her condition".
In England and Wales the concept of parental responsibility is set out in law, in the Children Act 1989. This gives parents the responsibility broadly to decide what happens to their child, including the right to consent to medical treatment. But this right is not absolute. If a public body considers that a parent's choices are not in the best interests of their child, and an agreement cannot be reached, it can challenge these choices by going to court. It comes down to a judge to make the final decision, based on the evidence available.
Read full story
Source: BBC News, 2 September
Patient Safety Learning

Hundreds of thousands of people in England are getting hooked on prescription drugs

Hundreds of thousands of people in England are getting hooked on prescription drugs, health chiefs fear. 
A Public Health England (PHE) review looked at the use of strong painkillers, antidepressants and sleeping tablets - used by a quarter of adults every year. It found that at the end of March 2018, half of people using these drugs had been on them for at least 12 months. Officials said long-term use on such a scale could not be justified and was a sign of patients becoming dependent.
PHE medical director Prof Paul Cosford said he was worried. "These medicines have many vital clinical uses and can make a big difference to people's quality of life." But he added there were too many cases where patients were using them for longer than "clinically" appropriate - where the drugs would have simply stopped working effectively or where the risks could outweigh the benefits.
Read full story
Source: BBC News, 10 September 2019
Patient Safety Learning

Improving safety in care homes

A new report from the AHSN Network is shining a light on ways we can do more to improve safety for residents of care homes.
The publication showcases over 30 examples of projects delivered by England’s 15 Patient Safety Collaboratives (PSCs) and the Academic Health Science Networks (AHSNs) which host them. They include case studies in medicines safety, dementia, monitoring and screening, and workforce development.
AHSN Network Patient Safety Director Dr Cheryl Crocker, said:
“Many residents have complex healthcare needs, reflecting multiple long-term conditions, significant disability and advanced frailty. All these factors make caring for residents an incredibly difficult job for care homes and their staff.
“Given this operating landscape, there are some fantastic examples of care, safety and quality improvement in care homes. The aim of this summary is to share good practice supported by the AHSN Network, and we are actively encouraging readers to get in touch with those who have shared their work for this report and discuss how we can have even greater impact on patient safety and improvement in care homes.”
Read full report
Patient Safety Learning

Don’t charge migrants for maternity care, say midwives

Midwives have called on the government to end the policy of charging some migrants for maternity care, saying it undermines trust and creates a climate of fear among vulnerable pregnant women.
A report by Maternity Action, backed by the Royal College of Midwives, says some women were seeking maternity care late in pregnancy, missing tests and treatments, or completely avoiding antenatal care for fear of charges and Home Office sanctions.
“Midwives should not act as gatekeepers to maternity services,” said Gill Walton, chief executive and general secretary of the Royal College of Midwives.
Read full story (paywalled)
Source: BMJ, 9 September 2019
Patient Safety Learning

Foundation trust to seek merger to avoid ‘patient safety risks’

A mental health trust is preparing to seek a merger or acquisition by another provider in a bid to address its financial challenges, HSJ has learned. 
In a message to staff, North West Boroughs Healthcare Foundation Trust said growing financial pressures were “likely to put the quality and safety of patients at risk”.
It said various options were discussed by governors and the trust board at a meeting yesterday, and it was agreed to pursue a “merger or acquisition of the whole organisation with one or more provider trusts”.
Read full story (paywalled)
Source: HSJ, 12 September
Patient Safety Learning

Northwest Ambulance Service case review published

The National Guardian’s Office (NGO) has published a 'Summary of speaking up learning and actions' in response to the referrals made from the review into the handling of two speaking up cases at Northwest Ambulance Service NHS Trust (NWAS). The review is the product of the NGO’s engagement process, the central feature of which is the actions the trust will take to address the issues highlighted.
These include explaining the scope of the role of the Freedom to Speak Up Guardians and the issues they can support workers to raise. The trust has also committed to consider their approach to the independence, timeliness and handling of investigations into speaking up matters. They also recognised the need to address perceived attitudes towards female workers.
“The trust has outlined significant steps it is making to ensure these issues are taken seriously, and the learning is embedded in effective improvement actions,” explained Dr Henrietta Hughes, National Guardian for the NHS.
Daren Mochrie, NWAS’ Chief Executive, said, “It’s really important for us to give our staff the confidence to be able to share any concerns and observations safely and confidentially. This creates an open and honest reporting culture within the trust. We welcome the findings of the report and are now putting the learning from this into action to even further improve our reporting system.”
Source: National Guardian's Office, 12 September 2019
Patient Safety Learning

Member of EEAST staff shares sepsis story

To raise awareness of an illness estimated to kill 30 million people a year globally – and up to 44,000 people a year in the UK – East of England Ambulance Service NHS Trust (EEAST) is encouraging people to learn to spot the signs of sepsis – and know what to do.
As part of World Sepsis Day, EEAST staff have been sharing stories about how they have been affected by sepsis in their families.
Read full story
Source: East of England Ambulance Service NHS Trust, 13 September 2019
 
Patient Safety Learning

Fiona Edwards, Chief Executive of Surrey and Borders Partnership NHS Foundation Trust: My thoughts on World Sepsis Day

Fiona Edwards, Chief Executive of Surrey and Borders Partnership NHS Foundation Trust, shares her thoughts and her own personal experience of sepsis.
Read full story
Source: Surrey Heartlands Health and Care Partnership, 13 September 2019
Patient Safety Learning

Pregnancy-related deaths are rising in the US. Geisinger among 30 health systems testing digital tools to stop the trend

Pregnancy-related deaths and maternal morbidity continue to rise in the US. A major factor is large areas of the country, 'maternity deserts' have little or no proper maternity care, officials say.
So 30 health systems are teaming up to implement digital tools and new care models to help close gaps in care for mothers and infants. Those digital solutions include screening tools to identify pregnant women with comorbidities like diabetes and hypertension to intervene earlier and using telehealth to connect expectant mothers to doulas. 
Read full story
Source: FierceHealthcare, 12 September 2019
Patient Safety Learning

Cancer survival in the UK improving, but lagging behind

Cancer survival in the UK is on the up, but is still lagging behind other high-income countries, analysis suggests.
Five-year survival rates for rectal and colon cancer improved the most since 1995, and pancreatic cancer the least. Advances in treatment and surgery are thought to be behind the UK's progress.
But the UK still performed worse than Australia, Canada, Denmark, Ireland, New Zealand and Norway, the study in Lancet Oncology found. Cancer Research UK said the UK could do better and called for more "investment in the NHS and the systems and innovations that support it".
Read full story
Source: BBC News, 12 September 2019
Patient Safety Learning

NHS admin: how does it affect patient experience?

At one time or another, most of us have experienced feeling frustrated by bureaucratic processes, outdated IT systems or unsatisfactory interactions with administrative staff. 
As in many other parts of our lives, when the administrative aspects of a service seem poor (and when they seem good) it can have a significant impact on how we feel about our experience of using it overall. In the case of healthcare, this often comes at a time when we are already feeling anxious. In some cases, administration can also have an impact on the care we receive – for example, if an appointment is delayed. For these reasons alone (though there are many others) NHS administration is important.
Despite this, there has been very little research into NHS administration and its impact on service users, and it is not routinely captured in NHS data. The King’s Fund are kicking off a project to explore patients’ experiences of NHS administration in more detail. As a first step, they reviewed a random sample of over 300 comments written on the Care Opinion website between 2016 and 2018.
This analysis is just the beginning. Over the next few months, The King's Fund will speak to patients and NHS staff to understand the issues around NHS administration in more detail. For more information, see their project page.
Read full story
Source: The King's Fund, 13 September 2019
Patient Safety Learning
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