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

Breast screening: One million women in UK may have missed scans

Almost one million women in the UK have missed vital breast screening due to coronavirus, a leading charity has estimated.
Breast screening programmes were paused in March as the NHS focused resources on tackling the pandemic. Breast Cancer Now calculates that around 8,600 women who have not had a scan have undetected breast cancer.
The scanning programme is running again, but social distancing measures have reduced capacity. Combined with the significant backlog of women waiting for a scan, and more women starting to come forward with concerns about possible symptoms, the charity warns the service is under intense pressure.
Breast cancer diagnosed at a later stage can be harder to treat.
Breast Cancer Now estimates that a total of 986,000 women across the UK missed their mammograms due to breast screening programmes being paused. The estimate is based on the average number of women screened per month, and the approximate length of time the screening programme was suspended, in each part of the UK. This breaks down to almost 838,000 women in England, 78,000 in Scotland, 48,000 in Wales and 23,000 in Northern Ireland.
The charity is calling for an action plan and new resources to tackle the problem.
Baroness Delyth Morgan, Breast Cancer Now chief executive, said: "That nearly one million women across the UK were caught up in the backlog waiting for breast screening is cause for grave concern.
"Mammograms are a key tool in the early detection of breast cancer, which is critical to stopping women dying from the disease.
"We understand that the breast screening programme was paused out of necessity due to the global Covid-19 pandemic, but we must now press play to ensure that all women can access breast screening, and we cannot afford for the programme to be paused again."
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Source: BBC News, 30 September 2020
Breast Cancer Now press release
Sam

Damning CQC report finds ‘bullying and predatory behaviour’ concerns at trust

An ambulance service could be put in special measures after a damning report criticised poor leadership for fostering bullying and not acting decisively on allegations of predatory sexual behaviour towards patients.
East of England Ambulance Service Trust failed to protect patients and staff from sexual abuse, inappropriate behaviour and harassment, the Care Quality Commission said.
It failed to support the mental health and wellbeing of staff, with high levels of bullying and harassment. Staff who raised concerns were not treated with respect and some senior leaders adopted a “combative and defensive approach” which stopped staff speaking out.
“The leadership, governance and culture still did not support delivery of high-quality care,” the CQC said.
Read full story (paywalled) 
Source: HSJ, 30 September 2020
Sam

Hospital stayed silence as surgeon 'harvested body parts'

For more than two decades, Derek McMinn harvested the bones of his patients, according to a leaked report – but it was not until last year that anyone challenged the renowned surgeon.
The full scale of his alleged collection was apparently kept from the care regulator until just days ago, and thousands of those who went under his knife for hip and knee treatment still have no idea that their joints may have been collected in a pot in the operating theatre, and stored in the 67-year-old’s office or home.
Clinicians and managers at the BMI Edgbaston Hospital, where McMinn carried out the majority of his operations, actively took part in the collection of bones and – even after alarms were raised – the hospital did not immediately act to stop the tissue being taken away, according to a leaked internal report seen by The Independent.
An investigation found operating theatre staff at the private hospital left dozens of pots containing joints removed from patients femurs during hip surgery in a storage area, in some cases for months. According to the report, there had been warnings about their responsibilities under the Human Tissue Act when an earlier audit between 2010 and 2015 identified the storage of femoral heads, the joints removed in the procedure.  
The internal report said there was no evidence McMinn had carried out any research or had been approved for any research work – required by the Human Tissue Authority to legally store samples. It said one member of staff told investigators the samples were being collected for research on McMinn’s retirement.
Although the Care Quality Commission knew about claims that a small number of bones being kept by McMinn, it is understood that the regulator received a copy of the BMI Healthcare investigation report only last Friday, after The Independent had made initial inquiries about the case. That report suggests a minimum of 5,224 samples had been taken by McMinn.
The regulator confirmed to The Independent it had not been aware of the extent of McMinn’s supposed actions.
An insider at BMI Healthcare accused the company of “covering up”, adding: “Quite senior staff at the hospital went along with it and just handed the pots over to his staff when they came to collect them.”
Read full story
Source: The Independent, 30 September 2020
Sam

South Wales hospital cancels most operations after Covid outbreak

Most operations have been cancelled at a hospital in a COVID-19 hotspot in south Wales after an outbreak of the virus involving more than 80 people.
Hospital chiefs said transmission had taken place within the Royal Glamorgan hospital at Llantrisant and some wards where patients and staff had been infected were closed.
The hospital, which is within Rhondda Cynon Taf, one of the areas under local lockdown restrictions, said it was trying to speed up the testing of patients and staff.
In a statement, it said: “Significant temporary service restrictions will be put in place at Royal Glamorgan hospital from 2pm Wednesday 30 September as increased action is taken to contain a COVID-19 outbreak within the hospital.
Teams have been working at pace to implement robust measures to manage the outbreak. However, additional cases linked to transmission within the hospital have been confirmed in recent days with the number of cases currently standing at 82."
Andrew RT Davies, shadow health minister for the Welsh Conservatives, called on the Welsh government to explore using field hospitals and other health facilities to alleviate pressure on the Royal Glamorgan.
He added: “This is very concerning, particularly as many of the additional cases are linked to transmission within the hospital, and so questions over processes and protocols must be asked.”
Read full story
Source: The Guardian, 30 September 2020
Patient Safety Learning

Patients left 'in limbo' by NHS virus response

The stress and anxiety caused to patients by "poor communication" from NHS bodies in England during the covid pandemic has been criticised by MPs.
While recognising the huge burden placed on the NHS, their report said cancelled treatments and surgery had left some "in limbo" and others "too scared" to seek medical help. The report also questioned why weekly testing of NHS staff had not yet begun. And it called for their mental and physical wellbeing to be supported.
Jeremy Hunt, who chairs the Health and Social Care Committee, which compiled the report, praised the "heroic contribution" made by front-line NHS staff during the pandemic, which had saved many lives. But he said the pandemic had "massively impacted normal NHS services" and this situation could have been improved with clearer communication to patients and better infection control measures in hospitals.
The report, based on evidence from doctors, nurses, patient groups and NHS leaders, said the case for routine testing for all NHS staff in all parts of the country was "compelling" and it should be introduced as soon as possible before winter to help reduce the spread of the virus.
The government and NHS England told the committee they wanted to bring in routine testing of staff but any plans depended on the capacity available.
Read full story
Source: BBC News, 1 October 2020
Patient Safety Learning

Almost nine in ten maternity services experienced decline in 'emergency pregnancy appointments amid pandemic'

Almost nine in ten maternity services experienced a decline in emergency pregnancy appointments during the pandemic due to women avoiding healthcare providers amid coronavirus chaos, a study has found.
The Royal College of Obstetricians and Gynaecologists, who carried out the research, said women refrained from attending appointments due to anxiety around going into a hospital and fears of overwhelming the NHS, as well as not being clear if the appointments were essential.
Researchers found 70% of maternity services reported a reduction in antenatal appointments, while 60% of units stopped the option of giving birth at home or in a midwife-led unit. Over half of services said postnatal appointments after childbirth had been reduced.
The findings come as maternity services warn staff must not be sent to work in other parts of the hospital in the wake of a second wave of coronavirus.
Royal College of Obstetricians & Gynaecologists and the Royal College of Midwives, who together represent the overwhelming bulk of maternity staff, say there must not be a repeat of the acute and widespread maternity staff shortages which played out during the health emergency’s peak.
Read full story
Source: The Independent, 30 September 2020
 
Patient Safety Learning

Coronavirus: Delirium 'key symptom' in frail older people

Doctors and carers should look out for signs of confusion or strange behaviour in frail older people because it could be an early warning sign of COVID-19, research suggests.
Even if they have no cough or fever, delirium is more common in vulnerable over-65s than other, fitter people of the same age. But it's not yet clear why this extreme confusion or delirium happens.
In this King's College London study, data from more than 800 people over the age of 65 was analysed. They included 322 patients in hospital with COVID-19, and 535 people using the Covid Symptom Study app to record their symptoms or log health reports on behalf of friends and family. All had received a positive test result.
The researchers found that older adults admitted to hospital who were classified as frail were more likely to have had delirium as one of their symptoms, compared with people of the same age who weren't frail.
For one in five patients in hospital with Covid, delirium was their only symptom.
The study calls for more awareness of it in hospitals and care homes.
Read full story
Source: BBC News, 30 September 2020
Patient Safety Learning

Patients ‘put in danger so scandal-hit surgeon could perform two operations at same time’

The surgeon at the centre of a body parts scandal operated on patients who were dangerously sedated so that their procedures could be carried out simultaneously, according to a leaked investigation seen by The Independent.
Renowned hip surgeon Derek McMinn and two anaesthetists at Edgbaston Hospital, Birmingham, were accused of putting “income before patient safety” in the internal investigation for BMI Healthcare, which runs the hospital.
It comes after a separate review found that McMinn had hoarded more than 5,000 bone samples from his patients without a licence or proper permission to do so over a period of 25 years, breaching legal and ethical guidelines. Police are investigating a possible breach of the Human Tissue Act.
According to the report on sedation by an expert from another hospital, the two anaesthetists, Imran Ahmed and Gauhar Sharih, sedated patients for so long that their blood pressure fell to dangerous levels in order to allow McMinn to carry out near-simultaneous surgery.
It found this meant long delays in the operations starting, with one sedated patient being subjected to prolonged anaesthesia for longer than one hour and 40 minutes – recommended best practice is 30 minutes.
Another patient was apparently "abandoned" for an hour and 26 minutes after their surgery was only partially completed while McMinn began operating on another patient.
The report’s author, expert anaesthetist Dr Dhushyanthan Kumar of Coventry’s University Hospital, said this was unsafe practice by all three doctors and urged BMI Healthcare to carry out a review of patients to see if any had suffered lasting brain damage. Both anaesthetists work for the NHS – Ahmed at Dudley Group of Hospitals, Sharih at University Hospitals Birmingham – without restrictions on their ability to practise.
Read full story
Source: The Independent, 30 September 2020
Patient Safety Learning

Covid-19: GPs need extra support to withstand second wave, BMA warns

General practices will struggle to cope with a second wave of COVID-19 unless urgent measures are put in place to support them, the BMA has warned.
It said that practices in England were reporting that they did not have the capacity to carry out all of the work required of them while managing ongoing patient care, dealing with the backlog of care put on hold during the first wave of the pandemic, and reconfiguring services.
Richard Vautrey, chair of the BMA’s General Practitioners Committee England, said, “GPs, like all doctors, are extremely concerned that without decisive action now services will be overwhelmed if we see another spike in the coming weeks and months.”
In the report, the committee called for a package of measures to support the GP workforce, including making occupational health services available to all staff to ensure that they are properly risk assessed and to provide free supplies of personal protective equipment. It also called for the suspension of routine inspections by the Care Quality Commission and of the Quality and Outcomes Framework, as part of efforts to reduce bureaucracy.
NHS England’s covid support fund for practices should be rolled over until March 2021 and expanded to ensure that all additional costs such as additional telephony and cleaning are included, it added.
Vautrey said, “The measures we’ve outlined are aimed at supporting practices and their staff to deliver high quality care while managing the increased pressures of doing so during a pandemic, and it is vital that the government and NHS England listen and implement these urgently, to ensure that primary care can continue to operate safely through what looks to be an incredibly difficult winter.”

Read full story
Source: BMJ, 1 October 2020
Patient Safety Learning

Chairs have high moral values but struggle with disruptive directors, claims landmark study

Nearly half of trust chairs fail to “effectively deal with non-performing board members” according to a major study of the role of NHS non-executive directors seen by HSJ.
The Henley Business School conducted in-depth research over a two-year period for its report 'The Independent Director in Society: Our Current Crisis of Governance & What to Do About It' which is published later this month. The research included a survey of NHS non-executive directors, which reveals that they have a broadly positive view about their contribution but also reveals significant areas of concern.
Only 55% of respondents agreed with the statement that NHS trust chairs “effectively deal with/remove non-performing and/or disruptive board members”. Just 47% said chairs had “positive relations with the media.”
The survey was undertaken before the onset of the pandemic, but nearly a third of the respondents disagreed with the statement that NHS chairs were “effective in a crisis”. However, almost every survey respondent claimed trust chairs had “high moral values” which were “aligned with those of the organisation.”
All but 2% of respondents backed the idea that non-executive directors “have a sense of duty to see things are done both ethically and morally”, while 94% claimed they were “truly independent”. However, a fifth claimed it was impossible for non-executive directors to be effective “given the mandate of the NHS”.
Read full story (paywalled)
Source: HSJ, 1 October 2020
Patient Safety Learning

Investigations launched after Atikamekw woman records Quebec hospital staff uttering slurs before her death

As she lay dying in a Joliette, Que., hospital bed, an Atikamekw woman clicked her phone on and broadcast a Facebook Live video appearing to show her being insulted and sworn at by hospital staff.
Joyce Echaquan's death on Monday prompted an immediate outcry from her home community of Manawan, about 250 kilometres north of Montreal, and has spurred unusually quick and decisive action on the part of the provincial government.
The mother of seven's death will be the subject of a coroner's inquiry and an administrative probe, the Quebec government said today. A nurse who was involved in her treatment has been dismissed.
But that dismissal doesn't ease the pain of Echaquan's husband, Carol Dubé, whose voice trembled with emotion as he told Radio-Canada his wife went to the hospital with a stomach ache on Saturday and "two days later, she died."
Echaquan's relatives told Radio-Canada she had a history of heart problems and felt she was being given too much morphine. 
In the video viewed by CBC News, the 37-year-old is heard screaming in distress and repeatedly calling for help. Eventually, her video picks up the voices of staff members. One hospital staff member tells her, "You're stupid as hell." Another is heard saying Echaquan made bad life choices and asking her what her children would say if they saw her in that state.
Dubé said it's clear hospital staff were degrading his wife and he doesn't understand how something like this could happen in 2020.
Read full story
Source: CBC News, 29 September 2020
Patient Safety Learning

Nurses barred from NHS 111 Covid clinical division after 60% of calls unsafe

The NHS 111 service has permanently stopped nurses and other healthcare professionals in a clinical division handling calls with people suspected of having COVID-19 after an audit of recorded calls found more than 60% were not safe.
The audit was triggered in July after many of the medical professionals recruited to work in that clinical division of the 111 service sounded the alarm, saying they did not feel “properly skilled and competent” to fulfil such a critical role.
An investigation was launched into several individual cases after the initial review found that assurances could not be given “in regard to the safety of these calls”, according to an email, seen by the Guardian, from the clinical assurance director of the National Covid-19 Pandemic Response Service. In a further email on 14 August, she told staff that after listening to a “significant number” of calls “so far over 60% … have not passed the criteria demonstrating a safe call”.
A number of “clinical incidents” were being investigated, she said, because some calls “may have resulted in harm”. One case had been “escalated as a serious untoward incident with potential harm to the patient”.
NHS England declined to answer questions about any aspect of these apparent safety failings, saying it was the responsibility of the South Central ambulance service (SCAS), which set up a section of NHS 111 called the Covid-19 Clinical Assessment Service (CCAS).
Read full story
Source: The Guardian, 1 October 2020
Sam

NHS England plans high street 'one-stop' diagnostic centres

People awaiting a CT or MRI scan will be able to have one on the high street under NHS plans to improve access to diagnostic tests.
NHS England plans to set up a network of new “one-stop shops” where patients will be able to have scans closer to home rather than having to go hospital. They are intended to reduce the risk of patients getting COVID-19 in hospital and speed up the time it takes to undergo diagnostic testing by having more capacity.
NHS England’s governing board approved a plan on Thursday by Prof Sir Mike Richards to create “community diagnostic hubs across the country over the next few years”.
It is part of a planned “radical overhaul” in the way patients access a range of diagnostic tests, screening appointments and other services.
The hubs, which would open six days a week, may also perform blood tests, lung function checks and endoscopies, in which a camera is put down the throat.
The new facilities would be sited in disused shops or in shopping centres. They are part of the NHS’s drive to make it easier for people to be tested without having to go to hospital, amid concern that reluctance to do so is part of the reason fewer people are undergoing cancer screening. It is already undertaking lung cancer tests in 10 mobile centres that are parked at supermarkets and shopping centres.
Bigger hubs could also offer mammograms, eye health checks, scans for pregnant women, hearing tests and gynaecological services.
Hospital bosses welcomed the plan, which they said should reduce waiting times. Miriam Deakin, the director of policy and strategy at NHS Providers, which represents NHS trusts, said: “Doing these checks in the community rather than in hospital could support trusts as they grapple with a second wave of Covid-19, winter pressures and tackling backlogs of care.”
Read full story
Source: The Guardian, 1 October 2020
Sam

Speak Up Month 2020

October is Speak Up Month – a chance to raise awareness of Freedom to Speak Up and the work which is going on in organisations to make speaking up business as usual. 
2020 has been an extraordinary year, and all NHS workers, whatever their role, have been under increased pressure from the COVID-19 crisis.
Throughout October the National Guardian Freedom to Speak Up will be sharing their Alphabet of Speak Up – from Anonymity to Zero Tolerance. 26 days to explore the issues, the people, the values, the challenges – everything which goes into what Freedom to Speak Up means in health.
#SpeakUpABC
National Guardian Freedom to Speak Up
Patient Safety Learning

The mystery of the capital’s ‘high-volume’ treatment centres

Next Thursday we’ll see more waiting list data released.
What is contained in it is probably why Sir David Sloman’s office has taken nearly a month to not answer this question: Your letter to system leaders said you would “eliminate” 52-week waits, by when?
The regional director’s office could not answer, nor could it reveal which hospitals were going to be the high-volume centre to burn through the lists in the six major specialities.
There are a couple of likely reasons for their not being able to say when the long waiters would be eliminated.
NHSI/E’s phase three letter set “mad” targets that don’t feel very real to many on the ground. I/E central will know this and have their own reasons for setting stretching-to-the-point-of-snapping targets, but trusts don’t really want to be held to submitting impossible commitments then being chastised for missing them (management teams have been moved on for this kind of thing in less fraught times).
The second reason is that the picture is likely to be scary and also to have an impact on the ongoing three-way negotiation between the NHS, the independent sector - which will be hosting a lot of this work - and the workforce that will actually do it in both places.
There is even less transparency than usual from the regional director’s office and I/E generally when asked anything at all about how effectively private sector facilities are being used, or how much it is costing.
Much more surprising is the fact that Sir David’s office cannot yet name where each of the ICS’s six high-volume centres will be.
Read full story (paywalled)
Source: HSJ, 1 October 2020
Patient Safety Learning

'My message to young people is just do the right thing' – teenage virus survivor's plea

A Dublin teenager has told of his harrowing battle with COVID-19 and is urging other young people to take the disease seriously.
Jack Edge, 17, from Rathfarnham, had no underlying health conditions when he contracted the virus in April. Five months on and three hospital admissions later, the Leaving Cert student is still suffering from the "destruction" the virus wreaked on his body.
Jack first displayed symptoms of COVID-19 on 15 April and five days later was admitted to Tallaght University Hospital. Within hours of being hospitalised, he was fighting for his life. Jack had to be put on a ventilator to help him breathe for 12 days. As his condition stabilised, he was transferred to a high dependency unit.
Jack said: "I couldn't sleep for three days. Every time I closed my eyes, there was just dizziness and loads of colours. "I literally stayed in the bed for 72 hours, just staring at the wall. I had a lot of dark times in the hospital, since I do struggle with anxiety too."
"But the care I received was absolutely amazing. They came in and talked to me if I needed to talk, as I would often get lonely, as it was mainly just me in an isolation room."
However, surviving COVID-19 was just the first step for Jack. On 28 May, he was readmitted to hospital in excruciating pain. Doctors told him he may have suffered nerve damage associated with the virus.
"I’m currently taking 18-20 tablets a day. Tablets for the nerve damage, for pain and for my anxiety. "
"I basically have to learn to walk again. I do two to two-and-a-half hours of physio every day, depending on how much energy I have. I wake up some days and I get really upset. I still don’t know why this happened to me or how I got it."
Jack hopes that by sharing his story he can raise awareness of the dangers and debilitating long-term effects of COVID-19 for young people.
Read full story
Source: RTE News, 2 October 2020
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