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

Surgery patients with deadly sepsis are not getting antibiotics fast enough, NHS audit finds

More than 80% of patients who have signs of a deadly sepsis infection before high-risk surgery are not getting antibiotics fast enough, a major NHS report has warned.
Sepsis kills an estimated 44,000 people in England every year and rapid access to antibiotics within the first hour after diagnosis is vital to halt the infection. However, a review of performance across 179 NHS hospitals has found a majority of patients undergoing emergency bowel surgery are not getting medication early enough. A leak of the bowel can cause sepsis and while antibiotics will help treat the infection, surgery is essential to repair any sepsis-causing leak.
The Royal College of Anaesthetists, which carried out the study for the NHS, said although the number of patients getting surgery in time had improved over the last five years, the numbers receiving antibiotics within an hour had not.
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Source: The Independent, 4 January 2020
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Hospital in bullying claims did not monitor at-risk patients

A hospital accused of bullying its staff is facing new claims that it failed to act on a leading doctor’s warning about a potentially fatal failure to monitor vulnerable patients, the Guardian newspaper can reveal.
Dr Jonathan Boyle, the UK’s top vascular surgeon, had warned West Suffolk NHS trust that patients at risk of dying from burst aneurysms were not being safely monitored. An IT glitch meant that patients were not followed up to see how soon they would need potentially life-saving surgery.
A doctor at the trust, however, says it initially repeatedly refused to take any action, raising further questions about its management.
The trust initially suggested the problem was the result of senior doctors not keeping up with emails, but later accepted its IT systems were at fault. The hospital was forced to recognise that patients were potentially put at risk and took action only after a whistleblower alerted the NHS regulator.
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Source: The Guardian, 5 January 2020
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Two-thirds of trusts failing to protect staff from violence

Around two-thirds of NHS providers were found to be breaking laws aimed at protecting staff from violence and aggression, when inspected by the Health and Safety Executive (HSE), information released to HSJ reveals.
The HSE has inspected 37 NHS organisations since April 2018, looking at how they manage risks to staff from violence and aggression, and found 25 of them (67%) were in breach of the law.
It comes amid concern about rising numbers of assaults on NHS and care staff. The HSE has identified that three staff members have been killed by patients or service users in the last five years.
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Source: HSJ, 6 January 2020
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Toddlers died after NHS 111 helpline said they were not in danger

The NHS 111 helpline for urgent medical care is facing calls for an investigation after poor decision-making was linked to more than 20 deaths.
Experts say that inexperienced call handlers and the software used to highlight life-threatening emergencies may not always be safe for young children. At least five have died in potentially avoidable incidents.
Professor Carrie MacEwen, Chairwoman of the Academy of Medical Royal Colleges, said: “These distressing reports suggest that existing processes did not safeguard the needs of the children in these instances.”
Since 2014 coroners have written 15 reports involving NHS 111 to try to prevent further deaths. There have been five other cases where inquests heard of missed chances to save lives by NHS 111 staff; two other cases are continuing and one was subject to an NHS England investigation.
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Source: The Times, 5 January 2020
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Myla’s mum left with ‘soul‑destroying sadness’

Mother Natalie Deviren was concerned when her two-year-old daughter Myla  awoke in the night crying with a restlessness and sickness familiar to all parents. Natalie was slightly alarmed, however, because at times her child seemed breathless.
She consulted an online NHS symptom checker. Myla had been vomiting. Her lips were not their normal colour. And her breathing was rapid. The symptom checker recommended a hospital visit, but suggested she check first with NHS 111, the helpline for urgent medical help. To her bitter regret, Natalie followed the advice.
She spoke for 40 minutes to two advisers, but they and their software failed to recognise a life-threatening situation with “red flag” symptoms, including rapid breathing and possible bile in the vomit.
Myla died from an intestinal blockage the next day and could have survived with treatment.
The two calls to NHS 111 before the referral to the out-of-hours service were audited. Both failed the required standards, but Natalie was told that the first adviser and the out-of-hours nurse had since been promoted. She discovered at Myla’s inquest that “action plans” to prevent future deaths had not been fully implemented. The coroner recommended that NHS 111 have a paediatric clinician available at all times.
In her witness statement at her daughter’s inquest in July, Natalie said: “You’re just left with soul-destroying sadness. It is existing with a never-ending ache in your heart. The pure joy she brought to our family is indescribable.”
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Source: The Times, 5 January 2020
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Hywel Dda cancels operations after 'critical pressures'

A health board has cancelled planned operations at four of its hospitals "in the interest of patient safety".
Hywel Dda University Health Board made the decision after "an extraordinary weekend" of "critical pressures". On Monday, inpatient operations were cancelled at Bronglais, Glangwili, Prince Philip and Withybush hospitals in mid and west Wales.
The health board said it had contacted the patients affected and outpatient appointments continued as normal. No decisions have been taken yet to cancel more non-emergency operations on Tuesday, it added.
Dr Philip Kloer, the health board's medical director, said the weekend saw hospitals "at a level of escalation not seen before".
"It is in the interest of patient safety that we have postponed planned operations today," he added.
Plaid Cymru's shadow minister for health, Helen Mary Jones, said the decision to cancel operations was "deeply concerning". She said that patients in Wales "deserve so much better".
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Source: BBC News, 6 January 2020
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Artificial intelligence can accurately diagnose brain tumours within minutes

Artificial intelligence can diagnose brain tumours more accurately than a pathologist in a tenth of the time, a study has shown.
The machine-learning technology was marginally more accurate than a traditional diagnosis made by a pathologist, by just 1%, but the results were available in less than 2 minutes and 30 seconds, compared with 20 to 30 minutes by a pathologist.
The study, published in Nature Medicine, demonstrates the speed and accuracy of AI diagnosis for brain surgery, allowing surgeons to detect and remove otherwise undetectable tumour tissue.
Daniel Orringer, an Associate Professor of Neurosurgery at New York University's Grossman School of Medicine and a senior author, said: “As surgeons, we’re limited to acting on what we can see; this technology allows us to see what would otherwise be invisible to improve speed and accuracy in the [operating theatre] and reduce the risk of misdiagnosis."
“With this imaging technology, cancer operations are safer and more effective than ever before.”
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Source: The Independent, 6 January 2020
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Hundreds of sexual assaults each year on mixed-gender wards

Hundreds of sexual assaults are reported each year on mixed-sex mental health wards in England, HSJ can reveal, highlighting the urgent need for investment to improve facilities.
New figures obtained by HSJ show there have been at least 1,019 reports of sexual assaults between men and woman on mixed wards since April 2017 to October 2019. This compares to just 286 reports of incidents on single-sex mental health wards over the same period.
Of those reports made on mixed-sex wards, 491 were considered serious enough to refer to safeguarding, and 104 were reported to the police.
The level of incidents still being reported suggests patients are not being protected from sexual assault on mixed wards, despite the issue being highlighted by several national reports in recent years.
Read full story  (paywalled)
Source: HSJ, 7 January 2020
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Improve brand and batch number recording, urge drug safety professionals

New research from the UK’s Drug Safety Research Unit (DSRU) has found that hospital pharmacists, doctors and nurses only recorded batch numbers for biologic medicines between 38% and 58% of the time during routine hospital practice.
Further, an analysis of spontaneous adverse drug reaction (ADR) reports showed that brand names were only included 38% of the time, while batch number traceability was only 15%.
Because of the study results, the DSRU is encouraging health professionals to improve the recording in order to aid patient safety, suggesting that it has “some way to go to encourage health professionals to record this information.”
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Source: PharmaTimes Online, 7 January 2020
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Implementation of safety improvements for the placement of nasogastric tubes

The Healthcare Safety Investigation Branch (HSIB) has launched an investigation looking at nasogastric tubes and how previously identified safety improvements for the placement of these tubes are put into practice.
Nasogastric (NG) tubes are used to deliver fluid, food and medication to patients via a tube that passes through the nose and down into the stomach. There is a risk of serious harm and risk to life if NG tubes are incorrectly placed into the lungs, rather than the stomach, and feed is passed through them.
HSIB has started this investigation after they were notified of a patient who inadvertently had a nasogastric tube inserted into his lung.
Further information
Source: HSIB, 7 January 2020
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Health strike: RCN nurses in second day's strike

About 9,000 nurses across Northern Ireland have begun a 12-hour strike today in a second wave of protests over pay and staffing levels.
More than 2,000 appointments and procedures have been cancelled, including a number of elective caesarean operations.
The Health and Social Care Board said it expects "significant disruption"
Royal College of Nursing (RCN) Director Pat Cullen told BBC Radio Ulster's Good Morning Ulster programme that nurses felt "bullied" by health officials. Her comments followed a warning by the heads of Northern Ireland's health trusts on Tuesday that this week's strikes could push the system "beyond tipping point".
Valerie Thompson, a deputy ward sister at Londonderry's Altnagelvin Hospital, said concerns over safe staffing levels and pay parity had brought her to the picket line.
"We need to have the proper amount of staff to care for our patients, give them the respects, dignity, care they deserve," she said. "We are a loyal workforce; we get on with it, and rally around. But it is difficult. We miss breaks, go home late, staff are just exhausted."
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Source: BBC new, 8 January 2020
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Anger over UK's failure to ban breast implants linked to 61 cancer cases

At least 61 women in the UK have been diagnosed with a potentially fatal cancer linked to breast implants, but the type they received continues to be used, with no plans by the regulator to follow France and Australia in banning them.
Lawyers for more than 40 of the women, who are bringing legal action against the manufacturers as well as the clinics and doctors who carried out the surgery, say the textured implants linked to anaplastic large cell lymphoma (ALCL) should be withdrawn from the market. Smooth implants are available instead, which have no proven connection to the cancer of the white blood cells.
The Medicines and Healthcare Products Regulatory Agency (MHRA) says the disease is very rare, but Sarah Moore, a solicitor at Leigh Day law firm, believes there are more cases than the regulator is aware of. “I think there has been misdiagnosis and under-diagnosis, and I think we have to bear in mind that in the last 18 months there have been 17 more reported cases of ALCL,” she said.
The leading manufacturer of textured implants, Allergan, has withdrawn them from worldwide sale. In December 2018 its European kitemark for the implants expired – the French agency that had granted certification had asked for extra safety data that the company said it could not provide in time. They have not been on sale in Europe since then. The US authorities asked the company to recall its textured implants in July 2019 and Allergan took them off the market.
France and Australia have since banned the sales of all textured implants, although neither has suggested that women should actively seek to have them removed.
In the UK, other brands of textured implants are still in use. Neither NHS England, the NHS Business Services Authority nor the MHRA could say how many had been given to women in the NHS after a mastectomy for breast cancer.
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Source: The Guardian, 7 January 2020
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Hospital wrong to ban woman visiting partner on his deathbed

The partner of a dying man was denied the chance to be at his bedside during his final moments after a hospital wrongly banned her from daily visits, an ombudsman report has found.
Brian Boulton, 70, was admitted to Royal Gwent Hospital in Newport, South Wales, after suffering from a chest infection, which was later diagnosed as aspiration pneumonia caused by oesophageal cancer.
Celia Jones, his “long term life partner” of twenty years, was accused by hospital staff of giving the retired tailor a larger dose of the prescribed furosemide medication than was allowed. Ms Jones, 65, was restricted to one-hour visits twice a week, meaning she was unable to be with him when he died a day after her last authorised visit on Wednesday 27 September 2017.
The Public Services Ombudsman for Wales has upheld her complaints about her “appalling” treatment, ruling that the visiting restrictions were imposed “without warning” and resulted in a “significant injustice”.
It found no record of Ms Jones, a retired nurse, admitting to a senior ward manager that she gave the large dose of medicine to her partner.
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Source: The Telegraph, 6 January 2020
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Death review backlog still growing despite NHSE commitment

A backlog of thousands of deaths of people with learning disabilities awaiting official review has grown further, despite NHS England committing in spring last year to “address” the buildup. 
Information obtained by HSJ shows the number of incomplete reviews increased slightly between May and November last year – from 3,699 to 3,802.
The “national learning disabilities mortality review” programme – known as LeDeR – was launched in 2016 and is meant to review all deaths of people aged four and over.
Mencap head of policy and public affairs, Dan Scorer, said: “It is unacceptable that thousands of deaths have still not been reviewed despite NHS England announcing further funding to make sure all reviews were carried out quickly and thoroughly. These latest figures show that little progress has been made; the programme is still failing to address outstanding reviews as well as keep pace with incoming referrals."
“Behind these figures are families whose loved ones’ deaths may have been potentially avoidable and they have a right to know that health and care services are learning and acting on LeDeR reviews’ recommendations.”
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Source: HSJ, 8 January 2020
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NHS use of puberty blockers legal challenge begins

Legal action is being launched against the NHS over the prescribing of drugs to delay puberty. 
Papers have been lodged at the High Court by a mother and a nurse against the Tavistock and Portman NHS Trust, which runs the UK's only gender-identity development service (Gids). Lawyers will argue it is illegal to prescribe the drugs, as children cannot give informed consent to the treatment.
The Tavistock said it had a "cautious and considered" approach to treatment.
The nurse, Sue Evans, left the Gids more than a decade ago after becoming increasingly concerned teenagers who wanted to transition to a different gender were being given the puberty blockers without adequate assessments and psychological work.
Ms Evans said: "I used to feel concerned it was being given to 16-year-olds. But now, the age limit has been lowered and children as young as perhaps 9 or 10 are being asked to give informed consent to a completely experimental treatment for which the long-term consequences are not known."
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Source: BBC News, 8 January 2020
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Latest HSIB report highlights ‘devastating’ impact of delays and pressure on national glaucoma services

Delays to follow-up appointments for glaucoma patients leaves them at risk of sight loss, the Healthcare Investigation Safety Branch (HSIB) warns in their new report.
The report highlights the case of a 34-year old woman who lost her sight as a result of 13 months of delays to follow-up appointments.
Lack of timely follow-up for glaucoma patients is a recognised national issue across the NHS. Research suggests that around 22 patients a month will suffer severe or permanent sight loss as a result of the delays. In HSIB’s reference case, the patient saw seven different ophthalmologists and the time between her initial referral to hospital eye services (HES) and laser eye surgery was 11 months. By this time her sight had deteriorated so badly, she was registered as severely sight impaired.
The investigation identified that there is inadequate HES capacity to meet demand for glaucoma services, and that better, smarter ways of working should be implemented to maximise the current capacity. The report makes several safety recommendations focused on the management and prioritisation of appointments. 
Helen Lee, RNIB Policy and Campaigns Manager, said: “This report has brought vital attention to a serious and dangerous lack of specialist staff and space in NHS ophthalmology services across the country. We know that thousands of patients in England are experiencing delays in time-critical eye care appointments, which is leading to irreversible sight loss for some."
“Without immediate action, the situation will only continue to deteriorate as the demand for appointments increases. RNIB urges full and immediate implementation of the recommendations set out in this report to improve the capacity, efficiency and effectiveness of ophthalmology services.”
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Source: HSIB, 9 January 2020
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