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

Distance not always factor in ambulance response times

There is significant variation in ambulance response times to patients with serious conditions such as suspected strokes or heart attacks, which is not fully explained by how rural an area is, an HSJ analysis has revealed.
The exclusive analysis represents the first time ambulance performance for category two calls, which have an 18-minute response time target, have been broken down to clinical commissioning group level. Category two, known as emergency calls, covers a wide range of conditions, including suspected stroke and heart attacks (except cardiac arrests), major burns and epileptic seizures. They account for well over half of ambulance responses.
The findings — described as “alarming” by the Stroke Association — lay bare the incredibly long waits which are usually hidden, because average waiting time data is usually published for ambulance trusts, which cover far larger areas than CCGs.
Mark MacDonald, Deputy Director of Policy at the Stroke Association, said: “It is alarming to hear that in some cases ambulance staff are taking over an hour to reach patients because when it comes to stroke, being assessed quickly and then, if necessary, transferred to hospital, is really important.”
Read full story (paywalled)
Source: HSJ, 5 March 2020
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Late diagnosis of ectopic pregnancy 'putting women at risk'

Women are at risk of serious harm and death because hospitals are not always diagnosing ectopic pregnancies quickly enough, an investigation reveals.
About 12,000 women a year in the UK suffer an ectopic pregnancy – when a fertilised egg grows outside the womb – putting them at risk if a fallopian tube containing the foetus ruptures and causes potentially fatal heavy bleeding.
An investigation by the Healthcare Safety Investigation Branch (HSIB)  has found flaws in the treatment women receive. It has highlighted late diagnosis and consequent delay in treatment as a major concern, especially as a result of the condition being mistaken for a urinary tract infection.
NHS patient safety data shows that 30 ectopic pregnancies were missed and led to “serious harm” between April 2017 and August 2018.
As well as the risk to life, an ectopic pregnancy can also damage a woman’s chances of conceiving again and have serious psychological effects.
Read full story
Source: The Guardian, 5 March 2020
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Shropshire baby deaths: Trust will return £1m it received for 'good care'

An NHS trust at the centre of an inquiry into preventable baby deaths will repay money it received for providing good maternity care.
In 2018, Shrewsbury and Telford NHS Trust received almost £1m, weeks before its services were rated inadequate. The BBC revealed in December the trust had qualified for the payment under the NHS's Maternity Incentive Scheme.
The trust said an "incorrect submission" had been made and it had ordered an independent review.
Shrewsbury and Telford NHS Trust (SaTH) is at the centre of England's largest inquiry into poor maternity care, with more than 900 families contacting a review looking into concerns over preventable deaths and long-term harm.
Former health secretary Jeremy Hunt wrote to ministers questioning if improvements to the Maternity Incentive Scheme were needed in light of payments made to both Shrewsbury and Telford and East Kent Hospitals, despite both facing serious questions over the safety of maternity services.
The trust in Shropshire was paid £963,391 after certifying it had met the 10 safety standards demanded by the scheme, which is run by NHS Resolution.
In the letter, seen by the BBC, Mr Hunt suggested one improvement would be to link payments to CQC maternity and safety ratings.
"The whole approach is likely to be discredited if trusts can meet all 10 actions and yet still be delivering poor standards of care," the letter said.
Read full story
Source: BBC News, 6 March 2020
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Feeling the strain: UK GPs the least satisfied with amount of time they have with patients

Just 1 in 4 UK GPs are satisfied with time they are able to spend with patients – appointment times are among the shortest of 11 countries surveyed.
A report published today by the Health Foundation paints a picture of high stress and low satisfaction with workload among UK GPs. The report is an analysis of an international survey of GPs from 11 high-income countries, including 1,001 UK GPs, undertaken by the Commonwealth Fund in 2019.
Among 11 high-income countries included in the study, only France has lower levels of overall satisfaction with practising medicine, and only Sweden reported higher levels of stress. Over half of UK GPs (60%) say they find their job 'extremely' or 'very' stressful, and almost half (49%) plan to reduce their weekly hours in the next three years.
UK GPs also reported significantly shorter appointment lengths than their international colleagues. The average length of a GP appointment in the UK is 11 minutes, compared with a 19 minute average appointment for GP and primary care physicians in the other countries surveyed. 
Dr Rebecca Fisher, one of the Health Foundation report's authors and a practising GP, says: "These findings illustrate the pressures faced by general practice, and the strain that GPs are under. Right now the health system is in unprecedented territory and mobilising to meet the challenge of Covid-19. This survey shows that over the long term we need concerted action to stabilise general practice. Despite performing strongly in some aspects of care, many GPs consider that appointments are simply too short to fully meet the needs of patients. Too many GPs are highly stressed and overburdened – to the point of wanting to leave the profession altogether."
Read full story
Source: The Health Foundation, 5 March 2020
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Maternity safety campaigners head to Downing Street to demand action

More than 20 leading NHS doctors and experts back Baby Lifeline demand for safety training for maternity staff to cut £7m a day negligence costs
The Independent’s maternity safety campaign goes to Downing Street today as senior figures from across the health service deliver a letter demanding action from prime minister Boris Johnson.
Charity Baby Lifeline will be joined by bereaved families, Royal Colleges and senior midwives and doctors in Downing Street to hand in a letter calling on the government to reinstate a national fund for maternity safety training.
Baby Lifeline, which has also launched an online petition today, said the government needed to find £19m to support training of both midwives and doctors to prevent deaths and brain damage, which can cost the NHS millions of pounds for a single case.
The letter to Mr Johnson has also been signed by Dr Bill Kirkup, who led the investigation into baby deaths at the Morecambe Bay NHS trust and is investigating poor care at the East Kent Hospitals University Trust.
He said: “There have been real improvements in maternity services, but as recent events in Kent and Shropshire have shown only too clearly, much more remains to be done. The Maternity Safety Training Fund is badly needed.”
Sir Robert Francis QC, Chairman of the public inquiry into poor care at Stafford Hospital, who also signed, said: “The cost in lost and broken lives, not to mention the unsustainable financial burden and the distress of staff caused by these avoidable mistakes, is indefensible.”
Other signatories included former health secretary Jeremy Hunt, the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists and a number of senior maternity figures, charities and clinical associations.
Read full story
Source: The Independent, 6 March 2020
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Call for bosses to quit at hospital that tried to conceal blunders

Executives in charge of the health secretary’s crisis-hit local hospital are facing calls to step down after The Sunday Times raised serious questions about attempts to cover up catastrophic medical mistakes.
West Suffolk Hospital in Bury St Edmunds had placed Dr Patricia Mills, one of its most senior consultants, under disciplinary investigation after she had voiced concerns about blunders that had killed one patient and left another seriously brain-damaged. A number of doctors have claimed that a bullying management culture has led to staff being too afraid to speak up about patient safety concerns at the hospital.
Executives were accused of being obsessed with maintaining the hospital’s “outstanding” status in annual Care Quality Commission. One of the governors said their were "frustrations and concerns" among his fellow council members that they were being kept in the dark by the hospital's executives.
Read full story (paywalled)
Source: The Sunday Times, 8 March 2020
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Warning over 'nursing staffing crisis' after NHS trust told to improve

The Royal College of Nursing (RCN) has issued a warning about insufficient staffing in the NHS in the wake of a mental health trust being downgraded.
Earlier this week, Tees, Esk and Wear Valleys (TEVW) NHS Foundation Trust being rated as "requiring improvement" by the Care Quality Commission. It had previously been rated as "good" but inspectors said some services had deteriorated. Among the concerns raised were ones over staffing, workload and delays. 
Glenn Turp, Northern Regional Director of the RCN: "The CQC has rightly highlighted some very serious concerns and failings which call into question whether this trust can provide safe patient care. After the very tragic and sad deaths of two vulnerable patients last year and the findings of the CQC, the trust and NHS commissioners must take immediate action to ensure patient and staff safety."
"They have a responsibility not to commission and open new beds with insufficient nursing staff to provide safe patient care. Having the right number of nursing staff with the right skills in the right place at the right time is critical to protecting patients. It also protects those staff who too often find themselves struggling to maintain services in the face of nursing vacancies."
Read full story
Source: The Northern Echo, 7 March 2020
Patient Safety Learning

Patient Safety Awareness Week

This week is Patient Safety Awareness Week, an annual recognition event intended to encourage everyone to learn more about healthcare safety. During this week, the Institute for Healthcare Improvement (IHI) seeks to advance important discussions locally and globally, and inspire action to improve the safety of the health care system — for patients and the workforce.
Patient Safety Awareness Week serves as a dedicated time and platform for growing awareness about patient safety and recognising the work already being done.
Although there has been real progress made in patient safety over the past two decades, current estimates cite medical harm as a leading cause of death worldwide.
The World Health Organization estimates that 134 million adverse events occur each year due to unsafe care in hospitals in low- and middle-income countries, resulting in some 2.6 million deaths. Additionally, some 40 percent of patients experience harm in ambulatory and primary care settings with an estimated 80 percent of these harms being preventable, according to WHO.
Some studies suggest that as many as 400,000 deaths occur in the United States each year as a result of errors or preventable harm. Not every case of harm results in death, yet they can cause long-term impact on the patient's physical health, emotional health, financial well-being, or family relationships.
Preventing harm in healthcare settings is a public health concern. Everyone interacts with the health care system at some point in life. And everyone has a role to play in advancing safe healthcare.
Learn more about IHI's work to advance patient safety.
Patient Safety Learning

Coronavirus: Visitors steal hand sanitiser gel from hospital

Visitors to a hospital are stealing hand sanitising gel daily – as demand for the product surges amid fears over coronavirus.
Bottles have been taken from patients' beds and dispensers ripped off walls at Northampton General Hospital. Bosses said the gel was "disappearing every day" and they have had to limit the supply on wards.
"Nothing like this has ever happened in all the years we've had the gel," said a hospital spokeswoman.
"Over the past week we've seen stocks on wards disappear from the end of beds every single day," Sally-Anne Watts, associate communications director, told the BBC.
"Three wall-mounted dispensers have been ripped off and we've even seen people coming in and topping up their own dispensers with our product," she said.
Since the hospital's supplies have been going missing, Mrs Watts said, bottles were no longer being put at the end of all beds.
"We don't have an unlimited supply and would ask that visitors to the site respect the fact that we are doing all we can to keep our patients, visitors and staff safe, and we need their support," she added.
Read full story
Source: BBC News, 6 March 2020
Patient Safety Learning

Former minister says government would lose human rights challenge

Sir Norman Lamb, chair of South London and Maudsley Foundation Trust and a former Liberal Democrat MP, has suggested the government would lose a legal challenge over its national programme for patients with learning disabilities and said the national Transforming Care programme was at the “very least a partial failure”.
“I regard this as a human rights issue. We’re locking people up when we don’t need to lock them up. We’re subjecting them to force, when we shouldn’t do so, and this is how I think we need to frame it. If the government were challenged in court on this, I think there’s a very good chance, as an ex-lawyer, that they would lose.”
Transforming Care was launched in 2011 following the Winterborne View scandal and aimed to discharge patients with learning disabilities and autism out of institutional inpatient units into the community. However, the most recent figures, from NHS Digital, show there were still more than 2,000 patients within inpatient units, ahead of the national programme’s expiration this month.
Kevin Cleary, deputy chief inspector for hospitals and lead for learning disability and mental health services for the CQC, said: “We have allowed our patients to be placed within places like Whorlton Hall.  I think the NHS provides very few services of this type, it has withdrawn from providing these services, and has become comfortable with providing that service, within the independent sector, several hundred miles away and that’s not right… absolutely not right."
“We cannot say we are providing patient centred care or say we are placing the patient at the heart of everything we do and have that response from the system. We are all responsible for that.”
Read full story (paywalled)
Source: HSJ, 10 March 2020
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Covid-19: out-of-hours providers are drafted in to manage non-urgent patients in community

Regional NHS leaders in England have been ordered to immediately organise a primary care management service to care for covid-19 patients who “do not require immediate admission” to hospital.
In a letter sent on 8 March, seen by The BMJ, NHS England and NHS Improvement’s strategic incident director for coronavirus, Keith Willett, has ordered regional primary care and public health directors to set up a 24 hour, seven day a week service to manage patients in the community. This service should be delivered by an out-of-hours provider, and every part of England must be covered by Tuesday 10 March, the letter said.
The service will be used to manage patients who are deemed well enough to be isolated at home, with active monitoring for people who are at high risk of developing severe illness, and advice to those not deemed high risk on what to do if their illness deteriorates.
The letter advises that patients “remain in isolation until 5 days after resolution of symptoms, unless [they are a] healthcare worker or work with high risk groups, in which case require one negative sample 5 days after resolution of symptoms before return to work.”
People with mild illness and not in a high risk group will be told to isolate themselves at home and will be given health advice on how to identify deterioration. All patients managed at home will be given a phone number to call if they feel more unwell.
The letter said that the community service should be provided by a nurse and GP team and that all clinical information should be recorded and transferred to the patient’s general practice.
Providers must also provide regular situation reports, including confirmed numbers of patients cared for under the service, numbers of patients who deteriorate, and numbers of patients admitted to and discharged from the service.
Read full story
Source: BMJ, 9 March 2020
Patient Safety Learning

Impaired consciousness: new guidelines aim to ensure people aren’t “lost in system”

Doctors who look after patients in a vegetative or minimally conscious state must ensure they initiate regular conversations with relatives about what is in the best interests of the person so that they do not get “lost in the system,” says new guidance.
The Royal College of Physicians has published new and revised guidelines on prolonged disorders of consciousness (PDOC) to take into account changes in the law and developments in assessment and management.
Read full story (paywalled)
Source: BMJ, 6 March 2020
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New Chairman appointed for Patient Safety Movement Foundation

Mike Ramsay has been appointed new Chairman of the Patient Safety Movement Foundation, taking over from Joe Kiani.
The Patient Safety Movement's goal is to get to ZERO preventable deaths. In their latest newsletter, Mike discusses how he intends to build on the tremendous momentum gained so far. 
"We are not competing with any organization but strongly support entities with the patient safety goal and hope that we can all pull together and use all our resources to reach zero preventable deaths and zero harm. Zero is our target and we can get there!"
Read Mike's Letter in the March Patient Safety Movement Foundation newsletter
Patient Safety Learning

Missing records hamper NHS complaint probes, watchdog says

Complaints about NHS care cannot always be investigated properly because of medical records going missing, the public services watchdog has said.
Ombudsman Nick Bennett said many people were left "suspicious" and thought there was a "darker motivation".
One woman whose notes went missing said she no longer trusted what doctors said and had lost faith in NHS transparency.
The Welsh NHS Confederation said staff were "committed to the highest standards of care".
In a report called Justice Mislaid: Lost Records and Lost Opportunities, Mr Bennett found 70% of 17 cases he looked at in Welsh NHS hospitals and care settings could not be properly investigated because of lost documents.
Read full story
Source: BBC News, 10 March
Sam

Family 'sick to stomach' as NHS calls TV report of son's death a 'malarkey'

The mother of a student, who took his own life, said today she felt 'sick to her stomach' after an NHS communications manager labelled a media report on her son's suicide a 'malarkey'.
Pippa Travis-Williams, whose son Henry was found dead days after leaving a mental health unit run by the Norfolk and Suffolk Foundation Trust (NSFT) in 2016, said an email sent by NSFT communications manager Mark Prentice to his boss was 'disgusting'.
It comes weeks after Mr Prentice gloated in another email to his boss that the NSFT had 'got away (again)' with media coverage of the death of a dementia patient.
In an email to his boss, explaining why NSFT chief executive, Jonathan Warren, was going on BBC Look East, Mr Prentice said the NSFT might look 'uncaring' if Mr Warren did not appear and then described the coverage of Mr Curtis-Williams' suicide as a 'malarkey'.
Read full story
Source: Ipswich Star, 10 March 2020
 
 
 
Sam

Coronavirus: NHS to ramp up testing capacity

With the number of UK coronavirus cases set to rise, NHS England says it is scaling up its capacity for testing people for the infection.
It means 10,000 tests a day can be done – 8,000 more than the 1,500 being carried out currently.
Confirmation of any positive test results will be accelerated, helping people take the right action to recover or quickly get treatment. Most of the people tested should get a result back within 24 hours.
Scotland, Wales and Northern Ireland will be expected to roll out their own testing services, but there will be some shared capacity between nations, depending on need.
Read full story
Source: BBC News, 11 March 2020
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