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

Mid Staffs scandal: 10 years on, inquiry chair worries NHS staff too scared to speak up

Ten years on from the Mid Staffordshire NHS trust scandal, the man who led the inquiry into one of the worst care disasters in the service’s history has said he remains worried about the safety of patients and a culture that leaves staff too frightened to speak up.
Sir Robert Francis QC said some safety risks highlighted a decade ago remain unresolved and he threw his weight behind calls for senior managers in the NHS to be regulated.
The barrister said he believed the NHS was safer now than a decade ago but added he worried whether actions taken since the disaster had made a real difference.
“What keeps me awake at night is not so much has anyone implemented recommendation 189 or not, but more whether the collectivity of what has happened since has actually resulted in things being better for patients and staff,” he told The Independent.
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Source: The Independent, 15 January 202
Patient Safety Learning

NHS hospitals need to appoint medical examiners now or risk mistakes such as Mid Staffs happening again

Medical examiners are doctors who look at every hospital death with a fresh pair of eyes to make an independent judgement about what took place. It is impossible to overestimate the importance of their role, and it is vital that NHS hospitals now get on with appointing them as a matter of urgency, says Jeremy Hunt, former Foreign Secretary, in an article in the Independent newspaper.
The big issue is not that bad things happen (sadly in an organisation of 1.4 million people there will inevitably be things that go wrong) but that they take so long to identify and put right. Mid Staffs took four years, Morecambe Bay took nine years and it now looks like the problems at Shrewsbury and Telford could have taken place over 40 years.
Anyone who has spoken to brave patient-safety campaigners who lost loved ones because of poor care will know that their motivation is never money, simply the desire to stop other families having to go through what they have suffered.
That is why they and other patient groups all campaign for medical examiners – a process through which every death is examined by a second, independent doctor. It was first recommended following the Shipman inquiry but has taken a long time to implement – inevitably for cost reasons. 
Where they have been introduced, medical examiners have been transformational. 
The main pilot sites in Sheffield and Gloucester, which scrutinised over 23,000 deaths, found that “medical examiners have triggered investigations that identified problems with post-operative infections faster than other audit procedures, based on surprisingly few cases”. Doctors also felt confident in raising concerns, as they were protected and supported by the independent medical examiner. Remarkably, pilot studies found that 25% of hospital death certificates were inaccurate and 20% of causes of death were wrong.
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Source: The Independent, 16 January 2020
Patient Safety Learning

Plan to scrap A&E target sparks furious backlash from medics

Plans to scrap the four-hour A&E target have sparked a furious backlash from doctors and nurses, with some claiming it is driven by ministers’ desire to avoid negative publicity about patients facing increasingly long delays.
A&E consultants led a chorus of medical opposition to the move. They pointedly urged NHS leaders and ministers to concentrate on delivering the long-established maximum waiting time for emergency care rather than finding “ways around” it.
Under the target, 95% of people arriving at A&E in England are meant to be treated and then discharged, admitted or transferred within four hours. But performance against the target plunged to a new record low of just 68.6% last month in hospital-based A&E units as a result of staffing problems, the decade-long squeeze on the NHS budget and the dramatic growth in the number of patients seeking care.
The Royal College of Emergency Medicine (RCEM), which represents A&E doctors, was responding to Wednesday’s apparent confirmation by the health secretary, Matt Hancock, that the target  is set to be axed because it is no longer deemed to be “clinically appropriate”.
“So far we’ve seen nothing to indicate that a viable replacement for the four-hour target exists and believe that testing [of alternatives to the target] should soon draw to a close,” said Dr Katherine Henderson, the President of the RCEM. “Rather than focus on ways around the target, we need to get back to the business of delivering on it.”
The Emergency Care Association, to which 8,000 A&E nurses belong, said ministers should exercise “extreme caution” in decisions about the target because “it could cause significant detriment to patient safety within our emergency departments if the four-hour target was abolished”. There are fears that patients thought to have only minor ailments could come to harm by having to wait a lot longer than four hours because they also have a more serious condition.
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Source: The Guardian, 15 January 2020
 
Patient Safety Learning

NHS maternity scandal: Inquiry into baby deaths now looking at 900 cases

The inquiry into Britain's worst maternity scandal is now reviewing 900 cases, a health minister has confirmed.
The Ockenden Review, which was set up to examine baby deaths in the Shrewsbury and Telford Hospital Trust, was initially charged with examining 23 cases, but Nadine Dorries, a health minister, confirmed to the Commons that an additional 877 cases are being reviewed.
A leaked report in November said a "toxic culture" stretching back 40 years reigned at the hospital trust as babies and mothers suffered avoidable deaths. The review will conclude at the end of the year.
Jeremy Hunt, the former health secretary, said it was "deeply shocking" to hear of the new details and asked that the inquiry is "resolved as quickly as possible".
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Source: The Telegraph, 16 January 2020
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‘Critical decision-making’ at major cancer centre left to trainees

Trainee oncologists at a major cancer centre covered clinics and made “critical” decisions without senior supervision, including for cancers they were not trained for, HSJ has revealed.
A Health Education England (HEE) reviews aid: “The review team was concerned to hear that trainees were still expected to cover clinics where no consultant was present, including clinics relating to tumour sites that they were unfamiliar with.”
Guy’s and St Thomas’ Foundation Trust’s trainee clinical oncologists felt “they could only approach 50–75% of the consultants for critical decision-making”, the document said.
The HEE “urgent concern review” report said: “The trainees also reported that there was a continued lack of clear consultant supervision for inpatient areas in clinical oncology, which meant that they were not able to access senior support for decision-making.”
A trust spokesman said: “We recognise that senior support to the clinical team is a vital part of keeping our patients safe.”
Read full story (paywalled)
Source: HSJ, 16 January 2020
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Cornwall hospital to discharge patients early despite saying it may be harmful

A major NHS hospital is under such pressure that it has decided to discharge people early even though it admits that patients may be harmed and doctors think the policy is unwise.
The Royal Cornwall Hospitals NHS trust has told staff to help it reduce the severe overcrowding it has been facing in recent weeks by discharging patients despite the risks involved.
In a memo sent on 8 January, three trust bosses said the Royal Cornwall hospital in Truro, which is also known as Treliske hospital and has the county’s only A&E department, “has been under significant pressure for the last two weeks and it is vital that we are able to see and admit our acutely unwell patients through our emergency department and on to our wards”.
The memo added: “One of these mitigations was to look at the level of risk that clinicians are taking when discharging patients from Treliske hospital either to home or to community services, recognising that this may be earlier than some clinicians would like and may cause a level of concern.
“It was agreed, however, that this would be a proportionate risk that we as a health community were prepared to take on the understanding that there is a possibility that some of these patients will be readmitted or possibly come to harm.”
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Source: 14 January 2020
Patient Safety Learning

Hernia mesh implants used 'with no clinical evidence'

"Too many" types of hernia mesh implants are being used on NHS patients with little or no clinical evidence, the BBC has been told.
New data shows more than 100 different types of mesh were purchased by NHS Trusts from 2012 to 2018 in England and Scotland, leading to fears over safety. The meshes can cut into tissue and nerves, leaving some people unable to walk, work or care for children.
Currently, hernia mesh devices can be approved if they are similar to older products, which themselves may not have been required to undergo any rigorous testing or clinical trials in order to assess their safety or efficacy.
In England, around 100,000 such operations are performed each year, the majority using mesh. Many go well. But the Victoria Derbyshire programme has heard from nearly 300 people who have experienced complications - including chronic pain, infections and organ perforations. International guidelines estimate one in 10 patients will experience "significant chronic pain" following a mesh repair.
The director of devices at the Medicines and Healthcare products Regulatory Agency (MHRA), Graeme Tunbridge, told the BBC: "The benefits and risks of using mesh for hernia repair have been considered in detail by clinicians and the professional bodies who represent them. We continue to monitor and review evidence as it becomes available and will take any appropriate action on that basis."
Mr Tunbridge said he recognised the system "does need strengthening" and said new legislation on medical devices would take effect from May 2020.
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Source: BBC News, 15 January 2020
Patient Safety Learning

From stargazing to mole-gazing

Astrophysics and dermatology are colliding through a new research project led by the University of Southampton – with potentially lifesaving consequences.
The project, dubbed MoleGazer, will take algorithms used for detecting exploding stars in astronomical imaging data and develop them to be used to spot changes in skin moles and, therefore, detect skin cancer.
MoleGazer, led by Professor Mark Sullivan, Head of the School of Physics and Astronomy at the University, and Postdoctoral Researcher Mathew Smith, has been awarded a Proof of Concept Grant from the European Research Council (ERC). It is the first time the University has won such a grant.
Currently, patients at high risk of developing skin cancer are photographed at regular intervals and a consultant visually compares images to detect changes. MoleGazer could automate this process, potentially leading to earlier diagnoses and improved survival rates.
“It’s a really exciting project that came along from nowhere,” added Professor Sullivan. “It also highlights the importance of blue sky science – curiosity-driven scientific research will always have a fundamentally important role to play.”
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Source: University of Southampton, 10 January 2020
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Stroke consultant shortage 'hurtling towards crisis'

Almost half of hospitals have a shortage of specialist stroke consultants, new figures suggest. One charity fears "thousands of lives" will be put at risk unless action is taken, with others facing the threat of a lifelong disability.
In 2016, Alison Brown had what is believed to have been at least one minor stroke, but non-specialist doctors at different hospitals repeatedly told her she did not have a serious health condition. One even described it as an ear infection. 
Ten months later, aged 34, she had a bilateral artery dissection - a common cause of stroke in young people, where a tear in a blood vessel causes a clot that impedes blood supply to the brain. She was admitted to hospital - but again struggled for a diagnosis. A junior doctor found an issue with blood flow to the brain but she says their comments were dismissed and she was told it was a migraine. It was only when she collapsed again, days later, and admitted herself to a hospital with a dedicated stroke ward that a specialist team was able to give her the care she needed.
Alison's case highlights the importance of being seen by stroke specialists. However, according to new figures from King's College London's 2018-19 Snapp (Sentinel Stroke National Audit Programme) report, 48% of hospitals in England, Wales and Northern Ireland have had at least one stroke consultant vacancy for the past 12 months or more. This has risen from 40% in 2016 and 26% in 2014.
The Stroke Association charity - which analysed the data - says the UK is "hurtling its way to a major stroke crisis" unless the issue is addressed.
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Source: BBC News, 17 January 2020
Patient Safety Learning

'Alarming' one in five deaths due to sepsis

One in five deaths around the world is caused by sepsis, also known as blood poisoning, shows the most comprehensive analysis of the condition.
The report estimates 11 million people a year are dying from sepsis - more than are killed by cancer. The researchers at the University of Washington said the "alarming" figures were double previous estimates. Most cases were in poor and middle income countries, but even wealthier nations are dealing with sepsis.
There has been a big push within the health service to identify the signs of sepsis more quickly and to begin treatment. The challenge is to get better at identifying patients with sepsis in order to treat them before it is too late. Early treatment with antibiotics or anti-virals to clear an infection can make a massive difference.
Prof Mohsen Naghavi said: "We are alarmed to find sepsis deaths are much higher than previously estimated, especially as the condition is both preventable and treatable. We need renewed focus on sepsis prevention among newborns and on tackling antimicrobial resistance, an important driver of the condition."
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Source: BBC News, 17 January 2020
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Hospital bosses launched ‘witch hunt’ to find whistleblower who revealed blunders in woman’s treatment, inquest told

Hospital bosses have been accused of launching a witch hunt to find a whistleblower who told a widower about blunders in the treatment his wife received.
The row emerged as an inquest began into the death of Susan Warby who died five weeks after bowel surgery. The 57-year-old died at West Suffolk Hospital in Bury St Edmunds after a series of complications in her treatment.
Her family received an anonymous letter after her death highlighting errors in her surgery, the inquest in Ipswich heard, and both Suffolk Police and the hospital launched investigations. These investigations confirmed that there had been issues around an arterial line fitted to Ms Warby during surgery, Suffolk’s senior coroner Nigel Parsley said.
Doctors were reportedly asked for fingerprints as part of the hospital’s investigation, with an official from trade union Unison describing the investigation as a “witch hunt” designed to identify the whistleblower who revealed the blunders.
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Source: The Independent, 17 January 2020
Patient Safety Learning

Ways to identify EHR usability issues and reduce patient harm

An electronic health record (EHR) bug that transmits and medication order for 25 mg of a drug – not the prescribed 2.5 mg – could be the difference between life and death. And it’s that seemingly impossible reality that’s bringing more industry stakeholders to the table working to better understand EHR usability and its effects on patient safety.
“Often times when people think about usability, they think about design and then they think about the EHR vendor,” Raj Ratwani, PhD, Director of MedStar Health Human Factors Center, said in an interview with EHRIntelligence.
“In reality, it's a very complex space. The products that are being used by frontline clinicians are shaped by the vendor. But they are also shaped by how that product is implemented at that provider site, how it's customized, and how it’s configured. All of those things shape usability.”
EHR usability issues are an exceptionally common issue, Ratwani reported in a recent JAMA article. About 40% EHRs reported having an issue that can potentially lead to patient harm and about 786 hospitals and 37,365 individual providers may have used EHRs with potential safety issues based on required product use reporting.
Direct safety challenges typically come from EHR products that are sub-optimally designed, developed, or implemented. Usability issues stem from a very cluttered interface or a complex medication list. Seeing a cluttered list can lead to a clinician selecting the wrong medication.  
A major usability issue also comes from data entry. EHR users want that process to be as clean as possible. Consistency in the way information is entered is also key, Ratwani explained.
Ratwani also wants to ensure that certification testing is as realistic as possible.
He compared it to when a vehicle is certified to meet certain safety standards each year. This type of mechanism does not exist when it comes to EHRs because right when the product is certified, it then gets implemented, and there is no further certification of safety done at all after the initial testing.
“One way to do that, at least for hospitals, is to have that process be something that the Joint Commission looks to do as part of their accreditation standards,” Ratwani said.
“They could introduce some very basic accreditation standards that promote hospitals to do some very basic safety testing.”
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Source: EHR Intelligence, 13 January 2020
Patient Safety Learning

The FDA is still letting doctors implant untested devices into our bodies

When Kathleen Yaremchuk, Chair of the department of otorhinolaryngology (ear, nose and throat) at Henry Ford Hospital in Detroit, began getting calls about mysterious cases of respiratory distress, she launched a study to figure out what was going on.
All these patients, it turned out, had a small device implanted in the top of their spines to relieve pain. The object, used to hold a protein that stimulates bone growth, was cleared for sale by the Food and Drug Administration in 2003 without clinical testing in humans.
When Yaremchuk and her colleagues reviewed the records of all 260 patients implanted with the device at Henry Ford Hospital between 2004 and 2009, they found that a significant number developed airway obstruction, trouble swallowing and respiratory failure, in some cases leading to death.
The neck implant is just one of the products associated over the past decade with 1.7 million injuries and more than 80,000 deaths.
A searing global investigation last year by the International Consortium of Investigative Journalists places much of the blame on significant failings in the FDA’s oversight. The agency’s laissez faire attitude has resulted in artificial hips that cause cobalt poisoning (which can damage the heart and brain); surgical mesh that cuts through flesh and organs, causing infections and haemorrhage; and defibrillators that repeatedly shock patients beyond human endurance.
Safety problems have led to recalls of devices implanted in hundreds of thousands of people. And the devices can be difficult or impossible to remove if they go bad
No wonder many patient advocates cheered when the FDA announced in November that it planned to make “transformative” changes in the way more than 80% of medical devices are cleared for sale in the United States. But the promised transformation is mere window dressing. Two key loopholes still exist, allowing most products to be approved for sale without clinical trials in humans.
Read full story (paywalled)
Source: The Washington Post, 4 January 2019
Patient Safety Learning

Dementia patient’s family feel let down over death

The daughter of a man with dementia who died after being pushed by another patient in a care facility, has said her family has been let down by authorities.
John O'Reilly died a week after sustaining a head injury at a dementia care unit in County Armagh. The 83-year-old was pushed twice by the same patient in the days leading up to the fatal incident. His family were not made aware of this until after his death.
On 4 December 2018, Mr O'Reilly was pushed by another dementia patient causing him to hit his head off a wall. His family have said he was pushed with such force that it left a dent in the wall. He was admitted to Craigavon Area Hospital with severe head injuries and died a week later.
Last week, an inquest heard that the dementia patient who pushed Mr O'Reilly had a history of aggressive behaviour linked to dementia.
The Southern Trust is carrying out as Serious Adverse Incident (SAI) investigation into Mr O'Reilly's death.
Maureen McGleenon said: "Our experience of the SAI process has been dreadful. In our view it allows the trust to park the fact that something catastrophic has happened to a family. We were told it would be a 12-week process. It's over a year now and we've expended so much energy trying to figure out this process and find things out for ourselves."
She added: "The system just knocks you down and makes you want to give up."
"We'll never get over what happened to dad and we can't give up on trying to understand it."
Read full story
Source: BBC News, 20 January 2020
Patient Safety Learning

Coroner slams scandal-hit NHS hospital for serious failings after mother bled to death when medic refused vital blood clotting drugs after C-section following long labour

A coroner has today slammed a hospital for a series of serious failings after a mother bled to death when a medic refused to allow her vital clotting products.
Gabriela Pintilie, 36, from Grays, Essex, gave birth to her healthy baby girl, Stefania, in February last year following a C-section after a long labour. But she suffered a major haemorrhage and died from a cardiac arrest hours later.
Basildon University Hospital, in Essex, came under fire after it emerged a locum haematologist refused to give Mrs Pintilie the blood after he followed the wrong set of guidelines. The fresh frozen plasma, which could have saved her life, remained outside the theatre after senior staff were not told it was available.
Essex Coroner Caroline Beasley-Murray today slammed the hospital for a lack of clear leadership and teamwork during the crucial minutes and hours when Mrs Pintilie suffered a massive haemorrhage.
The court heard how the on-call haematologist Dr Asad Omran, who was at home,  was called but refused to give permission for vital blood-clotting drugs to be issued until further tests were run. 
An expert witness said she believed the use of clotting drugs in the 'extreme situation' would have 'significantly increased' the chances of a different outcome. Dr Omran did not initially issue blood-clotting drugs because he followed the wrong protocol. He was following protocol for a normal adult, instead of a woman in labour, which was 'completely at odds with clinical guidelines'.
Read full story
Source: Mail Online, 20 January 2020
Patient Safety Learning

Hospice receives outstanding CQC rating

The Care Quality Commission (CQC) has awarded 'Outstanding' ratings to St Giles Hospice in Walsall and Whittington. 
The CQC, an independent regulator of health and social care services in England, has recently introduced a new regime holding hospices to the same level of scrutiny as hospitals, making this outstanding rating all the more impressive.
St Giles hospice, founded in 1983, started as a charity caring for local people dying from cancer and now supports people living with incurable illnesses and their families for free.
Care providers from the hospice work on-site and in patients’ own homes, and their level of care has made them one of only a handful of hospices to ever have been awarded this accolade.
In the CQC report inspectors complimented the hospice for its “compassionate” range of speciality services. 
Inspectors added: “People were truly respected and valued as individuals. They were empowered as partners in their care, practically and emotionally, by an exceptional and distinctive service.”
Read full story
Source: National Health Executive, 16 January 2020
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