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

Harry Richford inquest: 'Lives at risk' over locum doctor recruitment

Lives may be at risk unless the NHS reviews how stand-in doctors are recruited, a coroner has warned.
Harry Richford's death after a series of failings at a hospital in Margate, Kent, was ruled "wholly avoidable". An inquest heard he was delivered by an "inexperienced" locum doctor who was new to the hospital.
A national review into the recruitment, assessment and supervision of locums should be carried out, Christopher Sutton-Mattocks said in a report. The coroner wrote that particular emphasis should be considered upon the scope of locums' activities before they are left responsible for out-of-hours labour care.
He issued 19 recommendations to prevent future deaths, including a request that NHS England and the Royal College of Obstetricians and Gynaecologists consider such a review, warning "there may be a risk to other lives both at this trust and at other trusts in the future".
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Source: BBC News, 19 February 2020
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Abusive NHS patients to be banned from receiving non-emergency care

Patients who abuse NHS staff will be banned from receiving non-emergency care as new figures show more than one in four NHS staff have experienced harassment, bullying or abuse from patients, relatives or members of the public.
The annual survey of more than 560,000 NHS workers found one in seven staff (15%) had experienced physical violence in the last 12 months while 40,000 staff (7.2%) had faced some form of discrimination during 2019 – an increase from 5.8% in 2015.
A total of 13% of staff reported being bullied, harassed or abused by their own manager in the past 12 months and almost a fifth (19%) said they had experienced abuse from colleagues.
The health secretary Matt Hancock has written to staff condemning the abuse and warning assaults on NHS workers will not be tolerated. Under new plans NHS England said that from April NHS hospitals will be able to bar patients who inflict discriminatory or harassing behaviour on staff from receiving non-emergency care. Previously, individual NHS organisations could only refuse services to patients if they were aggressive or violent.
Hospitals will be required to act reasonably and take into account the mental health of the patient or member of the public.
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Source: The Independent, 19 February 2020
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NHS to benefit from digital 'Redbook' app

As part of the NHS Digital Child Health programme, Personal Child Health Records or “Redbook” will receive a digital makeover.

NHS Digital has considered the limitations of the physical Redbook and decided that digitalisation is the way forward for parents to easily access important health and development information.

Nurturey has been evolving its product to align with NHS' Digital Child Health programme. It aims to be an app that can make the digital Redbook vision a reality and currently in the process of completing all the necessary integrations and assurances.

It is hoped that by using smart digital records, parents will be more aware of their child’s health information like weight, dental records, appointments and other developmental milestones.  

Tushar Srivastava, Founder and CEO of Nurturey, said:

“Imagine receiving your child's immunisation alert/notification on the phone, clicking on it to book the immunisation appointment with the GP, and then being able to see all relevant immunisations details on the app itself. As a parent myself, I see the huge benefit of being able to manage my child’s health on my fingertips. We are working hard to deliver such powerful features to parents by this summer.”
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Source: National Health Executive, 5 February 2020
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NHS Digital and PHIN launch consultation on next phase of Acute Data Alignment Programme

NHS Digital and the Private Healthcare Information Network (PHIN) have launched a consultation as part of the next phase of a programme to align private healthcare data with NHS recorded activity.
The consultation sets out a series of changes to how data is recorded and managed across private and NHS care, along with a series of pilot projects, based upon feedback from a variety of stakeholders. It aims to seek the views of private and NHS providers, clinicians, the public and other organisations with an interest in private healthcare and will be used to help shape the future changes.
The consultation, which has been launched following the publication of the Paterson Inquiry, will be hosted on the NHS Digital Consultation Hub.
Under the changes proposed in the Acute Data Alignment Programme (ADAPt), PHIN will share the national dataset of private admitted patient care in England with NHS Digital, creating a single source of healthcare data in England.
This recommendation has been supported by recommendations in the Paterson Inquiry to create a single repository for practice of consultants in private and public healthcare across England.
Health Secretary Matt Hancock said: “Regardless of where you’re treated or how your care is funded, everybody deserves safe, compassionate care. The recent Paterson Inquiry highlighted the shocking failures that can occur when information is not shared and acted upon in both the NHS and independent sector. We are working tirelessly across the health system to deliver the highest standards of care for patients. Trusted data is absolutely critical to this mission and the ADAPt programme will help improve transparency and raise standards for all.”
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Source: NHS Digital, 19 February 2020
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Scans of 1,800 patients reviewed after private contract suspended

Ultrasound scans for around 1,800 patients have had to be reviewed over concerns about the “quality and safety” of work carried out by two sonographers employed by an independent provider.
The two sonographers were employed by Bestcare Diagnostics. The company held an “any qualified provider” contract for non-obstetric ultrasound scans with Coastal West Sussex Clinical Commissioning Group (CCG) from April 2017.
This contract was suspended in September 2018 over what the CCG said were “quality issues”. However, new information came to light in spring 2019 and the CCG decided to review all 1,800 patients seen by the pair, who worked for the company between April and August 2018.
The CCG said scans for these patients were reviewed and, wherever possible, the patients were contacted. A second stage of the review will look at whether any harm was caused to the patients.
Read full story (paywalled)
Source: HSJ, 20 February 2020
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NHS "took 18 months to help after suicide attempt"

Poor treatment and aftercare for people who self-harm or attempt suicide is putting their lives at risk, the Royal College of Psychiatrists says. Many patients treated in A&E for self-harm do not receive a full psychosocial assessment from a mental health professional to assess suicide risk.
Simon Rose, who has attempted suicide many times, told BBC News it once took 18 months to receive aftercare.
NHS England said reducing suicide rates was an "NHS priority".
Last year, UK suicide rates rose for the first time since 2013, with people born in the 1960s and 1970s being the most vulnerable. Experts are now calling for all self-harm patients to be offered a safety plan – an agreed set of bespoke activities and guidelines to help them deal with depressive episodes.
Dr Huw Stone, who chairs the patients' safety group at the Royal College of Psychiatrists, said patients, especially those under 30, were being systematically let down in their most vulnerable state.
"With hospital admissions for self-harming under-30s more than doubling in the last 10 years, there has never been a more important time to ensure patients are getting the care that they need," he said.
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Source: BBC News, 21 February 2020
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US medical center nurses to hold informational picket and strike vote for patient safety and a fair contract

Registered nurses at Queen of the Valley Medical Center (QVMC) in Napa, Calif, USA, will hold an informational picket followed by a vote to authorise a strike in an effort to raise patient care standards and win a fair contract, the California Nurses Association/National Nurses United, (CNA/NNU) has announced.
Nurses at QVMC will picket to highlight cutbacks and eroding patient care. Among the nurses’ top concerns is safe patient care, including safe staffing and dedicated staff for safe patient handling.
“After eight months of negotiations, it's time for Queen of the Valley nurses to bring our concerns to our community and let them know nurses are fighting to give them the best patient care,” said MaryLou Bahn, registered nurse in labour and delivery at QVMC and member of the bargaining team. “We’re fighting for adequate staffing levels because we refuse to put profits over the needs of our patients.”
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Source: National Nurses United, 20 February 2020
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Patients at risk in ‘crumbling’ mental health wards, NHS leaders warn

Patient safety is at risk in “crumbling” NHS mental health hospitals starved of the money needed to improve dilapidated buildings, new data has revealed.
Hundreds of vulnerable mentally ill patients are still being cared for in 350 old dormitory-style wards, 20 years after the NHS was told to provide all patients with en-suite rooms. A lack of funding to refurbish hospitals has also meant too many wards still have ligature points that patients can use to try to harm themselves.
NHS leaders said the lack of cash from the government meant they could not deal with warnings issued by the Care Quality Commission (CQC), the sector’s watchdog.
A survey of mental health trust leaders by NHS Providers has now found bosses are worried the state of psychiatric wards is undermining their ability to keep patients safe.
Read full story
Source: The Independent, 20 February 2020
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The Paterson inquiry is a missed opportunity to tackle systemic patient safety risks in private healthcare

The Independent Inquiry into the issues raised by Paterson is yet another missed opportunity to tackle the systemic patient safety risks which lie at the heart of the private hospital business model, says David Rowland from the Centre for Health and the Public Interest in a recent BMJ Opinion article.
Although the Inquiry provided an important opportunity for the hundreds of patients affected to bear witness to the pain and harm inflicted upon them it fundamentally failed as an exercise in root cause analysis. None of the “learning points” in the final report touch on the financial incentives which may have led Paterson to deliberately over treat patients. Nor do they cover the business reasons which might encourage a private hospital’s management not to look too closely. 
He suggests that the Inquiry report threw the responsibility for managing patient safety risks back to the patients themselves in two of its main recommendations but that it should be for the healthcare provider first and foremost to ensure that the professions that they employ are safe, competent and properly supervised, and for this form of assurance to be underpinned by a well-functioning system of licensing and revalidation by national regulatory bodies.
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Source: BMJ Opinion, 20 February 2020
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Regulating AI in health and care

In his latest blog post, Matthew Gould, CEO of NHSX, has reiterated the potential AI has to reduce the burden on the NHS by improving patient outcomes and increasing productivity. However, he said there are gaps in the rules that govern the use of AI and a lack of clarity on both standards and roles.
These gaps mean there is a risk of using AI that is unsafe and that NHS organisations will delay employing AI until all the regulatory gaps have been filled. Gould says, “The benefits will be huge if we can find the sweet spot” that allows trust to be maintained whilst creating the freedom for innovation but warns that we are not in that position yet.
At the end of January, the CEOs and heads of 12 regulators and associated organisations met to work through these issues and discuss what was required to ensure innovation-friendly processes and regulations are put in place.
They agreed there needs to be a clarity of role for these organisations, including the MHRA being responsible for regulating the safety of AI systems; the Health Research Agency (HRA) for overseeing the research to generate evidence; NICE for assessing whether new AI solutions should be deployed; and the CQC to ensure providers are following best practice.
Read the full blog
Source: Techradar, 13 February 2020
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Scottish mesh implant women to be offered case reviews

Women in Scotland who have experienced complications following vaginal mesh surgery are to be offered an independent review of their case notes.
Mesh implants have been used to treat conditions some women suffer after childbirth, such as incontinence and prolapse. However, many women experienced painful, debilitating side effects.
Some of the women who have suffered complications met First Minister Nicola Sturgeon last November. She was told a number of them had understood the mesh would be completely removed but that had not happened, leaving some of the synthetic substance still attached.
After hearing about their experiences, Ms Sturgeon has now written to the women she saw, confirming that in the spring they will be given the chance to sit down with an independent clinician for a review of their case notes. That will be followed up by a report and possible referral to specialist care.
The case note review will initially only be offered to those who attended the first minister's meetings however, it may be offered more widely at a later date.
Read full story
Source: BBC News, 23 February 2020
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Hospital ‘bed blocking’ numbers hit highest level since 2017

The number of patients stuck in hospitals because they could not be transferred is at its highest quarterly level since 2017, reversing years of progress amid ongoing crises in health and care services.
“Delayed transfers of care” – often known as “bed blocking” – rose in the mid-2010s as austerity hit council-run adult-care services, meaning hospitals were unable to discharge patients into the community.
The number of “delayed days” in the NHS increased from an average of 114,000 a month in 2012 to more than 200,000 in October 2016, before extra funding and higher council taxes brought the numbers back down.
But the latest NHS figures show the problem is returning. December 2019 saw 148,000 delayed days across England, 15% higher than the same month a year earlier. The combined figures for the last quarter of 2019 were the highest in two years.
Read full story
Source: The Guardian, 23 February 2020
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Patients in need of hip and knee surgery left in agony for a year

Patients in need of a new hip or knee are increasingly being left in agony for more than a year, an investigation reveals.
The number of patients forced to endure such waits has risen by more than 50% in 12 months, NHS data shows.
Charities said that the findings were "devastating", with thousands of people left in pain and misery, with some left house-bound, and younger patients unable to work, as they waited for NHS help. 
The figures show that in 2018/19, 55,251 patients waited at least 18 weeks for hip and knee surgery – a more than doubling from 25,704 such cases in 2013/14.  In total, 2,889 patients were left waiting at least 12 months, up from 1,863 a year before, and 780 cases five years ago. 
Experts warned that even these figures from NHS Digital are an underestimate, as they only measure the wait from the point a hospital doctor decides that surgery is required, not from point of GP referral. 
Read full story
Source: The Telegraph, 22 February 2020
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"Patients are not empowered to prevent their own harm", says Sir Liam Donaldson

Today, Sir Liam Donaldson is chairing a patient safety meeting at the World Health Organization (WHO) 'A Global Consultation – A decade of Patient Safety 2020–2030' to formulate a Global Patient Safety Action Plan. His introductory address this morning focused on the task ahead – to maintain the World Health Assembly resolution momentum and patient safety as a global movement. 
"Patients are not empowered to prevent their own harm", Donaldson said, as he highlighted patient stories of unsafe care and the alarming parallels of patient and family experiences across the world. 
So where is the power? Donaldson went on to to highlight how the six current power blocks are not doing enough to improve safety and that we need to engage and motivate these power blocks to achieve change:
Designing of health systems – we have not seen much evidence of systems being designed for safety. Health leaders are not using their power to lead for reduced harm. Educational institutions – these have to happen faster to train staff in. Research community – has patient safety research led to sustainable reduction in risk? Data and information – how has this improved patient safety? Industry – pharma doing very little on medication packaging and labelling; medical devices industry also could do more.
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Nurses to carry out surgery under NHS plans to slash waiting times

Nurses will be trained to perform surgery under new NHS measures to cut waiting times.
Nursing staff will be urged to undertake a two year course to become “surgical care practitioners” as part of the drive to slash waiting times but critics have warned it will worsen the nursing shortage. Nurses who qualify will be tasked with removing hernias, benign cysts and some skin cancers, according to the Daily Mail.
They will also assist during major surgeries such as heart bypasses and hip and knee replacements. The re-trained nurses will be tasked with closing up incisions after operations. 
The proposals are contained within the NHS’s People Plan, due to be unveiled next month. 
Lib Dem health spokesman Munira Wilson said: "This is a sticking plaster solution to very serious staffing crisis across our NHS workforce.'"
However the proposals were backed by Professor Michael Griffin, president of the Royal College of Surgeons of Edinburgh. He said: "We are totally supportive of this. We have very little anxiety about this.”
Read full story
Source: 24 February 2020
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Fall in school nurses prompts fears that children’s lives are ‘at risk’

The number of nurses in schools has fallen in recent years, prompting fears that pupils’ lives are being put “at risk”. 
Teaching assistants are being asked to carry out medical interventions, such as injections, without adequate training or support, the GMB union, which represents school staff, has said. 
Data, obtained by the GMB union through a Freedom of Information request, shows the number of school nurses has fallen by 11 per cent in four years – from 472 in 2015 to 420 in 2018.
Karen Leonard, National Schools Officer at the GMB union, said: “The uncomfortable truth is that in too many schools children are not getting the medical support they need.”
Ms Leonard added: “School staff should not administer medicine unless they feel fully confident in their training and lines of accountability, but often they are placed in uncomfortable situations."
“This is a highly stressful state of affairs for children, parents, and staff, who fear they will be blamed if something goes wrong. It is not alarmist to say that lives are at risk.”
Read full story
Source: The Independent, 23 February 2020
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