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

NHS treatment delays linked to more child deaths than coronavirus

More children died after failing to get timely medical treatment during lockdown than lost their lives because of coronavirus, new research by the Royal College of Paediatrics and Child Health (RCPCH) suggests.
Six children under the age of 16 have died from COVID-19 in Britain since the pandemic began, according to the Office for National Statistics (ONS). 
However, seeking medical help too late was a contributory factor in the deaths of nine children in paediatric care new analysis has found, with the figure likely to be higher.
A survey of 2,433 paediatricians, carried out by the RCPCH, found that one in three handling emergency admissions had dealt with children who turned up later than usual for diagnosis or treatment.
Read full story (paywalled)
Source: The Telegraph, 25 June 2020
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'Unacceptable' drop in care at Kettering home with 12 COVID-19 deaths

A dramatic collapse in standards at a care home where a dozen people died from COVID-19 has been revealed by inspectors who discovered hungry and thirsty residents living with infected wounds in filthy conditions.
Infection control was inadequate, residents with dementia were left only partially dressed and one family complained of finding their loved one smeared in dried faeces at Temple Court care home in Kettering, which is operated by Amicura, a branch of Minster Care which runs more than 70 homes in the UK.
Amicura said the home had been “completely overwhelmed” by COVID-19 infections which it said arrived with 15 patients discharged from hospitals in the second half of March.
They were overrun,” one relative told the inspectors. “They were short-staffed and then with the influx of people, they couldn’t cope.”
Residents’ wounds had become necrotic and infected, requiring hospital treatment and several people had experienced falls, some of which resulted in injuries needing hospital treatment, the inspectors found.
The conditions discovered by the Care Quality Commission on 12-13 May were so poor that surviving residents were moved out immediately. The CQC report into the service, published on Friday, found multiple breaches of the health and social care act. Northamptonshire police have launched an investigation to identify whether any offences may have been committed.
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Source: The Guardian, 26 June 2020
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Region used ‘clinically unsafe’ healthcare app for three years

A healthcare app which was investigated over failing to meet clinical and governance standards has been dropped by north London commissioners after it was deemed “clinically unsafe”.
The Health Help Now app, currently used in eight north London boroughs, will be scrapped by the end of June and patients will be directed to the NHS app.
In a statement, the North West London Collaboration of Clinical Commissioning Groups said it decided to carry out a review of the app as it had low uptake and dwindling funds, despite reporting in 2017 that it was being used by 500,000 patients. 
During the reivew, stakeholders told commissioners that a lack of clinical oversight meant the app was “unsafe” and financial constraints meant it was unsustainable.
Read full story
Source: HSJ, 26 June 2020
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COVID-19 may cause brain complications in some, say doctors

Brain complications, including stroke and psychosis, have been linked to COVID-19 in a study that raises concerns about the potentially extensive impact of the disease in some patients.
The study, published in Lancet Psychiatry, is small and based on doctors’ observations, so cannot provide a clear overall picture about the rate of such complications. However, medical experts say the findings highlight the need to investigate the possible effects of COVID-19 in the brain and studies to explore potential treatments.
“There have been growing reports of an association between COVID-19 infection and possible neurological or psychiatric complications, but until now these have typically been limited to studies of 10 patients or fewer,” said Benedict Michael, the lead author of the study, from the University of Liverpool. “Ours is the first nationwide study of neurological complications associated with Covid-19, but it is important to note that it is focused on cases that are severe enough to require hospitalisation.”
Scientists said the findings were an important snapshot of potential complications, but should be treated with caution as it is not possible to draw any conclusions from the data about the prevalence of such complications.
Read full story
Source: The Guardian, 26 June 2020
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Coronavirus: Survivors 'at risk of PTSD'

People who were seriously ill in hospital with coronavirus need to be urgently screened for post-traumatic stress disorder (PTSD), leading doctors say.
The Covid Trauma Response Working Group, led by University College London and involving experts from south-east England, said those who had been in intensive care were most at risk.
The experts said regular check ups should last at least a year.
More than 100,000 people have been treated in hospital for the virus. The experts say tens of thousands of these would have been seriously ill enough to be at risk of PTSD.
The working group highlighted research which showed 30% of patients who had suffered severe illnesses in infectious disease outbreaks in the past had gone on to develop PTSD, while depression and anxiety problems were also common.
Tracy is just one of many people who has been left with psychological scars from her coronavirus experience. She was admitted to Whittington Hospital in north London in March and spent more than three weeks there - one of which was in intensive care.
"It was like being in hell. I saw people dying, people with the life being sucked from them. The staff all have masks on and all you saw was eyes - it was so lonely and frightening."
Since being discharged in April the 59-year-old has been struggling to sleep because of the thought she will die and she has constantly suffered flashbacks. She is now receiving counselling.
Read full story
Source: BBC News, 29 June 2020
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Bullying, bad behaviour and broken IT uncovered at worst trusts for junior doctors

Regulators have uncovered multiple examples of patients being put at risk when junior doctors are left with tasks they are not trained for, lacking support, and facing bullying and inappropriate behaviour.
Inspection teams have had to intervene – in some cases contacting senior trust staff – to ensure urgent issues are addressed, after the inspections.
Health Education England oversees training nationally, which includes making the checks at trusts which have been put under “enhanced monitoring” by the professional regulator, the General Medical Council, because of concerns from trainees.
HSJ has obtained and examined 20 reports, all produced since the beginning of 2019. Themes running through the reports included:
Lack of support from consultants. Trainees struggled to contact consultants out of hours.  Bullying and inappropriate behaviour was reported at several trusts.  Inspectors found a reluctance to report concerns and/or a lack of knowledge of how to do it.  Teaching was often of poor quality or cancelled – and sometimes trainees struggled to attend sessions because of how their shifts and rotations were scheduled. Trainees in several trusts reported IT problems, such as being locked out of systems so being unable to access clinical notes and blood tests, and IT systems taking up to 30 minutes to start up, sometimes delaying patient care.  Read full story (paywalled)
Source: HSJ, 29 June 2020
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Coronavirus: London’s Nightingale hospital recorded 144 safety incidents in 29 days

London’s Nightingale hospital recorded 144 patient safety incidents during its 29 days treating 54 patients, it has emerged.
There were two serious incidents at the field hospital, a doctor told a Royal Society of Medicine webinar.
Dr Andrew Wragg, consultant cardiologist and director of quality and safety at Barts Health NHS Trust, said a study of the long-term outcomes of the 54 patients was ongoing, as 20 of those treated at the ExCel conference centre site were still recovering in hospitals across London.
Johanna Cade, a nurse at Guy’s and St Thomas’ NHS trust and who worked at the Nightingale, said: “We had quite high incident reporting at 144 incidents reported and I think that demonstrates that Nightingale really did well at building a no blame safety culture for resolution and learning. This system manifested itself and staff were really striving to make things better continually. We knew who to report to and how to escalate things.”
She showed data revealing the largest number of safety incidents involved medical devices.
There were 25 incidents that included the ventilators used to keep patients alive. Staffing issues and medication, as well as pressure ulcer and communication incidents, were also among the highest numbers.
Read full story
Source: The Independent, 27 June 2020
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Hospitals 'want to cut PPE requirements to speed surgery return'

Some hospitals have sought to water down PPE requirements in order to “accelerate” the return of planned surgery, senior doctors have said, as they issued new guidance aiming to inform the decision. 
The Royal College of Anaesthetists, along with partners including the Faculty of Intensive Care Medicine, released a document to members to tackle “marked uncertainty amongst operating theatre team members as to which infection prevention and control precautions should be taken when treating screened patients in planned surgical pathways”.
The document provides recommendations for teams on how to adjust PPE usage, which the college said was “supportive and consistent” with current Public Health England guidance.
Professor William Harrop-Griffiths, consultant anaesthetist and council member of the Royal College of Anaesthetists, told HSJ some hospitals wanted to decrease the amount of PPE used as it might enable them to “accelerate and increase the workload”.
However, the college has argued that there is currently “no clear guidance on when you might consider making that change”.
“You have to balance that to the risk to the staff,” Professor Harrop-Griffiths stressed.
Read full story (paywalled)
Source: HSJ, 29 June 2020
Patient Safety Learning

NHS rolls out additional support for pregnant BAME women

After new analysis showed pregnant black women were eight times more likely and Asian women four times as likely to be admitted to hospital with COVID-19, the NHS is rolling out additional support for pregnant women of a Black, Asian and Ethnic Minority (BAME) background.
Given evidence of the heightened risk to BAME expectant mums, urgent action is being taken in England including increasing uptake of Vitamin D and undertaking outreach in neighbourhoods and communities in their area.
Research carried out by Oxford University has shown 55% of pregnant women admitted to hospital with coronavirus are from a BAME background, even though they represent only a quarter of the births in England and Wales.
In response, England’s most senior midwife, Jacqueline Dunkley-Bent, has written to all maternity units in the country calling on them to take four specific actions to minimise avoidable COVID-19 risk for BAME women and their babies.
The steps include:
Increasing support of at-risk pregnant women – e.g. making sure clinicians have a lower threshold to review, admit and consider multidisciplinary escalation in women from a BAME background. Reaching out and reassuring pregnant BAME women with tailored communications. Ensuring hospitals discuss vitamins, supplements and nutrition in pregnancy with all women. Women low in vitamin D may be more vulnerable to coronavirus so women with darker skin or those who always cover their skin when outside may be at particular risk of vitamin D insufficiency and should consider taking a daily supplement of vitamin D all year. Ensuring all providers record on maternity information systems the ethnicity of every woman, as well as other risk factors, such as living in a deprived area (postcode), co-morbidities, BMI and aged 35 years or over, to identify those most at risk of poor outcomes. Read full story
Source: NHE, 29 June 2020
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“We have been totally abandoned” people left struggling for weeks as they recover from COVID at home

Initial survey findings show the long road to recovery for people who have faced COVID at home without going into hospital
New survey findings from over 1,000 people show that those recovering from mild-moderate COVID are struggling for weeks with symptoms, raising concerns that there is not adequate support for people who have not been in hospital with the illness.
The ongoing survey is being run by Asthma UK and the British Lung Foundation, through their post-COVID HUB, which they set up, alongside a helpline and WhatsApp service, to support anyone left with breathing difficulties after COVID.
Read full article here
Clive Flashman

It'll take four years for NHS to recover from COVID-19, health chiefs warn

The NHS will not be able to get back to providing its full range of services for as long as four years because of the huge disruption caused by COVID-19, hospital bosses have warned.
Patients will face much longer waits than usual for operations and diagnostic tests because hospitals’ drive to remain infection-free means they are closing beds, and surgeons’ need to wear protective clothing means they are carrying out fewer procedures than before the pandemic.
In a stark admission of the complexity of reopening the NHS, a key health service leader has predicted that some hospitals will be able to provide only 40% of the care they previously delivered.
Hospitals are under pressure from ministers and health charities to restart services as soon as possible for patients with conditions such as cancer, obesity and joint problems. But the chief executives of three NHS trusts in England have told the Observer that the “sheer complexity” of getting back to normal amid the lingering effects of COVID-19 means progress will be very slow.
“It could be four years before waiting times get back to pre-Covid levels. We could see that. It’s certainly years, not months,” said Glen Burley, the group chief executive of Warwick hospital, George Eliot hospital in Nuneaton and County hospital in Hereford.
Read full story
Source: The Guardian, 27 June 2020
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'Blown away’: Australian coronavirus researchers examine everything from breastfeeding to explosives technology

A new report by Research Australia details more than 200 ongoing COVID-19 studies that extend far beyond the search for a vaccine.
Almost every COVID-19 research project being led by Australians has been in the new report, including studies of breastfeeding guidelines for parents with COVID-19, filter systems to remove the virus via air-conditioning systems, monitoring of sewage to detect the prevalence of COVID-19, and repurposing technology normally used to identify explosives to see if it can detect the presence of COVID-19.
The report was compiled by Research Australia, the national peak body for health and medical research.
It’s chief executive, Nadia Levin, said the report was not a complete catalogue of COVID-19 related research in Australia, but provided a useful insight into the scale of the response from the health and innovation sectors.
“All of this Australian research kept popping up and we were blown away by the scale and scope of it, so we asked all of our members to share what they are working on,” Levin told the Guardian Australia.
Read full story
Source: The Guardian, 27 June 2020
Patient Safety Learning

One quarter of patients unable to access mental health services during lockdown, suggests survey

A quarter of people who sought help for mental health problems during lockdown were unable to access NHS services, a new survey shows.
A survey by the mental health charity Mind found that 25% of respondents who contacted primary care services could not get support.
More than a fifth (22%) of adults with no previous experience of poor mental health now say that their mental health has deteriorated, according to the survey.
Many people who were previously well will develop mental health problems as a “direct consequence of the pandemic and all that follows”, according to Mind.
Two out of three (65%) adults aged 25 and over and three-quarters of young people aged 13-24 with an existing mental health problem reported worse mental health during the lockdown.
Mind predicts that prolonged worsening of wellbeing and “continued inadequate access” to NHS mental health services will lead to a marked increase in people experiencing longer-term mental health problems.
Read full story
Source: The Independent, 30 June 2020
Patient Safety Learning

COVID-19: Delays in attending emergency departments may have contributed to deaths of nine children

Delays in going to the emergency department because of the coronavirus pandemic lockdown may have been a contributory factor in the deaths of nine children, a snapshot survey of consultant paediatricians in the UK and Ireland has shown.
Three of the reported deaths associated with delayed presentation were due to sepsis, three were due to a new diagnosis of malignancy, in two the cause was not reported, and one was a new diagnosis of metabolic disease.
Read full story (paywalled)
Source: BMJ, 30 June 2020
Patient Safety Learning

Gosport's Brockhurst Medical Centre closed over 'risk of harm' concerns

A GP surgery that had been told it required improvement has been shut down after an inspection found patients could be at "risk of harm".
Hampshire's Brockhurst Medical Centre had already been due to close on 31 December.
However, the Care Quality Commission (CQC) suspended its registration with "immediate effect" following an unannounced inspection on Monday.
Patients are expected to be transferred to other practices on Saturday.
In September, a CQC assessment of the practice, on Brockhurst Road in Gosport, rated it overall as "requires improvement".
The issues highlighted in the report included that the practice "did not have systems for the appropriate and safe use of medicines" and "there was a risk that some patients were not receiving the care and treatment they needed".
Following Monday's inspection, Garry Higgins, of the CQC, said it had taken "urgent action" to suspend the registration of the GP surgery.
"We took the action because we believe if we didn't people using the service may be exposed to the risk of harm," he added.
Read full story
Source: BBC News, 5 December 2020
Sam

Short surveys will support better connected social care and health services

The Professional Record Standards Body would like you to take part in two surveys about the information that should be shared between health and social care. The project aims to improve connections between different services, to allow people better access to the personalised care and wellbeing support they need. They’ve also produced an easy read version for anyone who has difficulty reading, which can be found here.
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