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

Senior doctors warned of service failings before 12 deaths

Senior doctors repeatedly raised concerns over safety and staffing problems at a mental health trust before a cluster of 12 deaths, an HSJ investigation has found.
The deaths all happened over the course of a year, starting in June 2018, involving patients under the care of the crisis home treatment services at Birmingham and Solihull Mental Health Trust. The causes of the deaths included suicides, drug overdoses, and hanging.
Coroners found several common failings surrounding the deaths and have previously warned of a lack of resources for mental health services in the city.
HSJ has now seen internal documents which reveal senior clinicians had raised repeated internal concerns about the trust’s crisis home treatment teams during 2017 and early 2018. The clinicians warned of inadequate staffing levels, long waiting lists, and a lack of inpatient bed capacity.
In the minutes of one meeting in February 2018, just two months before the first of the 12 deaths, a consultant is recorded as saying he had “grave concerns over safety in [the home treatment teams]”.
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Source: HSJ, 9 June 2020
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Three in four GP partners fear for staff safety as practice workload floods back

Almost three quarters of GP partners are concerned about how to keep colleagues safe as numbers of patients attending practices return to pre-pandemic levels - with access to PPE a major worry, a GPonline poll has found.
Half of the 185 GP partners responding to the poll said that they were either 'very worried' or 'slightly worried' about the government's ability to supply the PPE that GPs and practice staff needed to keep them as safe as possible through the rest of the pandemic.
Only 9% said they were 'very confident' that the government would be able to supply adequate PPE, with a further 20% saying they were 'slightly confident'.
Some 73% of GP partners said that they were concerned about how to ensure the safety of practice staff as the number of patients attending the surgery begins to rise.
BMA GP committee chair Dr Richard Vautrey said keeping staff safe was 'a challenge for everyone in the NHS'.
He told GPonline: 'Even months now into this crisis the government still hasn’t sorted out PPE in a way that means people have absolute confidence that they will have enough to meet their needs, and the growing needs of practices as they will need to be seeing more patients face-to-face for important procedures that can’t be done remotely.
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Source: GPonline, 8 June 2020
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'I am very angry at the way I have been treated due to COVID-19': Horrendous toll on non-virus patients is emerging

As the death toll from the virus soars above 40,000, slowly the horrendous toll on non-Covid patients is emerging.
These are patients who are not afflicted by coronavirus, but who have had their treatment or diagnosis for other potentially deadly conditions postponed or cancelled, as hospitals scrambled to make way for an overwhelming burden of COVID-19 patients.
Sherwin Hall, a 27-year-old from Leeds, had tried 13 times in one month during the lockdown to get a proper diagnosis for the crippling pain in his groin. He was initially told it might be a sexually transmitted disease. Eventually he was given the all clear of any STD after multiple blood tests and begged for an MRI scan. But he claims he was told no scans would be available because of the COVID-19 emergency.
Finally he got a scan which confirmed a 14 cm tumour near his pelvis. He clams his consultant confirmed the delay in diagnosis and therefore cancer treatment may have serious consequences on his chances of survival.
He told ITV news "I am very angry at the way I have been treated due to COVID-19 and the delay on my cancer treatment and now I am fighting for my life."
His lawyer, Mary Smith, who specialises in medical negligence at Novum Law in Bristol, says she is worried there will be a spike in cases involving delayed diagnosis or treatment coming across her desk.
She wants an urgent overhaul of the management of this crisis, now its peak appears to have passed. 
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Source: ITV News, 9 June 2020
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Coronavirus: 'Structural racism' must be taken into account when dealing with BAME deaths

"Structural racism and social inequality" should be taken into account when looking at the impact of COVID-19 on Britain's black, Asian and minority ethnic, according to an expert involved in a recent review.
Professor Kevin Fenton was a major part of a Public Health England (PHE) report ordered by the government into why the BAME community has been disproportionately affected by coronavirus. It found people from BAME groups were up to twice as likely to die with COVID-19 than those from a white British background.
The review was also meant to offer recommendations, but sources have told Sky News that these were "held back" by the government.
Health Secretary Matt Hancock said coming from a non-white background was a
Speaking at a public meeting for Hackney Council, Prof Fenton said: "Over the last six weeks I've worked with over 4,000 individuals to understand what are some of the contextual issues that are driving the excess risk amongst, black, Asian and minority ethnic groups."
"Some of the structural issues, like racism, discrimination, stigma, distrust, fair, these are real issues that are challenging for the communities and are seen as underpinning some of the disparities we see for COVID. Any conversation about what we need to do, should take into consideration these things."
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Source: Sky News, 9 June 2020
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Swann reveals future of Northern Ireland health service post COVID-19

Northern Ireland faces a massive challenge rebuilding health and social care in the wake of the first COVID-19 wave, Health Minister Robin Swann has said.
Speaking at the Northern Ireland Assembly on Tuesday, Mr Swann said that the rebuilding process can secure better ways of delivering services but will require innovation, sustained investment and society-wide support.
He said that services will not be able to resume as before and that rebuilding will be significantly constrained by the continuing threat from COVID-19 and the need to protect the public and staff from the virus.
“Our health and social care system was in very serious difficulties long before Coronavirus reached these shores. The virus has taken the situation to a whole new level. The Health and Social Care system has had its own lockdown – services were scaled back substantially to keep people safe and to focus resources on caring for those with COVID-19."
The Health Minister said that despite the pressures, there are opportunities to make improvements.
“I have seen so many examples of excellence, innovation and commitment as our health and social care staff rose to the challenges created by COVID-19. Decisions were taken at pace, services were re-configured, mountains were moved. Staff have worked across traditional boundaries time and time again. I cannot thank them enough. We must build on that spirit in the months and years ahead. Innovations like telephone triage and video consultations will be embedded in primary and secondary care.”
Mr Swann added that the health system can't go back to the way it was and that it must be improved.
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Source: Belfast Telegraph, 9 June 2020
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UK ministers face legal challenge for refusal to order PPE inquiry

Ministers are facing a high court legal challenge after they refused to order an urgent investigation into the shortages of personal protective equipment faced by NHS staff during the coronavirus pandemic.
Doctors, lawyers and campaigners for older people’s welfare issued proceedings on Monday which they hope will lead to a judicial review of the government’s efforts to ensure that health professionals and social care staff had enough personal protective equipment (PPE) to keep them safe.
They want to compel ministers to hold an independent inquiry into PPE and ensure staff in settings looking after Covid-19 patients will be able to obtain the gowns, masks, eye protection and gloves they need if, as many doctors fear, there is a second wave of the disease.
About 300 UK health workers have so far died of COVID-19, and many NHS staff groups and families claim inadequate PPE played a key role in exposing them.
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Source: The Guardian, 8 June 2020
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Covid aftercare piles pressure on ‘understaffed’ community services

The aftercare of COVID-19 patients will have significant financial implications for ‘understaffed’ community services, NHS England has been warned.
This month the national commissioner released guidance for the care of patients once they have recovered from an immediate covid infection and been discharged from hospital.
It said community health services will need to provide “ongoing health support that rehabilitates [covid patients] both physically and mentally”. The document said this would result in increased demand for home oxygen services, pulmonary rehabilitation, diagnostics and for many therapies such as speech and language, occupational, physio, dieticians and mental health support.
One GP heavily involved in community rehab told HSJ: “There is a lot detailed information about what people might experience in recovery, but it doesn’t say what should actually happen.
“We have seen people discharged from hospital that don’t know anything about their follow-up and the community [health sector] hasn’t got any instructions of what they should be doing or what services have even reopened. This guidance needs to go a step further and rapidly say what is expected so local commissioners can put that in place.”
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Source: HSJ, 10 June 2020
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Doctors fear 'tsunami' of investigations over delayed care in COVID-19 pandemic

A poll of members by the Medical Protection Society (MPS) found that 43% of doctors fear investigation if patients come to harm because of delays to referrals and reduced NHS services during the pandemic.
Treatment has been delayed for millions of patients while the NHS has focused on managing the pandemic - with GPs in many areas still unable to refer as normal and even urgent referrals delayed while the UK has been in lockdown. The NHS Confederation has warned that 10 million people could be on NHS waiting lists by Christmas.
Reduced NHS services during the pandemic have left even patients who need urgent treatment or scans for cancer waiting longer. GPonline reported in April that patients had been waiting more than a month for urgent cancer checks - and Cancer Research UK warned in May that 2.4 million patients were waiting longer for scans or treatment because of disruption to services during the pandemic.
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Source: GPonline, 11 June 2020
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Recovering COVID-19 patients given devices to spot dips in oxygen levels

Those recovering from Covid-19 are to be given devices which can help spot dips in their blood oxygen-levels while they recover at home.
The NHS is trialling the use of oximeters, combined with an app, which will make it easier to spot whether people need to be re-admitted to hospital.
The new oximeter service is being tested with more than 150 patients in sites on Watford, Hertfordshire and north London.
Clinicians in ‘virtual wards’ are able to track patients’ vital signs – including temperature, heart rate and blood oxygen saturation – in near real-time, receiving alerts if they suggest a patient is deteriorating so that further assessments and care can be arranged.
Health and Social Care Secretary, Matt Hancock, said: “While we restore face to face NHS services too, new innovations will ensure patients can benefit from the comfort of home, with the reassurance that they can be fast tracked to support from the NHS should they need. NHS at Home will help keep people safe and out of hospital while providing the best possible care.”
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Source: Digital Health, 5 June 2020
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Two hospitals see 60 percent of new covid cases caught on the wards

More than 60% of new covid cases diagnosed at two hospitals in the Midlands in recent days were caught at least two weeks after the patient was admitted — suggesting there may be particular problems with the virus spreading on their wards.
Northamptonshire is also still grappling with larger numbers of covid cases in hospital, in contrast to most of England. Its NHS organisations have said they do not know the cause of its ongoing problems.
But the large share of cases diagnosed among patients who have been in hospital for at least 15 days – classed by NHS England as definitely “healthcare associated” – indicate that problems controlling the spread within the hospitals may be playing a significant part, rather than the outbreaks in the community.
There has been major national concern about in-hospital spread of the virus in recent weeks, with the government introducing new mandatory controls on Friday.
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Source: HSJ, 11 June 2020
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NHS blood unit is “systemically racist” and “psychologically unsafe,” investigation finds

An independent investigation into working conditions at a unit of the NHS’s blood and organ transplant service has concluded that it is “systemically racist” and “psychologically unsafe.”
The internal investigation was commissioned in response to numerous complaints from ethnic minority staff working in a unit of NHS Blood and Transplant (NHSBT) in Colindale, north London. The report, carried out by the workplace relations company Globis Mediation Group, concluded that the environment was “toxic” and “dysfunctional.”
The report found evidence that ethnic minority employees had faced discrimination when applying for jobs and that white candidates had been selected for posts ahead of black applicants who were better qualified. “Recruitment is haphazard, based on race and class and whether a person’s ‘face fits,’” it said.
“Being ignored, being viewed as ineligible for promotion and enduring low levels of empathy all seem to be normal,” the report noted. “These behaviours have created an environment which is now psychologically unsafe and systemically racist.”
Chaand Nagpaul, BMA council chair, commented, “This report highlights all too painfully the racial prejudices and discrimination we are seeing across healthcare. We must renew efforts to challenge these behaviours and bring an end to the enduring injustices faced by black people and BAME healthcare workers here in the UK.”
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Source: BMJ, 10 June 2020
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Babylon apology after GP app lets patients see other people's consultations

Babylon Health is investigating whether NHS patients were among those affected by a 'software error' that allowed people registered with its private GP service to view recordings of other people's consultations earlier this month.
Babylon Health has confirmed that a small number of patients were able to view recordings of other patients' consultations earlier this week. The issue came to light after a patient in Leeds who had access to the Babylon app through a private health insurance plan with Bupa reported that he had been able to view around 50 consultations that were not his own.
The patient told the BBC he was 'shocked' to discover the data breach. "You don't expect to see anything like that when you're using a trusted app," he said. "It's shocking to see such a monumental error has been made."
Babylon told GPonline that the app used by private and NHS patients is the same, but it had yet to confirm whether the roughly 80,000 patients registered with the company's digital first NHS service GP at Hand were among those affected.
The problem is understood to have cropped up when a new feature was introduced for patients who switched from audio to video mid-way through a consultation.
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Source: GPOnline, 10 June 2020
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Patients received ‘derogatory’ treatment at women’s unit

Inspectors have placed a women’s mental health service into special measures after patients were said to have been subjected to “inappropriate” and “derogatory” treatment by staff.
St Andrew’s Healthcare, which runs the women’s inpatient facility in Northampton, has received a series of damning reports among its services over the past two years.
The inspectors noted during visits between February and March that staff reportedly used language to describe patients on a medium secure ward such as “self-harmers”, “attention seeking”, and “kicking off”.
Patients said staff used “inappropriate restraint techniques that caused pain” with reports they “bent the patient’s wrist and arm behind their back.”
They also said staff spoke to them in a “derogatory manner, for example telling them to sort themselves out when engaging in self harm behaviour.”
Inspectors rated the service “inadequate” overall, noting concerns elsewhere including “forensic failure incidents due to staff shortages”, that staff were not reporting all safeguarding concerns and that “managers did not ensure safe and clean environments in the long stay rehabilitation service and learning disability service.”
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Source: HSJ, 10 June 2020
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English care bosses say lack of resources cost thousands of lives

Thousands of people lost their lives “prematurely” because care homes in England lacked the protective equipment and financial resources to cope with the coronavirus outbreak, according to council care bosses.
In a highly critical report, social care directors say decisions to rapidly discharge many vulnerable patients from NHS hospitals to care homes without first testing them for COVID-19 had “tragic consequences” for residents and staff.
In many places, vulnerable people were discharged into care facilities where there was a shortage of personal protective equipment (PPE) or where it was impossible to isolate them safely, sometimes when they could have returned home, the report says.
“Ultimately, thousands have lost their lives prematurely in social care and were not sufficiently considered as part of wider health and community systems. And normality has not yet returned,” James Bullion, the president of the Association of Directors of Adult Social Services (Adass), said in a foreword to the report.
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Source: The Guardian, 11 June 2020
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Coronavirus: 'Start public inquiry now to prevent more deaths'

Relatives of 450 people who have died in the coronavirus pandemic are demanding an immediate public inquiry. The families want an urgent review of "life and death" steps needed to minimise the continuing effects of the virus and a guarantee that documents relating to the crisis will be kept.
A full inquiry would take place later, says lawyer, Elkan Abrahamson, who is representing the families.
The government has said its current focus is on dealing with the pandemic.
But the COVID-19 Bereaved Families for Justice UK group say immediate lessons need to be learned to prevent more deaths, and that waiting for ministers to launch an inquiry will cost lives.
The call for an inquiry comes as a report from the National Audit Office - assessing the readiness of the NHS and social care in England for the pandemic - has shown it is not known how many of the 25,000 people discharged from hospitals into care homes at the peak of the outbreak were infected with coronavirus.
Health and Social Care Select Committee chairman Jeremy Hunt said it seemed "extraordinary that no one appeared to consider" the risk.
The Department of Health says it took the "right decisions at the right time".
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Source: BBC News, 12 June 2020
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Cancer patients missed out on tests during lockdown, NHS England figures show

Huge numbers of people with suspected cancer were not referred to hospital for urgent checks or did not have a test during the first month of the lockdown, prompting fears that late diagnosis of the disease will reduce some patients’ chances of survival.
Unprecedented numbers of cancer patients missed out on vital treatments, diagnostic tests and outpatient appointments as the pandemic unfolded, NHS England data shows.
Macmillan Cancer Support estimates that 210,000 people should have entered the system this month. That means roughly 130,000 people who would ordinarily be referred to a consultant have not been. About 7% of these patients would usually require cancer treatment, meaning approximately 9,000 people might not have had their cancer diagnosed in April. 
The organisation said that around 2,500 people who should have been referred for their first treatment after a cancer diagnosis will not have received that treatment.
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Source: The Guardian, 11 June 2020
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