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

Police investigating death of teenager at acute hospital

Police in Bristol have launched investigations into the circumstances that led to the death of a teenager with autism and learning disabilities. Avon and Somerset Police told HSJ they are investigating the circumstances behind the death of Oliver McGowan in 2016, at North Bristol Trust.
They said: “As part of the enquiry [officers] will interview a number of individuals as they seek to establish the circumstances around Oliver’s death before seeking advice from the Crown Prosecution Service.”
Oliver died in 2016 at Bristol’s Southmead Hospital after being admitted following a seizure. He had mild autism, epilepsy and learning difficulties.
During previous hospital spells he experienced very bad reactions to antipsychotic medications, prompting warnings in his medical records that he had an intolerance to these drugs. Despite this Oliver was given anti-psychotic medication by doctors at Southmead against his own and his parents’ wishes. This led him to suffer a severe brain swelling which led to his death.
His death has since prompted a national training programme for NHS staff on the care of people with autism and learning disabilities. 
Read full story (paywalled)
Source: HSJ, 1 July 2020
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Coronavirus: Calls for government to plan public inquiry

The government must set out plans for an inquiry into its handling of the coronavirus pandemic, the health service ombudsman has said. This was not about blaming staff but about "learning lessons", he said.
Ombudsman Rob Behrens said patients were reporting concerns about cancelled cancer treatment and incorrect COVID-19 test results.
Ministers have not committed to holding an inquiry, but have accepted there are lessons to be learned.
The Parliamentary and Health Service Ombudsman (PHSO) stopped investigating complaints against the NHS on 26 March, to allow it to focus on tackling the COVID-19 outbreak.
But people had continued to phone in with these concerns, Mr Behrens said.
"Complaining when something has gone wrong should not be about criticising doctors, nurses or other front-line public servants, who have often been under extraordinary pressure dealing with the Covid-19 crisis," he said.
"It is about identifying where things have gone wrong systematically and making sure lessons are learned so mistakes are not repeated."
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Source: BBC News, 1 July 2020
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Shrewsbury hospital: ‘New and ongoing’ safety concerns revealed by NHS watchdog

Inspectors have raised “new and ongoing” patient safety concerns at Shrewsbury and Telford Hospitals Trust, it has emerged.
The Care Quality Commission has issued a new warning notice to the Midlands trust after an inspection of the hospital earlier this month sparked concerns for the welfare of patients on its medical wards.
These concerns are separate from the trust’s maternity service, which, it was revealed on Tuesday, is now facing a police investigation alongside an NHS inquiry into more than 1,200 allegations of poor maternity care dating back to the 1970s.
In October, a patient at the hospital bled to death after a device used to access his bloodstream became inexplicably disconnected while he was receiving care on the renal unit.
The Health Service Journal reported the latest concerns related to the inappropriate use of bed rails and risks of patients falling from beds after several incidents. The CQC is also concerned about the trust’s use of powers to detain elderly or vulnerable patients on wards.
The concerns also include patients being at risk of abuse and learning from past incidents not being shared with staff.
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Source: The Independent, 1 July 2020
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COVID-19: NHS leaders braced for longer waiting times as service deals with fallout

Waiting times for tests and treatment not related to COVID-19 are likely to increase significantly in the second half of 2020 because of the fallout from the pandemic, the head of NHS England has acknowledged.
Giving evidence to the Commons health select committee on 30 June, NHS England’s chief executive Simon Stevens said that contrary to some commentary, the NHS’s overall waiting list actually dropped by over half a million people between February and April 2020 because fewer people were coming forward for treatment.
But, he added, “As referrals return we expect that will go up significantly over the second half of the year.”
Stevens said that there were 725 000 fewer elective admissions to NHS hospitals during March and April, but that number has begun to recover significantly. “As we speak, we think we’re now somewhere north of 55% of pre-covid-19 elective activity levels,” he said. He added that he hoped the NHS would return to around three quarters of normal activity levels by July or August.
Stevens told MPs that the NHS would pursue a range of measures to increase capacity over the coming months, including extending the deal with the private sector to use its facilities, and repurposing some of the Nightingale hospitals for diagnostic testing.
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Source: BMJ, 1 July 2020
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‘Urgent’ reviews launched by NHSE as death rates double

NHS England and NHS Improvement have ordered urgent reviews into the deaths of people with a learning disability and autism during the pandemic, HSJ has learned.
In May, the regulators said the COVID-19 death rates among this population were broadly in line with the rest of the population.
But in early June, the Care Quality Commission published data which suggested death rates of people with learning disabilities and/or autism had doubled during the pandemic.
In an announcement posted on a social media group for Royal College of Nursing members last week, NHSE/I said they were “urgently seeking clinical reviewers with experience in learning disability”.
The message to the private Facebook group, seen by HSJ, added: “The effects of coronavirus are having a far-reaching impact on all our lives. As we learn more about the virus, we are taking steps to make changes to safeguard our well-being.
“For people with a learning disability, the number of deaths has doubled during the covid pandemic. (compared to data on the number of deaths recorded during the same period last year). As a result, we have a large number of deaths of people with a learning disability who have died during the pandemic whose deaths we want to review.”
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Source: HSJ, 1 July 2020
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Report finds ‘profound failings’ in Scottish NHS IT systems

A Scottish Government committee has found that the “profound failings” of IT systems are the biggest problem facing a medicine-prescribing service that does not sufficiently focus on patients.
A report from the members of Scottish Parliament on the Health and Sport Committee describes a medicines system “burdened by market forces, public sector administrative bureaucracy and under resourcing, inconsistent leadership and a lack of comprehensive, strategic thinking and imagination, allied to an almost complete absence of useable data”.
The committee particularly criticised the failure of the NHS to introduce appropriate IT systems.
“We are extremely disappointed that once again all roads lead to the dismal failure of the NHS in Scotland to implement comprehensive IT systems which maximise the use of patient data to provide a better service,” the report says.
Committee members are calling for an overhaul of the system to allow for collection and analysis of data that would ensure the best possible outcomes for patients and cost savings for the NHS.
MSPs found a “lack of care” to understand patients’ experience of taking medicines and a lack of follow up to ensure that medicines were effective or even being used.
Prescribers were “instinctively reaching for the prescription pad” and not taking the time to discuss medicines with patients, nor were the principals of realistic medicine, in which patients and clinicians share decision making about their care, being followed.
Read full story
Source: Public Technology.net, 1 July 2020
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Investigation of maternity deaths "too late"

Parents of babies who died at a hospital trust at the centre of a maternity inquiry say a police investigation has come "too late".
West Mercia Police said it was looking at whether there was "evidence to support a criminal case" at Shrewsbury and Telford NHS Hospital Trust. An independent review, contacted by more than 1,000 families, said it was working with police to identify relevant cases.
"It's bittersweet," one mother said. 
"It's come too late for my daughter, she should still be here," said Tasha Turner, whose baby, Esmai, died four days after she was born at Royal Shrewsbury Hospital in 2013.
Ms Turner's case is part of the Ockenden Review, an independent investigation into avoidable baby deaths at the trust, which runs Royal Shrewsbury Hospital and Telford's Princess Royal.
LaKamaljit Uppal, 50, from Telford, who is also part of the review following the death of her son Manpreet in April 2003 at Royal Shrewsbury Hospital, said she hoped the police inquiry would bring some closure.
"The trust put me through hell, someone should be held accountable," she said.
Read full story
Source: BBC News, 1 July 2020
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Lockdown: Suicide fears soar in LGBT community

There has been a significant rise during lockdown in the UK in the number of LGBT people seeking suicide-prevention support.
Support group LGBT Hero reports 11,000 people have accessed its suicide-prevention web pages - up over 44% on the first three months of the year.
The government considers LGBT people to be at higher risk of suicide but no national data on LGBT suicides is kept.
In total, eight charities told BBC News they had seen an increase in LGBT people accessing their support for suicide prevention.
The LGBT Foundation has received more calls about suicide "than ever before". 
Gavin Boyd, of The Rainbow Project, based in Northern Ireland, said: "In just the last three weeks, we know of three LGBT people who have ended their lives."
And another chief executive of a charity, in the south of England, who did not want to be named in case it affected its funding, said: "We know of two young LGBT people in the past two weeks. We're under more pressure to deliver than ever before. The government has done absolutely nothing to help regional LGBT charities cope with the demand from our already struggling service users."
Read full story
Source: BBC News, 2 July 2020
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Weekly testing for care home staff to start on Monday

Staff working in care homes are to be tested every week starting on Monday, with residents tested every month, the government has said.
The expansion of testing comes as a whistleblower at one of the testing laboratories revealed dozens of shifts had been cancelled throughout May and June because of a lack of test samples.
Ministers hope that the expansion of testing will help to prevent the spread of infection to vulnerable residents.
Read full story
Source: The Independent, 3 July 2020
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Royal colleges should be more open on care reviews

The leader of the Morecambe Bay inquiry has spoken of his disappointment that some of the recommendations have not led to changes, and said royal colleges could inform regulators when they are commissioned to carry out care quality reviews.  
Bill Kirkup was speaking after HSJ revealed only a small proportion of royal college “invited reviews” were made public, and in some cases even the Care Quality Commission (CQC) had not been made aware of the reviews, or seen final reports. Trusts had commissioned dozens of them into care failings over three years.
The inquiry which he chaired into maternity services at the University Hospitals of Morecambe Bay Foundation Trust recommended that all external reviews of suspected service failings should be registered with the CQC and that NHS boards should have a duty to report their findings “openly”. The recommendations of the inquiry were accepted by both the government and the CQC.
HSJ used freedom of information law to get copies of reports from recent years, but in many cases trusts refused to share them.
Dr Kirkup, who stressd his comments did not refer to any individidual trust, said the findings highlighted a weakness in implementation of “an important recommendation”.
Read full story (paywalled)
Source: HSJ, 3 July 2020
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Third of frail hospital leavers in England find post-discharge care lacking

Problems with hospital discharges in England, highlighted in the largest annual patient survey, reinforce the need for greater integration between health and social care, the sector regulator has said.
The Care Quality Commission inpatient survey found that a majority of patients were positive about their hospital care but a significant minority experienced problems on discharge.
A third of respondents who were frail said the care and support they expected when they left hospital was not available when they needed it. Three in 10 frail people said they had not had discussions with staff about the need for further health and social care services they might require post-discharge.
Four in 10 of all patients surveyed left hospital without printed or written information about what they should or should not do after discharge, and the same proportion said their discharge was delayed.
Read full story
Source: The Guardian, 2 July 2020
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Coronavirus 'long haulers' are sick for months. This doctor is one of them

Psychiatrist Dr. Scott Krakower was diagnosed with the coronavirus in April and continues to have symptoms more than two months later, making him what’s known as a “long hauler.”
Although Krakower said he's feeling better, he is not able to return to work.
“Each day is different. Some days are up, some days are down. I would say the mornings are better for me and then by 1 or 2 o’clock is when my voice and my shortness of breath kick in more and then it’s harder to do things.”
Krakower hasn’t had a clear answer about when he will recover or whether that may happen, although he takes solace in the fact that he is improving.
Krakower continues to try and shake off the symptoms, a signature of long hauling. It’s a trait that has been on display before with MERS and SARS, says Dr Robert Glatter, an emergency physician at Lenox Hill Hospital in New York City.
“What we’re seeing is that this is a byproduct of the inflammation from the virus itself. In other words, dead fragments of virus elicit an immune response. And as a result of this, the body reacts and produces certain types of substances that can really have adverse effects,” Glatter said.
Read full story
Source: Today, 1 July 2020
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Patients endangered by ‘hazardous’ use of PPE

The “hazardous” use of personal protective equipment (PPE) required because of COVID-19 is contributing to the spread of secondary infections in intensive care units and other hospital settings, a leading expert has told HSJ.
Infection Prevention Society vice president Professor Jennie Wilson, said: “[PPE] has been used to protect the staff, but the way it has been used has increased the risk of transmission between patients. The widespread use of PPE particularly in critical care environments has exacerbated the problem (of patient to patient transmission). Unless we tackle the approach to PPE we will continue to see this major risk of transmission of infections between patients.”
Professor Wilson warned this was espeically worrying as the risk includes spreading antibiotic resistant infections among ICU patients. There is increasing concern these are developing more often in covid patients due to widespread use of broad spectrum antibiotics in the early days of the pandemic, she added.
Read full story (paywalled)
Source: HSJ, 3 July 2020
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‘Long covid’ – The under-the-radar coronavirus cases exhausting thousands

We’re swiftly learning the symptoms of Covid-19 may last longer than previously thought. One in 10 people are reporting a longer tail of symptoms, which exceeds the suggested two-week recovery time.
It’s thought around 30,000 people in the UK could be impacted by a prolonged version of the illness – what some are calling ‘long covid’. These people are months into their recovery from the virus and still fighting a range of persistent symptoms. In some cases, the symptoms disappear for a while before coming back. In others, they’re gradually improving over time.
Research from the Covid-19 Symptom Study in the UK, led by Professor Tim Spector of King’s College London, shows after three weeks of first reporting symptoms, a group of people continue to experience fatigue, headaches, coughs, loss of smell, sore throats, delirium and chest pain.
People with mild cases of the disease are more likely to have a wide range of symptoms that come and go over an extended period, Prof Spector found. And these people are often flying under the radar because they’re not in hospital.
Those who believe they’ve had ‘long covid’ are now calling on the government to recognise their plight, invest in research and put support in place.
Read full story
Source: Huffpost, 2 July 2020
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Scientists investigate cases of post-COVID-19 fatigue

Most people experience COVID-19 as a short-term illness: once the infection has been fought off, they bounce back to health. But evidence is emerging of a significant minority – sometimes referred to as “long haulers” – who struggle with long-term symptoms for a month or longer.
Anecdotal reports have abounded of people left with fatigue, aching muscles and difficulty concentrating. Online support groups on Facebook and Slack have sprung up, already hosting thousands of members who say they have not got better.
Speaking to the BBC’s Andrew Marr Show on Sunday, Matt Hancock said it was difficult to gauge the scale of the problem. “This is a really serious problem for a minority of people who have Covid,” the health secretary said. “Some people have long-term effects that look like a post-viral fatigue syndrome.”
Scientists are only just beginning to investigate the potential causes of enduring fatigue, but say that there are likely to be a wide variety of reasons why some people face a longer road to recovery.
Read full story
Source: The Guardian, 5 July 2020
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There is a shocking silence over the thousands of people with disabilities who have died during the pandemic

Figures released by the Office for National Statistics show that about two-thirds of fatalities from this disease during its peak from start of March to mid-May were people with disabilities. That is more than 22,000 deaths.
Then dig down into the data. It indicates women under 65 with disabilities are more than 11 times more likely to die than fellow citizens, while for men the rate is more than six times higher. Even for older people the number of deaths was three times as high for women and twice as high for men. There are some explanations for such alarming figures, although they tend to reveal other profound concerns.
Yet the report showed even when issues such as economic status and deprivation are taken into account, people with disabilities died at about twice the rate of their peers. So where was the fury over this obvious and deep inequality, even in death? Where was the fierce outcry over persistent failures that left many citizens and their families at risk, lacking even the most basic advice, support or protection from the state?
Chris Hatton, the dedicated professor of public health and disability at Lancaster University, delved into all available data. He found people with autism and learning disabilities were in reality at least four times more likely to die at the peak of pandemic than other citizens.
They also died at far younger ages. “Information released about deaths of autistic people and people with learning disabilities has been minimal, grudging and seems deliberately designed to be inaccessible,” he says.
This adds up to one more shameful episode in the scandal of how Britain treats such citizens.
Read full story
Source: iNews, 5 July 2020
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