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

Up to 100,000 on antipsychotics with no review

A national strategy is needed to tackle health risks linked to antipsychotic drugs because current policy is letting tens of thousands of people fall through the gaps, commissioners in London are warning.
Commissioners and clinicians in City and Hackney found more than 1,000 patients in their area who were on these drugs without having regular medication reviews or health checks. They warned that, if their findings applied across England, 100,000 patients could be in the same position. 
Although NHS England funds GP practices to carry out regular health checks on patients who are on the serious mental illness register, this excludes patients who are prescribed antipsychotics without having an SMI diagnosis — which typically covers psychoses, schizophrenia or bipolar active disorder. 
An audit by City and Hackney Clinical Commissioning Group, carried out in July 2019 and shared with HSJ, found 1,200 patients in the area were taking antipsychotics but did not have a formal SMI diagnosis.
The audit found most of these patients were not receiving regular health checks and a significant number may have benefited from having their medication reduced. 
Read full story (paywalled)
Source: HSJ, 27 January 2020
Patient Safety Learning

NHS is ‘losing its memory’ warns new report on patient safety alerts

In a report published today, AvMA, the charity Action Against Medical Accidents, reveals serious delays in NHS trusts implementing patient safety alerts, which are one of the main ways in which the NHS seeks to prevent known patient safety risks harming or killing patients.
The report, authored by Dr David Cousins, former head of safe medication practice at the National Patient Safety Agency, NHS England and NHS Improvement, identifies serious problems with the system of issuing patient safety alerts and monitoring compliance with them. Compliance with alerts issued under the now abolished National Patient Safety Agency and NHS England are no longer monitored – even though patient safety incidents continue to be reported to the NHS National Reporting and Learning System.
David said: “The NHS is losing it memory concerning preventable harms to patients. Important known risks to patient safety are being ignored by the NHS. The National Reporting and Learning System, the NHS Strategy and new format patient safety alerts, all managed by NHS Improvement, now ignore the majority of ‘known/wicked harms’ which have been the subject of patient safety alerts in the past and have now been archived."
“Implementation of guidance in new Patient Safety Alerts can be delayed, for years in some cases. The Care Quality Commission that inspects NHS provider organisations also no longer appear to check that safeguards to major risks, recommended in patient safety alerts, have been implemented, or continue to be implemented, as part of their NHS inspections.
Read full story
 
Source: AvMA, 28 January 2020
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Nearly 35,000 patients overdue follow-ups at single trust

Nearly 35,000 patients are overdue a follow-up appointment at North Lincolnshire and Goole Foundation Trust, HSJ has learned.
Almost 20% of the 34,938 follow-up appointments are in ophthalmology. A paper from the trust’s November board meeting said the “backlog of follow-up appointments… clearly remains a risk”.
The report also said the service was failing some of the quality guidelines set out by the National Institute for Health and Care Excellence (NICE).
The trust told HSJ it had introduced a clinical harm review process last year to address the backlog. It has reviewed “more than 5,000 patients”, out of the 34,938 cases to date, according to Chief Operating Officer Shaun Stacey.
He said the trust had initially identified 83 patients who could have come to “potential harm”.
Read full story
Source: HSJ, 28 January 2020
Patient Safety Learning

Urgent inquiry ordered into 'witch-hunt' at West Suffolk hospital

The government has ordered an urgent inquiry into the local hospital of the health secretary, Matt Hancock, after the Guardian revealed its unprecedented “witch-hunt” for a whistleblower.
The Department of Health and Social Care (DHSC) has told NHS England to commission a “rapid review” of the actions of bosses at West Suffolk hospital.
They are under fire for demanding that staff give fingerprints and samples of their handwriting to help identify who wrote to a family alerting them to failings in care that contributed to a patient’s death.
Unusually, the investigation has been instigated by Edward Argar, a junior minister at the DHSC, because Hancock and another health minister, Jo Churchill, are both local MPs who have close ties to the hospital.
Argar has made clear to NHS England that the inquiry must be undertaken by independent experts, given those existing relationships.
Announcing the review, Argar made clear that he wanted hospital personnel to speak openly. “I want all staff to feel that they can speak up and have the confidence that anything they raise will be taken seriously,” he said.
Read full story
Source: The Guardian, 28 January 2020
Patient Safety Learning

Ministers reject calls for immediate compensation for infected blood victims

Calls for immediate compensation for thousands of victims contaminated by infected NHS blood have been rejected by ministers at a meeting with campaigners and survivors – but more health support may be made available.
Despite one person dying every four days on average from HIV, hepatitis C or other conditions, the government on Tuesday turned down a request for a national compensation scheme.
There are estimated to be between 5,000 and 7,000 victims still alive who acquired viral infections through transfusions from the health service. Many are haemophiliacs who need regular transfusions to help their blood clot.
Products supplied by the NHS in the 1970s and 1980s came from the US using blood obtained from prisoners and drug addicts who were paid for their donations. Imported products were inadequately screened.
Read full story
Source: The Guardian, 28 January 2020
Patient Safety Learning

Seriously ill wait more than an hour for ambulance

Heart attack, stroke and burns victims are among the seriously ill and injured patients waiting over an hour for an ambulance to arrive in England and Wales, a BBC investigation shows.
The delays for these 999 calls - meant to be reached in 18 minutes on average - put lives at risk, experts say.
The problems affect one in 16 "emergency" cases in England - with significant delays reported in Wales.
NHS bosses blamed rising demand and delays handing over patients at A&E.
Rachel Power, Chief Executive of the Patients Association, said patients were being "let down badly at their moment of greatest need" and getting a quick response could be "a matter of life or death".
She said the delays were "undoubtedly" related to the sustained underfunding of the NHS.
Read full story
Source: BBC News, 29 January 2020
 
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Top hospital downgraded amid safety fears and whistleblowing inquiry

The hospital at the centre of a whistleblowing inquiry has been downgraded by the care watchdog and issued with a warning notice amid concerns over leadership and patient safety.
West Suffolk Foundation Trust has been rated requires improvement by the Care Quality Commission (CQC) in a damning report having previously been rated outstanding since 2017.
The trust, whose Chief Executive Stephen Dunn received a CBE for services to patient safety in 2018, has faced criticism after bosses threatened senior doctors with a fingerprint and handwriting analysis to try and identify a whistleblower.
In a new report published today, the CQC inspectors said they had significant concerns about the safety of mothers and babies in the trust’s maternity unit and the criticised the culture of the trust leadership referencing what they called “threatening” actions.
In the West Suffolk hospital maternity unit the CQC found staff had not completed key safety training, did not protect women from domestic abuse, and staff did not always report safety incidents. They also found maternity staff were not taking observations and the unit lacked enough staff with the right qualifications to keep women safe.
The trust was issued with a warning notice by the trust demanding it make improvements before the end of this month.
On the trust leadership the CQC report said: “The style of executive leadership did not represent or demonstrate an open and empowering culture. There was an evident disconnect between the executive team and several consultant specialities."
Read full story
Source: The Independent, 30 January 2020
Patient Safety Learning

Nurse begs hospital bosses to ‘see for themselves how unsafe it is’

An advanced nurse practitioner working in primary care services at Grimsby Hospital has called on the hospital senior leadership to ‘see for themselves how unsafe it is’.
The nurse, who has penned a letter to bosses at Northern Lincolnshire and Goole NHS Foundation Trust says they are having “worst experience to date” in their career and fears somebody will die unnecessarily unless something is urgently done.
“I have never in my whole career seen patients hanging off trolleys, vomiting down corridors, having ECGs down corridors, patients desperate for the toilet, desperate for a drink. Basic human care is not being given safely or adequately," says the nurse.
Hospital bosses say they are taking the letter seriously and are investigating. Earlier this month it was revealed that some hospitals were being forced to deploy ‘corridor nurses’ in a bid to maintain patient safety while dealing with unprecedented demand.
Dr Peter Reading, Chief Executive, said: “I can confirm we have received this email and that the hospital and North East Lincolnshire CCG are taking these concerns seriously. The person who raised the concerns with us has been contacted and informed that we are jointly investigating what they have told us.
Read full story
Source: Nursing Notes, 22 January 2020
Patient Safety Learning

Better tech: not a ‘nice to have’ but vital to have for the NHS

In a keynote speech at the Healthtech Alliance on Tuesday, Secretary of State for Health and Social Care, Matt Hancock, stressed how important adopting technology in healthcare is and why he believes that it is vital for the NHS to move into the digital era. 
“Today I want to set out the future for technology in the NHS and why the techno-pessimists are wrong. Because for any organisation to be the best it possibly can be, rejecting the best possible technology is a mistake.”
Listing examples from endless paperwork to old systems resulting in wasted blood samples, Hancock highlights why in order to retain staff and see a thriving healthcare, embracing technology must be a priority.
He also announced a £140m Artificial Intelligence (AI) competition to speed up testing and delivery of potential NHS tools. The competition will cover all stages of the product cycle, to proof of concept to real-world testing to initial adoption in the NHS.
Examples of AI use currently being trialled were set out in the speech, including using AI to read mammograms, predict and prevent the risk of missed appointments and AI-assisted pathways for same-day chest X-ray triage.
Tackling the issue of scalability, Hancock said, “Too many good ideas in the NHS never make it past the pilot stage. We need a culture that rewards and incentivises adoption as well as invention.”
Read full speech
Patient Safety Learning

Over half of incidents resulting in death reported by Welsh health boards came from Betsi

More than half of all incidents resulting in death reported by health boards in Wales came from troubled Betsi Cadwaladr. The 53% figure from a Welsh Government safety report came to light during First Minister Questions in the Senedd yesterday.
Plaid Cymru Leader Adam Price said there had been “an alarming rate” of patient safety incidents in the Betsi Cadwaladr University Health Board area and that between December 2018 and November 2019 there were 40 incidents resulting in death registered within Betsi. Between November 2017 and November 2019 there were 520 incidents within Betsi that resulted in death or serious harm - higher than all the other health boards in Wales combined.
Mr Price questioned whether there is an issue with Betsi itself, or whether there is an issue of "under-reporting of serious incidents" in the rest of Wales.
Defending the figures, the First Minister said that reporting incidents and learning from them has become part of the culture of a health board that they “want to see everywhere in Wales”.
Read full story
Source: North Wales Live, 29 January 2020
Patient Safety Learning

Report reveals the impact of Freedom to Speak Up

A new report published by the National Guardian’s Office reveals that the perception of the speaking up culture in health is improving.
An annual survey, conducted by the National Guardian’s Office, asked Freedom to Speak Up Guardians, and those in a supporting role, about how speaking up is being implemented in their organisation. The results reveal details about the network’s demographics and their perceptions of the impact of their role.
Headlines from the survey include a measure of whether those in speaking up roles think their work is making a difference, with 76 per cent agreeing or strongly agreeing – compared to 68 per cent last year. They also reported that awareness of the guardian role is improving.
“It’s really important we listen to guardians in order to understand the impact Freedom to Speak Up is making,” said Dr Henrietta Hughes OBE, National Guardian for the NHS. “The report we are publishing today will help organisations better understand how to work with their guardians to improve their speaking up cultures.”
Read full story
Source: National Freedom to Speak Up, 30 January 2020
Patient Safety Learning

Number of self-harm incidents in prisons reaches record high

Levels of self-harm in prisons have hit a new high, with more than 60,000 incidents in a year, official figures show.
The number of self-harm incidents was up 16% to 61,461 in the 12 months to September 2019, when there were 53,076, according to data released by the Ministry of Justice (MoJ).
Prison reform campaigners have criticised the government for failing to respond effectively to serious mental health problems and called Thursday’s figures a “national scandal”.
Deborah Coles, the Director of the charity Inquest, said: “Despite investment and scrutiny, the historical context shows that still more people are dying in prison than ever before. A slight recent reduction in the number of deaths comes alongside unprecedented levels of self-harm, while repeated recommendations of coroners, the prison ombudsman and inspectorate are systematically ignored."
"This is a national scandal and reflects the despair and neglect in prisons. Despite this, the health and safety of people in prison appears to be very low on the agenda of the new government."
Read full story
Source: 30 January 2020
Patient Safety Learning

‘Inherently risky’ children’s cancer service to be overhauled

Children’s cancer services in south London are to be reconfigured after a new review confirmed they represented an “inherent geographical risk to patient safety” — following HSJ revelations last year of how serious concerns had been “buried” by senior leaders.
Sir Mike Richards’ independent review was commissioned after HSJ revealed a 2015 report linking fragmented London services to poor quality care had not been addressed, and clinicians were facing pressure to soften recommendations which would have required them to change.
The review, published in conjunction with Thursday’s NHS England board meeting, recommended services at two sites should be redesigned as soon as possible to improve patient experience.
Read full story (paywalled)
Source: HSJ, 31 January 2020
Patient Safety Learning

Two coronavirus cases confirmed in UK

Two people have tested positive for coronavirus in the UK, the Chief Medical Officer for England has announced.
They are both members of the same family and are receiving specialist NHS care. No more details are being released about their identity or where they are being treated.
At least 213 people in the China have died from the virus, mostly in Hubei, with almost 10,000 cases nationally. There have been 98 cases of the virus in another 18 countries.
Prof Chris Whitty, Chief Medical Officer for England said: "The NHS is extremely well-prepared and used to managing infections and we are already working rapidly to identify any contacts the patients had, to prevent further spread. "We have been preparing for UK cases of novel coronavirus and we have robust infection control measures in place to respond immediately," he added.
Prof Whitty said the UK was working closely with the World Health Organization (WHO) and the international community as the outbreak in China develops "to ensure we are ready for all eventualities".
The new coronavirus was declared a global emergency yesterday by the World Health Organization, as the outbreak continues to spread outside China.
"The main reason for this declaration is not what is happening in China but what is happening in other countries," said WHO Chief Tedros Adhanom Ghebreyesus.
The concern is that it could spread to countries with weaker health systems.
Read full story
Source: BBC News, 31 January 2020
Patient Safety Learning

Nurse died from cervical cancer after catalogue of errors

A nurse from South Gloucestershire died after doctors missed signs of her cervical cancer amid a series of "gross" failings, a coroner has ruled.
Julie O’Connor’s cancer was not picked up by North Bristol NHS Foundation Trust despite abnormalities in a smear test in 2014 and a biopsy in 2015. She went for multiple further checks for gynaecological problems in 2016 and 2017 and was referred three times to specialists. However, Ms O'Conner only received a cancer diagnosis once she decided to seek private treatment at Spire Hospital in Bristol.
An inquest into her death was held in Flax Bourton, Somerset, this week.
Maria Voisin, Senior Coroner for the Avon area, found the cause of Ms O’Connor’s death to be of “natural causes contributed to by neglect". She recorded three instances of "gross failures" including the inaccurate smear test as well as mistakes in two further assessments.
Deputy medical director Tim Whittlestone said: “We accept the findings of the coroner and support her actions to build on our correspondence with the Royal College of Obstetricians and Gynaecologists."
“...I would like to reaffirm that North Bristol has investigated these errors and more importantly that we have learnt lessons from our mistakes."
Read full story
Source: Nursing Times, 31 January 2020
Patient Safety Learning

CQC calls for NHSE to publish 'safety test' of triage apps amid warnings of variation

Healthcare apps that triage patients should be put through a ‘fair test of clinical performance’ published by NHS England to ensure their safety, according to the Care Quality Commission (CQC).
In addition, the Department of Health and Social Care should look into whether ‘safety-netting’ advice should be available to the public about how to use symptom checkers, said the CQC.
The CQC made the recommendations as part of work to shape its approach to regulating healthcare apps. It found digital triage tools are currently not fully clinically validated or tested by product regulators and discovered ‘there is great variation in their clinical performance’.
NHS England and other bodies should assess where people have been wrongly escalated, resulting in undue anxiety, as well as where tools have failed to address people’s ill health, said the CQC.
Read full story
Source: PULSE, 30 January 2020
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