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

NHS faces huge clinical negligence legal fees bill

The NHS in England faces paying out £4.3 billion in legal fees to settle outstanding claims of clinical negligence, the BBC has learned through a Freedom of Information request. Each year the NHS receives more than 10,000 new claims for compensation. 
The Department of Health has pledged to tackle "the unsustainable rise in the cost of clinical negligence".
Estimates published last year put the total cost of outstanding compensation claims at £83 billion. NHS England's total budget in 2018-19 was £129 billion.
The Association of Personal Injuries Lawyers (APIL) believes the cost is driven by failures in patient safety.
Doctors represented by the Medical Defence Union (MDU), which supports doctors at risk of litigation, are calling for "a fundamental" reform of the current system.
Suzanne White, from APIL, said people came to her on a daily basis with no intention of suing the NHS. But she said they often found it difficult to get answers from the medical authorities - and were left with no other option but to sue.
"What they want to do is find out what went wrong, why they have received these injuries ... and to make sure it doesn't happen to other patients."
Read full story
Source: BBC News, 21 January 2020
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NHS England asked ‘inadequate’ hospital to admit patient despite ban

NHS England asked an “inadequate” hospital for people with learning disabilities and autism to admit a patient, despite the service having a “voluntary” ban on admissions in place — and shortly before inspectors decided to impose a legal restriction.
The provider said it was an “exceptional case”, where the individual “had several failed placements”, and had stayed at the hospital — Jeesal Cawston Park in Norfolk — “in the past”. 
However, it appears to highlight the shortage of good quality accommodation and placements available and pressure on commissioners to make use of “inadequate” facilities.
Read full story (paywalled)
Source: HSJ, 21 January 2020
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Patient had wrong eye injected after software error

Herefordshire clinicians injected a patient in the wrong eye after a technical blunder, board papers have revealed.
The Wye Valley Trust patient was injected with an antivascular endothelial growth factor to treat age-related macular degeneration. They did not come to harm as a result of the incident.
The mistake occurred after the ophthalmology department deleted a poor quality image of one of the patient’s eyes. This shifted up the other images, which were stored sequentially using software called IMAGEnet6, which led to the mistake. 
Although initially reported as a “never event,” the incident was downgraded to a “serious incident” after a review by the Herefordshire Clinical Commissioning Group (CCG). 
The trust, which is still using the software, is updating its standard operating procedure and has installed new technology that can take higher quality images. A spokesman said: “Patient safety is the trust’s priority. While no harm was caused to this patient, the trust has taken this incident seriously.”
Read full story (paywalled)
Source: HSJ, 21 January 2020
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Dementia patients being 'dumped in hospital'

Dementia patients are being dumped in hospitals in England because of a lack of community care, a charity says.
The Alzheimer's Society called for action, highlighting data showing one in 10 dementia patients spends over a month in hospital after being admitted.
The figures also suggested the overall number of emergency admissions among people with dementia is rising - with some patients yo-yoing back and forth.
Ministers said they were "determined" to tackle the problems. Central to this, the government said, would be plans for reforming the social care system, which encompasses care home places and support in people's homes.
Alzheimer's Society Chief Executive Jeremy Hughes said people were falling through the "cracks of our broken social care system".
"People with dementia are all too often being dumped in hospital and left there. Many are only admitted because there's no social care support to keep them safe at home. They are commonly spending more than twice as long in hospital as needed, confused and scared."
Read full story
Source: BBC News, 22 January 2020
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Hundreds of serious incidents recorded at struggling small trust

One of the country’s smallest trusts recorded 277 serious incidents over a two-year period, HSJ can reveal.
Delays in treatment, missed diagnoses, adverse media coverage and “suboptimal” care were among the hundreds of serious incidents reported at the struggling Isle of Wight Trust from the start of 2018 and up to November 2019.
There were also two never events in 2019 — a “wrong site” surgery and an incident in which a patient was mistakenly connected to an air flow meter, rather than an oxygen supply.
The trust said the level of incidents did not neccessarily reflect poor care, and did not mean patients had come to harm.
The trust was placed in special measures in April 2017 after it was rated “inadequate” by the Care Quality Commission due to “significant” concerns over patient safety. It was upgraded to “requires improvement” in September 2019, but remains in special measures. 
Read full story (paywalled)
Source: HSJ, 22 January 2020
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Earlier recognition of aortic dissection needed to prevent deaths

Up to half of all patients who suffer an acute aortic dissection may die before reaching crucial specialist care, according to a new Healthcare Safety Investigation Branch (HSIB) report.
The report highlights the difficulty which can face hospital staff in recognising acute aortic dissection. The investigation was triggered by the case of Richard, a fit and healthy 54-year old man, who arrived at his local emergency department by ambulance after experiencing chest pain and nausea during exercise. It took four hours before the diagnosis of an acute aortic dissection was made, and he spent a further hour waiting for the results of a CT scan. Although Richard was then transferred urgently by ambulance to the nearest specialist care centre, he sadly died during the journey.
The report has identified a number of risks in the diagnostic process which might result in the condition being missed. These include aortic dissection not being suspected because patients can initially appear quite well or because symptoms might be attributed to a heart or lung condition.
It also highlighted that, once the diagnosis is suspected, an urgent CT scan is required to confirm that an acute aortic dissection is present. 
Gareth Owens, Chair of the national patient association Aortic Dissection Awareness UK & Ireland, welcomed the publication of HSIB’s report, saying: “HSIB’s investigation and report have highlighted that timely, accurate recognition of acute Aortic Dissection is a national patient safety issue. This is exactly what patients and bereaved relatives having been telling the NHS, Government and the Royal College of Emergency Medicine for several years."
Read full story
Source: HSIB, 23 January 2020
 
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East Kent hospitals: Baby deaths 'could have been prevented'

At least seven preventable baby deaths may have occurred at one of the largest groups of hospitals in England since 2016, a BBC investigation has found.
Significant concerns have been raised about maternity services at the trust.
East Kent NHS Foundation Trust has apologised, saying it has "not always provided the right standard of care".
The trust has struggled to improve maternity care for years, despite repeatedly being made aware of the problems.
In 2015, the medical director asked experts from the Royal College of Obstetricians and Gynaecologists to review maternity care, amid "concerns over the working culture". Their review, seen by the BBC, found poor team working in the unit, a number of consultants operating as they saw fit, a lack of performance management of the consultant body and out of date clinical guidelines.
It highlights consultants who:
failed to carry out labour ward rounds, review women, make plans of care or attend out of hours when requested rarely attended CTG training were reported "as doing their own thing rather than follow guidelines". Read full story
Source: BBC News, 23 January 2020
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Whorlton Hall: Care regulator ‘was wrong’ to bury whistleblower’s report into failings at hospital where patients were abused

The Care Quality Commission (CQC) missed multiple opportunities to identify abuse of patients at a privately run hospital and did not act on the concerns of its own members, an independent review has found.
Bosses at the CQC have been criticised in an independent report by David Noble into why the regulator buried a critical report into Whorlton Hall hospital, in County Durham, in 2015.
His report published today said the CQC was wrong not to make public concerns from one of its inspection teams in 2015.
“The decision not to publish was wrong,” his report said, adding: “This was a missed opportunity to record a poorly performing independent mental health institution which CQC as the regulator, with the information available to it, should have identified at that time.”
Read full story
Source: The Independent, 22 January 2020
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LloydsPharmacy launches pilot programme to help and support mental health patients

LloydsPharmacy is piloting an innovative new service that offers extra help and support to mental health patients. Funded by The National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre (NIHR GM PSTRC), which is a partnership between The University of Manchester and Salford Royal, the pilot is being carried out in ten community pharmacies in Greater Manchester.
The new service, referred to as AMPLIPHY, enables pharmacists to provide personalised support to people who have been newly prescribed a medicine for depression or anxiety, or those who have experienced a recent change to their prescription.
The pilot programme has been funded and designed by researchers at the NIHR GM PSTRC in collaboration with LloydsPharmacy. Central to the programme is the ability for patients to lead the direction of support they receive. They set their own goals and objectives and the pharmacist supports them in these. 
Professor Darren Ashcroft, Deputy Director of the NIHR Greater Manchester PSTRC, said: "The NIHR Greater Manchester PSTRC focuses on improving patient safety across four themes, which include Medication Safety and Mental Health. AMPLIPHY covers two of these areas and we believe it has the potential to make a difference to patients, by providing enhanced support for their care in the community."
The pilot is set to run until April 2020 when its impact will be evaluated before a decision is made on the next steps.
Read full story
Source: News-Medical.net, 22 January 2020
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Cancer care backlog may cost 30,000 lives, Boris Johnson told

Scores of MPs and former ministers have urged the prime minister to tackle a backlog in NHS cancer care that threatens to lead to thousands of early deaths over the next decade.
More than 100 MPs have written to Boris Johnson after the coronavirus lockdown caused severe disruption to cancer diagnoses and treatments. They have called on him to deliver an emergency boost to treatment capacity.
One senior oncologist has claimed that in a worst-case scenario the effects of the pandemic could result in 30,000 excess cancer deaths over the next decade.
Read full story (paywalled)
Source: The Times, 22 August 2020
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East Kent hospitals: Care watchdog inspects trust after baby death apology

England's care watchdog has carried out a no-notice inspection of an NHS trust at the centre of concerns over the possible preventable deaths of babies. The Care Quality Commission (CQC) is investigating East Kent Hospitals NHS Trust but has not yet decided whether to prosecute.
It comes as the trust is likely to be heavily criticised at an inquest into the death of baby Harry Richford.
On Thursday, the BBC revealed significant concerns have been raised about maternity services at the trust, and a series of preventable baby deaths may have occurred there. On Wednesday and Thursday this week, the trust's maternity services were subject to an unannounced inspection from the CQC.
On Thursday night, East Kent Hospitals University NHS Foundation Trust said in a statement: "We are truly sorry for the death of baby Harry and our thoughts and deepest sympathies go out to Harry's family. We accept that Harry's care fell short of the standard that we expect to offer every mother giving birth in our hospital and we are fully cooperating with the CQC's investigation into Harry Richford's death."
Read full story
Source: BBC News, 24 January 2020
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England's poorest 'get worse NHS care' than wealthiest citizens

England’s poorest people get worse NHS care than its wealthiest citizens, including longer waiting for A&E treatment and worse experience of GP services, a new study has shown.
Those from the most deprived areas have fewer hip replacements and are admitted to hospital with bed sores more often than people from the least deprived areas. With regard to emergency care, 14.3% of the most deprived had to wait more than the supposed maximum of four hours to be dealt with in A&E in 2017-18, compared with 12.8% of the wealthiest. Similarly, just 64% of the former had a good experience making a GP appointment, compared with 72% of those from the richest areas.
Research by the Nuffield Trust and Health Foundation thinktanks found that the poorest people were less likely to recover from mental ill-health after receiving psychological therapy and be readmitted to hospital as a medical emergency soon after undergoing treatment.
The findings sparked concern because they show that poorer people’s health risks being compounded by poorer access to NHS care.
Read full story
Source: The Guardian, 23 January 2020
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Justice is being denied to too many families

Harry Richford's death underlines the need for the health secretary to bring back the national maternity safety training fund – and there are other issues that require urgent attention – The Independent reports. 
Harry Richford had not even been born before the NHS failed him. An inquest has concluded he was neglected by East Kent University Hospitals Trust in yet another maternity scandal to rock the NHS. His parents and grandparents have fought a tireless campaign against a wall of obfuscation and indifference from the NHS. In their pursuit of the truth they have exposed a maternity service that did not just fail Harry, but may have failed dozens of other families.
As with the family of baby Kate Stanton-Davies at Shrewsbury and Telford Hospitals Trust, or Joshua Titcombe at the University Hospitals of Morecambe Bay Trust, it has taken a family rather than the system to expose what was going wrong. It is known that there are about 1,000 cases a year of safety incidents in the NHS across England, including baby deaths, stillbirths and children left brain damaged by mistakes.
Last week, the charity Baby Lifeline, joined The Independent to call on the Department of Health and Social Care (DHSC) to reinstate the axed maternity safety training fund. This small fund was used to train maternity staff across the country. Despite being shown to be effective, it was inexplicably scrapped after just one year. 
There are other issues that also need urgent attention. The inquest into Harry’s death, which concluded on Friday, lasted for almost three weeks. Without pro bono lawyers from Advocate, Brick Court Chambers and Arnold & Porter law firm, the family would have faced an uphill struggle. At present, families are not automatically entitled to legal aid at an inquest, yet the NHS employs its own army of lawyers who attend many inquests and can overwhelm bereaved families in a legal battle they are ill-equipped to fight. Even the chief coroner, Mark Lucraft QC, has called for this inequality of legal backing to end, but the government has yet to take action.
Read full story
Source: The Independent, 26 January 2020
 
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Health secretary to investigate allegations of women denied epidurals

Women in labour are being denied epidurals by NHS hospitals, amid concern that a “cult of natural childbirth” is leaving rising numbers in agony.
Last night, Matt Hancock, the Health Secretary, promised an investigation, and action to ensure women’s choices were respected, pledging to make the NHS maternity services the world-leader.
An investigation by The Sunday Telegraph found hospitals refusing clear requests from mothers-to-be, in breach of official guidelines from the National Institute for Health and Care Excellence (NICE).
Mr Hancock said all expectant mothers should be able to make an informed choice, knowing their choice would be fully respected.
“Clinical guidance clearly state that you can ask for pain relief at any time – before and during labour – and as long as it is safe to do so this should never be refused. I’m concerned by evidence that such requests are being denied for anything other than a clinical reason,” he said.
“It's vital this guidance is being followed right across our NHS, as part of making it the best place in the world to give birth. Women being denied pain relief is wrong, and we will be investigating.”
One mother, describing her experience at one NHS Hospital said: "It made me feel unsafe psychologically - I couldn't speak up, I couldn’t say what I wanted to say, I couldn’t advocate for myself medically because people were ignoring or belittling me. It feels that in childbirth, it’s a given that the doctor is taking their personal beliefs with them to the table, whereas in any other area of healthcare that would be unacceptable."
Read full story
Source: The Telegraph, 26 January 2020
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Morecambe Bay inquiry chief voices criticisms over East Kent hospital scandal

The failure to pass a damning report about a scandal-hit hospital trust to the care watchdog has been criticised by the man who led the inquiry into baby deaths at Morecambe Bay.
On Friday, a coroner ruled that the death of baby Harry Richford in 2017 resulted from neglect in the maternity unit of East Kent Hospitals NHS Trust.
A report by the Royal College of Obstetrics and Gynaecologists (RCOG) completed a year earlier had warned of issues that contributed to Harry’s death, including senior doctors not showing up for their shifts. However, the report was never passed on to the Care Quality Commission (CQC), despite the recommendation of the Morecambe Bay inquiry in 2015 that relevant external reviews should be passed on to the watchdog.
Bill Kirkup, who chaired the inquiry into deaths of mothers and babies at Furness General Hospital in Barrow-in-Furness, told The Independent: “When there is sufficient concern about a service to prompt an external review, the report must be available immediately to those responsible for assuring the quality of the service. That was the reason for the recommendation of the Morecambe Bay investigation, and it is disappointing that the Care Quality Commission apparently had no sight of this report until now.”
Read full story
Source: 26 January 2020
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Hundreds recalled as consultant accused of ‘unnecessary’ surgery

A surgeon has been accused of carrying out “unnecessary” shoulder operations on several NHS patients at a private hospital linked to the Ian Paterson scandal, with 217 patients recalled.
HSJ has been told at least five patients, all commissioned by the NHS, have instructed solicitors to take legal action against Habib Rahman, a consultant orthopaedic surgeon at Spire Parkway Hospital in Solihull.
Mr Rahman is accused of undertaking “unnecessary or inappropriate surgical procedures at Spire Healthcare hospitals” . Spire has confirmed it has recalled 217 patients over the concerns.
The allegations come weeks before the findings are due from an independent inquiry into disgraced surgeon Ian Paterson – who was found guilty of wounding with intent after giving hundreds of patients unnecessary breast surgeries in Spire hospitals across the Midlands.
Read full story (paywalled)
Source: HSJ, 24 January 2020
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