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

Chemo doorstep drops help to keep cancer patients safe

Thousands of patients with cancer have had chemotherapy delivered to their doors so that they can more safely receive treatment during the coronavirus pandemic.
Up to 10,000 chemo home deliveries were made over three months at the peak of the outbreak, avoiding the need for patients to venture out and risk infection when their immune system was low.
The drops are part of the COVID-friendly treatments introduced in response to the pandemic which have helped to ensure that 85,000 people could start treatment between March and June, with latest data showing referrals beginning to recover to pre-pandemic levels.
NHS staff, including community nurses and pharmacists, and volunteers have been dropping off the life-saving medication – they step back two metres when they arrive at a patient’s house, identify them and make sure they have everything they need.
Hospitals have also significantly increased the use of chemo at home, with local pharmacy teams and community nurses providing the service to reduce cancer patients’ risk of exposure to the virus.
The action joins a series of measures, including the rollout of COVID protected cancer hubs for treatment and introducing ‘COVIDfriendly’ cancer drugs.
NHS England is spending £160 million on drugs that mean patients do not have to go to hospitals for regular checks and treatment.
Dame Cally Palmer, director of cancer for the NHS in England said: “NHS staff have treated more than 108,000 patients requiring specialist hospital care for COVID-19 while also keeping other vital services such as cancer, maternity and A&E running throughout the pandemic.
“The NHS has also fast tracked modern, more convenient services that help to keep patients and staff safe – from video consultations to chemotherapy delivered to patients’ doors – that have allowed 85,000 people to start cancer treatment during the pandemic.”
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Source: NHS Improvement, 17 August 2020
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NHS launches steroid emergency card to be carried by patients at risk of adrenal crisis

Following four deaths and more than 300 incidents with steroid replacement therapy involving patients with adrenal insufficiency in the past two years, patients at risk of adrenal crisis will be issued with a steroid emergency card.
All adults with primary adrenal insufficiency (AI) will be issued an NHS steroid emergency card to support early recognition and treatment of adrenal crisis, a National Patient Safety Alert has said.
The cards will be issued by prescribers — including community pharmacists — from 18 August 2020.
AI is an endocrine disorder, such as Addison’s disease, which can lead to adrenal crisis and death if not identified and treated. Omission of steroids in patients with AI, particularly during physiological stress such as an additional illness or surgery, can also lead to an adrenal crisis.
The alert has requested that “all organisations that initiate steroid prescriptions should review their processes/policies and their digital systems/software and prompts to ensure that prescribers issue a steroid emergency card to all eligible patients” by 13 May 2021.
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Source: The Pharmaceutical Journal, 17 August 2020
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Risky business: new changes tying financial allocations and incentives to system-level performance

A quiet revolution in the NHS has happened. After decades of an internal market, NHS England has outlined new changes tying financial allocations and incentives to system-level performance instead. 
Over the past six months, providers had been allocated block funding based on activity from 2019/20 with top-ups and retrospective funding to support covid pressures, ensuring they financially break even during the crisis.
Now, in a letter accompanying funding envelopes for Integrated Care Systems and Sustainability and Transformation Partnerships around the country, NHSE outlined how health service finances will be system managed for the remainder of the year.
Systems will have not only control of the kitty (with all system costs to be met from its allocation) but funding will be linked to the performance of their member organisations, with some incentive payments or penalties for over/under performance at a system level.
Glen Burley, the chief executive of a group of three acute trusts in the West Midlands, branded the move “very risky”  and suggested a more traditional tariff performance would drive performance.
Highlighting another of his concerns he said: “We have very little experience of doing so at system level, so this is a very risky tactic in a very risky year.”
How systems will manage the shortfalls will hinge on elective delivery, system co-ordination, how to reduce forecast costs and recover income, set, of course, against the threat of a second wave of COVID-19.
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Source: HSJ, 17 September 2020
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ECRI and the Institute for Safe Medication Practices (ISMP) launch new Patient Safety Organization

Leaders of US ECRI and its affiliate, the Institute for Safe Medication Practices (ISMP), announce the launch of a joint Patient Safety Organization (PSO), an important step in making medication, medical devices, and healthcare practices safer for patients across all care settings, now during the COVID-19 pandemic, and into the future. 
Read full story
Source: CISION PR Newswire
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Maternity unit death 'lessons not learned'

High-risk women at a maternity unit were not monitored closely enough and there was a "lack of learning" from a mother's death, inspectors found.
A Care Qualtiy Commission (CQC) report rated the unit at Basildon University Hospital as inadequate with "failings" found in six other serious cases. Inspectors carried out unannounced checks in June after a whistleblower voiced fears about patient safety.
The unit was criticised following the deaths of baby Ennis Pecaku in September 2018 and mother Gabriela Pintilie, 36, in February 2019.
The CQC previously carried out an inspection of the department the month Mrs Pintilie died and said the unit, which had once been rated outstanding, required improvement. Inspectors returned for the surprise "focused" inspection after being contacted by an anonymous whistleblower. The report found babies were born in a poor condition and then transferred for cooling therapy, which can be offered for newborn babies with brain injury caused by oxygen shortage during birth.
During their visit, inspectors found:
High-risk women giving birth in a low-risk area. Not enough staff with the right skills and experience. "Dysfunctional" working between midwives, doctors and consultants, which had an impact on the "increased number of safety incidents reported". Concerns over foetal heart monitoring. Women being referred to by room numbers instead of their names.  A "lack of response by consultants to emergencies" resulting in delays The CQC also referred to issues relating to the death of Mrs Pintilie, who was not named in the report, and said five serious incidents "identified the same failings of care".
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Source: BBC News, 18 August 2020
"This demonstrated there had been a lack of learning from previous incidents and actions put in place were not embedded."
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Depression in British adults doubles during pandemic, new data shows

The number of adults experiencing depression has almost doubled during the pandemic, according to new figures.
Data from the Office for National Statistics showed that almost one in five adults (19.2 per cent) were likely to be experiencing some form of depression in June. This had risen from around one in 10 (9.7%) between July 2019 and March 2020, before the imposition of the nationwide lockdown.
Dame Til Wykes, a professor of clinical psychology and rehabilitation at King’s College London, warned of a looming “mental health crisis” once the pandemic passes.
“This study tells us, yet again, that we might have a mental health crisis after this pandemic. The social effects of distancing and isolation for some affects their emotional wellbeing.
Dr Billy Boland, chairman of the General Adult Faculty at the Royal College of Psychiatrists, said the UK’s mental health services would be faced with a “tsunami of referrals” in the coming months.
“Isolation, bereavement and financial insecurity are some of the reasons why the nation’s mental health has deteriorated since the start of the pandemic.
“The government must speed up the investment to mental health services if we are to treat the growing numbers of people living with depression and other mental illnesses.”
Read full story
Source: The Independent, 18 August 2020
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COVID-19: Impact of long term symptoms will be profound, warns BMA

A third of doctors have treated patients with long term COVID-19 symptoms, including chronic fatigue and anosmia, a survey conducted by the BMA has found.
Richard Vautrey, chair of the BMA’s GP committee for England, said it was clear that the long term impact of COVID-19 on patients and the NHS would be profound. 
“With more patients presenting with conditions as the result of infection, it’s essential that sufficient capacity is in place to support and treat them,” Vautrey said. “With the growing backlog of non-COVID-19 treatment, the likelihood of a season flu outbreak, and the possibility of a second wave of infections we need to see a more comprehensive long term plan to enable doctors to care for their patients this winter and beyond.”
The survey also asked doctors about their own experiences of COVID-19: 63% said they did not believe they had contracted the virus, 12% had had a diagnosis of COVID-19 confirmed by testing, and 14% believed they had been infected with the virus.
David Strain, co-chair of the BMA’s medical academic staff committee, said that the NHS could not afford more failures of quality and supply in personal protective equipment. “Risk assessments should be available to all working in the NHS and appropriate steps should be put in place to mitigate the risk of catching the virus, even in those that have a low risk of a bad outcome from the initial infection,” he said.
Read full story
Source: BMJ, 13 August 2020
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Hancock extends emergency patient data sharing rules

Matt Hancock has extended four national data sharing orders which allow GPs and NHS organisations to share confidential patient information, as part of the ongoing response to the COVID-19 pandemic.
The data sharing instructions were initially put in place in March when the pandemic broke out in earnest, and they were due to expire at the end of September.
Under the arrangement GPs, NHS providers, NHS Digital, NHS England/Improvement, local authorities and the UK Biobank can share information about patients’ treatment and medical history - if doing so would help their response to COVID-19.
The data sharing instructions have now been extended until 31 March next year. 
According to the Department of Health and Social Care’s update which notified organisations of the extension, NHS entities can share information for reasons such as helping to support the NHS Test and Trace service, identifying further patients at risk of COVID-19, and understanding information about patient access to health and adult social care services.
Read full story (paywalled)
Source: HSJ, 20 August 2020
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Coronavirus: Study into 'Long COVID' finds 3 in 4 patients suffering symptoms months later

Nearly three-quarters of coronavirus patients admitted to hospital suffer ongoing symptoms three months later, new research suggests.
A total of 81 patients out of 110 discharged from Southmead Hospital in Bristol were still experiencing symptoms from the virus, including breathlessness, excessive fatigue and muscle aches, after 12 weeks.
Many were struggling to carry out daily tasks such as washing, dressing or going back to work, the study found.
The majority of patients reported improvements in the initial symptoms of fever, cough and loss of sense of smell, and most had no evidence of lung scarring or reductions in lung function.
The findings are part of North Bristol NHS Trust's Discover project, which is studying the longer-term effects of coronavirus - so-called Long COVID.
An intensive care doctor, Dr Jake Suett, told Sky News in June that he was still suffering COVID-19 symptoms three months after contracting the disease. Dr Jake Suett, 31, had no underlying health conditions but was still suffering chest pain, breathlessness, blurred vision, memory loss, a high temperature, concentration problems.
Dr Rebecca Smith, from North Bristol NHS Trust, said: "There's still so much we don't know about the long-term effects of coronavirus, but this study has given us vital new insight into what challenges patients may face in their recovery and will help us prepare for those needs."
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Source: Sky News, 20 August 2020
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Millions of women lose access to contraception and abortions amid coronavirus crisis

Millions of women and girls around the world have been left unable to access contraception and abortions amid the coronavirus crisis, a new report has found.
A study by Marie Stopes International, which provides abortion and contraception services worldwide, warns 1.9 million women and girls lost their usual access to its contraception and safe abortion services in the first half of the year as a result of the global public health emergency.
The abortion provider is preparing for 900,000 additional unintended pregnancies, 1.5 million extra unsafe abortions, and 3,100 additional pregnancy-related deaths after the disruption to services in the first half of the year.
Dr Rashmi Ardey, of Marie Stopes, said: “Women’s needs do not suddenly stop or diminish during an emergency – they become greater. And as a doctor, I have seen only too often the drastic action that women and girls take when they are unable to access contraception and safe abortion.
“This pandemic has strained healthcare services all over the world, but sexual and reproductive healthcare was already so under prioritised that once again women are bearing the brunt of this global calamity.”
Read full story
Source: The Independent,19 August 2020
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Coronavirus: Majority of pregnant women who died were ethnic minority background, report finds

A majority of pregnant women who died from coronavirus during the peak of the pandemic were from an ethnic minority background, it has emerged.
A new study of more than a dozen women who died between March and May this year also heavily criticised the reorganisation of NHS services which it said contributed to poor care and the deaths of some of the women.
This included one woman who was twice denied an intensive care bed because there were none available, as well as women treated by inexperienced staff who had been redeployed by hospitals and who made mistakes in their treatment of the women.
The report, by experts at the National Perinatal Epidemiology Unit, based at the University of Oxford, also criticised mental health services after four women died by suicide. The report said women were “bounced” between services which had stopped face-to-face assessments during the crisis.
The report looked at 16 women’s deaths in total. Eight women died from COVID-19, seven of whom had an ethnic minority background. Two women with Covid-19 died from unrelated causes, four died by suicide and two were victims of homicide.
In the report, published on Thursday, the authors concluded improvements in care could have been made in 13 of the deaths they examined. In six cases, improvements in care could have meant they survived.
Read full story
Source: The Independent, 21 August 2020
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Trust warned after CQC’s ‘serious concerns’ for patients

Safety inspectors have ordered a mental health trust to make immediate improvements after visiting two inpatient wards where three patients died inside six months.
The Care Quality Commission this week warned Devon Partnership Trust it would take “urgent action” over “serious concerns about patients” unless the trust made the required improvements swiftly.
The watchdog inspected the trust’s Delderfield and Moorland wards in June following concerns about three patient deaths in September, October and March, along with “a number of” patient safety incidents - including ligature incidents.
The CQC also highlighted poor patient observation routines and a lack of learning from previous incidents, amid delays in completing investigations into safety incidents.
Read full story
Source: HSJ, 21 August 2020
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Coronavirus: Study reveals alarming impact of Covid on care home sector

Nursing homes were put under “constant” pressure to accept patients with coronavirus while being regularly refused treatment from hospitals and GPs for residents who became ill at the height of the Covid crisis, a landmark study has found.
The Queen’s Nursing Institute said homes were told hospitals had blanket “no admissions” policies during April and May while GPs and local managers imposed unlawful do not resuscitate orders on residents.
The findings have emerged in a survey by the QNI, the world’s oldest nursing charity, which surveyed 163 care home nurses and managers working across the country.
Carried out between May and June this year, the study establishes an evidence base of the impact on the sector from coronavirus, in addition to the official figures showing care home death rates.
One nurse said they were under “constant pressure to admit people who were Covid positive” while another said: “The acute sector pushed us to take untested admissions. The two weeks of daily deaths during an outbreak were possibly the two worst weeks of my 35-year nursing career.”
Read full story
Source: The Independent, 22 August 2020
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Primodos scandal: Government should consider ‘redress’ for victims of pregnancy test drug, says Theresa May

Theresa May has urged the government to consider “redress” for the victims of a hormone pregnancy test blamed for causing serious birth defects.
The former prime minister said that while Primodos victims had received an apology, “lives have suffered as a result” of the drug’s use.
In an interview for a Sky News documentary, she praised campaigners who had been “beating their head against a brick wall of the state” which tried to “stop them in their tracks”.
A review in 2017 found that scientific evidence did “not support a causal association” between the use of hormone pregnancy tests such as Primodos and birth defects or miscarriage. But Ms May ordered a second review in 2018, because, she said, she felt that it “wasn’t the slam-dunk answer that people said it was”.
“At one point it says that they could not find a causal association between Primodos and congenital anomalies, but neither could they categorically say that there was no causal link,” she said.
The second review concluded last month that there had been “avoidable harm” caused by Primodos and two other products – sodium valproate and vaginal mesh.
An interview for Bitter Pill: Primodos, which will air on Sky Documentaries, Ms May said: “I think it’s important that the government looks at the whole question of redress and about how that redress can be brought up for people.
Read full story
Source: The Independent, 28 August 2020
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CQC chief sceptical about need for ‘patient safety commissioner’

The Care Quality Commission's chief executive Ian Trenholm has said he is sceptical about the need to appoint an NHS patient safety commissioner, one of the key recommendations of the recently published Cumberlege review.
In a wide-ranging interview with HSJ, Mr Trenholm also revealed that he wants the Care Quality Commission to review the collaboration of every health system in England.
Mr Trenholm told HSJ he is “not sure” a patient safety commissioner was needed and that it would need to perform a “role that was different from what’s already in place” for it to add value.
He said: “If you look at the work we’re doing on patient safety, the work that HSIB are doing on patient safety, and then we’ve got people within the NHS itself doing work on patient safety, I think there are enough people playing. The question is, are we all working together as effectively as we possibly could be.
“If another player helps that work [then] great, but I’m not sure that’s something that is necessary.”
Read full story (paywalled)
Source: HSJ, 24 August 2020
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‘I want to hide under the covers’: Female NHS staff suffering stress and exhaustion amid coronavirus crisis

Women working in the NHS are suffering from serious stress and exhaustion in the wake of the coronavirus crisis, a troubling new report has found.
Some 75% of NHS workers are women and the nursing sector is predominantly made up of women – with 9 out of 10 nurses in the UK being female.
The report, conducted by the NHS Confederation’s Health and Care Women Leaders Network, warns the NHS is at risk of losing female staff due to them experiencing mental burnout during the global pandemic.
Researchers, who polled more than 1,300 women working across health and care in England, found almost three quarters reported their job had a more damaging impact than usual on their emotional wellbeing due to the COVID-19 emergency.
Read full story
Source: The Independent, 25 August 2020
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