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

NHS to get millions of pounds to help save babies’ lives

Ministers are to invest millions in making Britain's maternity wards safer, it was announced on Wednesday after The Independent exposed a series of cases in which mothers and babies had suffered avoidable harm during childbirth.
The new money, almost £10m, was announced as part of the spending review unveiled by Rishi Sunak, the chancellor, in the Commons and will deliver new pilots of what the Treasury called “cutting-edge training” to improve practice during childbirth.
Significant failings in maternity safety units across the NHS have devastated families and left some babies needing tens of millions of pounds to look after them in later life.
In November last year, The Independent joined with the charity Baby Lifeline to call for a new fund to be set up after exposing the single largest maternity scandal in NHS history at Shrewsbury and Telford Hospitals Trust, where dozens of babies have died or been left with brain damage.
The new funding will also cover the final year of the independent investigation into the Shrewsbury trust.
Read full story
Source: The Independent, 26 November 2020
Patient Safety Learning

Trust CEO asks for ‘scientific evidence’ on covid vaccine safety to reassure staff

NHS trust chief executives have told HSJ  they need more clarity the Pfizer-BioNTech covid vaccine is safe to reassure their worried staff. 
Trusts were told last week they need to be ready to start vaccinating their staff from early next month. On Tuesday, it was confirmed that they would initially be asked to use the covid vaccine produced by Pfizer and BioNTech, assuming it is granted a licence by the Medicines and Healthcare products Regulatory Agency.
Speaking at the HSJ Provider Virtual Summit, St George’s University Hospitals Foundation Trust chief executive Jacqueline Totterdell said there was a lot of “anxiety” around the vaccine among her staff. Leeds Community Healthcare Trust chief Thea Stein added leaders in her city feel “anxious and uncertain”.
Ms Totterdell said: “As a responsible officer for 9,000 staff, I also need to be clear that the vaccination is safe. That bit of narrative just needs to come out from the centre, about the reasons why they think it is safe.
“I think there is a lot of anxiety, and some of the polls we’ve done around south west London show that as little as 50 per cent of people are willing just to have it without any of that [assurance]."
Northumbria Healthcare FT chief executive Sir Jim Mackey, who also spoke at the summit, admitted he was “a bit surprised” by some staff who said they were not going to get the vaccine.
The former NHS Improvement chief added: “I think when it actually comes to it, and we get the messaging right about it, not just the responsibility for you but also your responsibility for the people you work with… then the vast majority of people will get it and take confidence in the fact that it’s been developed really quickly and effectively.
“These things don’t get signed off if they’re dangerous, so we need to embrace it as the thing that’s going to get us back to normal.”
Read full story (paywalled)
Source: HSJ, 26 November 2020
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England set to open specialist surgical mesh removal centres in April

A network of specialist surgical mesh removal centres is to be set up around England, with a launch planned for April 2021.
The move implements a recommendation of the review, chaired by the Conservative peer and former health minister Julia Cumberlege, into three treatments which caused avoidable harm. These included the use of transvaginal tape and pelvic mesh to treat pelvic organ prolapse and urinary incontinence.
The review, which published its report in July, heard “harrowing” stories about women left with serious complications. The mesh is hard to remove and only a few surgeons in the UK are able to carry out the procedure.
Read full story (paywalled)
Source: BMJ, 25 November 2020
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Elizabeth Dixon death inquiry 'exposes 20-year cover-up' of mistakes

The death of a premature baby in 2001 led to a "20-year cover-up" of mistakes by health workers, an independent inquiry has found.
Elizabeth Dixon, from Hampshire, died due to a blocked breathing tube shortly before her first birthday. The government, which ordered the inquiry in 2017, said the mistakes in her care were "shocking and harrowing".
The inquiry report by Dr Bill Kirkup said some of those involved had been "persistently dishonest".
Elizabeth, known as Lizzie, died from asphyxiation after suffering a blockage in her tracheostomy tube while under the care of a private nursing agency at home.
Dr Bill Kirkup, who was appointed by the government to review the case, said her "profound disability and death could have been avoided".
He said: "There were failures of care by every organisation that looked after her, none of which was admitted at the time, nor properly investigated then or later."
"Instead, a cover-up began on the day that she died, propped up by denial and deception."
Read full story
Source: BBC News, 26 November 2020
Patient Safety Learning's statement on the Dixon Inquiry report
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Cancer: Blood test for 50 types to be trialled by NHS

A blood test designed to detect more than 50 types of cancer at an early stage will be trialled by the NHS.
More than 165,000 people in England will be offered the tests from next year. If successful, the NHS hopes to expand it to 1m people from 2024.
Sir Simon Stevens, NHS England chief executive, said early detection had the potential "to save many lives".
While some welcomed the pilot, others cautioned the test was still untried and untested.
Developing a blood test for cancer has been keeping scientists busy for many years without much success.
Making one that's accurate and reliable has proved incredibly complex - the danger is that a test doesn't detect a person's cancer when they do have it, or it indicates someone has cancer when they don't.
This test, developed by the Californian firm Grail, is designed to detect molecular changes in the blood caused by cancer in people with no obvious symptoms.
As part of a large-scale pilot, also funded by the company, 140,000 participants aged between 50 and 79 will be asked to take the tests for the next three years.
Another 25,000 people with possible cancer symptoms will also be offered testing after being referred to hospital in the normal way.
Read full story
Source: BBC News, 27 November 2020
Sam

Head of NHS inquiry warns other families could be victims of cover-ups

The chairman of an inquiry that has confirmed a 20-year cover-up over the avoidable death of a baby has warned there are other families who may have suffered a similar ordeal.
Publishing the findings of his investigation into the 2001 death of Elizabeth Dixon, Dr Bill Kirkup said he wanted to see action taken to prevent harmed families having to battle for years to get answers.
Dr Kirkup, who has been involved in multiple high-profile investigations of NHS failures in recent years, said: “There has been considerable difficulty in establishing investigations, where events are regarded as historic. I don't like the term historic investigations. I think that these things remain current for the people who've suffered harm, until they're resolved, it’s not historic for them.  
“There has been significant reluctance to look at a variety of cases. Mr and Mrs Dixon were courageous and very persistent and they were given help by others and were successful in securing the investigation and it worries me that other people haven't been.
“I do think we should look at how we can establish a proper mechanism that will make sure that such cases are heard."
“It's impossible to rule out there being other people who are in a similar position. In fact, I know of some who are. I think it's as important for them that they get heard, and that they get things that should have been looked at from the start looked at now, if that's the best that we can do.”
Read full story
Source: The Independent, 27 November 2020
Sam

Covid: Woman left blind after treatment delayed in pandemic

A woman has become blind after her monthly eye injections were delayed for four months during lockdown.
Helen Jeremy, 73, said everything she enjoyed doing has "gone out of the window" after losing her eyesight. She has glaucoma and was diagnosed with age-related macular degeneration four years ago.
Monthly injections controlled the condition and meant she could still drive and play the piano. However, her appointments were cancelled when the pandemic struck and her eyesight deteriorated.
"I was panicking. It was terrifying. Because I'm a widow I'm on my own and it was awful," she said.
"Suddenly my eyesight was basically gone. By the time of my next appointment I was told there was no point in going on with these injections because the damage had been done to the back of my eye."
Thousands more people in Wales are at risk of "irreversible sight loss" because of treatment delays, RNIB Cymru warns.
The Welsh Government said health boards are working to increase services.
Read full story
Source: BBC News, 27 November 2020
Sam

Shouting, screaming and microaggressions uncovered at NHS organisation

A review of a clinical commissioning group has discovered “microaggressions and insensitivities” towards Black, Asian and minority ethnic staff, and the use of derogatory slurs about other groups.
The report into Surrey Heartlands CCG also uncovered incidents of shouting, screaming and bullying among other inappropriate behaviour. And it was reported some staff were unwilling to accept Black Lives Matter events as important, stating “all lives matter”.
The review also discovered a culture of denial and turning a blind eye to consistent concerns, with staff fearful of speaking up. In particular, the HR department was said to have been repeatedly told about the behaviour of one staff member but had chosen to ignore or delay dealing with the issues. 
However, the review found “no evidence for widespread discriminatory practices” and “no clear evidence for a widespread culture of bullying and ill-treatment” — but it added the systems to deal with concerns had failed and there was a sense of “organisational inaction”. 
Read full story (paywalled)
Source: HSJ, 27 November 2020
Sam

New trust’s ‘inexperienced’ leadership criticised as CQC serves warning

The Care Quality Commission (CQC) has criticised a new trust’s leadership after issuing it with a warning notice to improve care in its two emergency departments.
The watchdog warned North Cumbria Integrated Care Foundation Trust that patients were not always receiving timely and appropriate care, while delayed transfers of care had “resulted in significant delays in admitting patients on to wards”.
The CQC — which carried out focused inspections at the trust in August and September after concerns were raised about risks to patient and staff safety — added there was evidence of “insufficient numbers of suitably qualified, skilled, competent and experienced clinical staff”.
The CQC also said there was a lack of an effective system to mitigate risks, including infection control in the emergency department escalation areas and on some medical wards.
Of the trust’s Cumberland Infirmary and West Cumberland hospitals, the CQC said: “People could not access the urgent and emergency care and medicine service when they needed them and often had long waits for treatment.”
The CQC’s inspection report, published today, also said the trust had an “inexperienced leadership team” which “did not always have the necessary skills and abilities to lead effectively”. It added there were “few examples of leaders making a demonstrable impact on the quality or sustainability of services”.
Read full story (paywalled) 
Source: HSJ, 30 November 2020
Patient Safety Learning

Demand for public inquiry into NHS mental health deaths to be debated by MPs

A mother fighting for a public inquiry into the death of her son and more than 20 other patients at an NHS mental health hospital in Essex has won a debate in parliament after more than 100,000 people backed her campaign.
On Monday, MPs in the House of Commons will debate Melanie Leahy’s petition calling for a public inquiry into the death of her son Matthew in 2012, as well as 24 other patients who died at The Linden Centre, a secure mental health unit in Chelmsford, Essex, since 2000.
The centre is run by Essex Partnership University NHS Trust which has been heavily criticised by regulators over the case.
A review by the health service ombudsman found 19 serious failings in his care and the NHS response to his mother’s concerns.
This included staff changing records after his death to suggest he had a full care plan in place when he didn’t.  
Matthew was detained under the Mental Health Act but was found hanged in his room seven days later. He had made allegations of being raped at the centre, but this was not taken seriously by staff nor properly investigated by the NHS.
The trust has admitted Matthew’s care fell below acceptable standards.
In November, it pleaded guilty to health and safety failings linked to 11 deaths of patients in 11 years.
Read full story
Source: The Independent, 29 November 2020 
Patient Safety Learning

Inspectors moving between Covid-hit England care homes without tests

Health inspectors in England have been moving between care homes with high levels of COVID-19 infection without being tested, raising fears they have put more residents at risk of catching the virus, leaks to the Guardian have revealed.
In recent weeks all care home inspections carried out in the north of England have been of infected homes, including a facility where 38 of the 41 people receiving care and 30 staff – almost half of the workers – had tested positive, internal documents from the Care Quality Commission (CQC) show.
Over the last two months inspectors have been checking infection control procedures and care standards in up to 600 care homes, many of which were dealing with outbreaks of COVID-19, but the Department of Health and Social Care (DHSC) has yet to provide testing. The CQC said on Friday it was expecting to start testing inspectors “in the coming weeks”.
Weekly Covid deaths in care homes have been rising. In the week to 20 November, 398 people were notified to the CQC as having died from Covid, up from 138 a month earlier. The death toll remains lower than at the peak of the pandemic, when more than 2,500 people were dying a week in late April.
The situation has sparked “very real anxieties about contracting the disease” and spreading it between infected homes, the leaked memos reveal. One inspector described work to his managers as like “going into the eye of the storm”.
Read full story
Source: The Guardian, 27 November 2020
Patient Safety Learning

Great Ormond Street Hospital admits errors led to boy’s death

Mistakes by Great Ormond Street contributed to the death of a five-year-old boy, the children’s hospital has admitted – just months after it concluded a legal case with his family in which it denied responsibility.
The world-renowned children’s hospital failed to flag results of a crucial blood test, showing that Walif Yafi had a dangerous infection, to doctors at King’s College Hospital where he had been receiving treatment. He died a few weeks later, in September 2017.
In September this year, Walif’s parents agreed an out-of-court settlement with Great Ormond Street, which admitted negligence but denied liability for the boy’s death. However, this week the hospital admitted an expert had reviewed the case ahead of the settlement and concluded its actions did contribute to Walif’s death. The hospital said it had been under no duty to share these results with Walif’s parents at the time.
Walif had a liver transplant in 2012 after suffering cancer shortly after his birth, and was being overseen by Great Ormond Street as an outpatient, as well as by the transplant team at King’s College Hospital, in south London. 
On 24 August 2017, he had a routine blood test at Great Ormond Street, which showed he had an adenovirus infection – something that is common in children whose immune system is being suppressed by drugs, as Walif’s was because of his transplant. If untreated, the infection can be deadly.
But the blood test result was not communicated to the team at King’s College Hospital. Shortly afterwards, Walif’s health deteriorated and he was admitted to hospital. He was transferred to King’s College Hospital a week later, and it was not until 7 September that the infection was confirmed. 
By this stage, he was severely unwell and, though he began anti-viral therapy, Walif suffered multiple organ failure from the spread of the infection. On 30 September, he suffered cardiac arrest and died.
It was only when approached by The Independent this week that the trust revealed its expert had, in the course of negotiating the settlement with Walif’s parents, determined the hospital did materially contribute to the child’s death.
Read full story
Source: The Independent, 29 November 2020
Patient Safety Learning

Welsh Covid rules on hospital visits and maternity appointments relaxed

New Covid guidance for hospitals could see more patients receiving face-to-face visits from loved ones.
NHS Wales has given health boards and hospices flexibility to allow visits based on local levels of COVID-19. Until now accompanying people to medical appointments and hospital visits have not been allowed, with a few exceptions. 
It also allows for pregnant women in low Covid rate areas to take their partners to maternity appointments.
The Welsh Government said the new flexibility was "due to the changing picture of coronavirus transmission across Wales, with significant variations in community transmission across different parts of the country and differences in the rate of nosocomial transmission".
Read full story
Source: BBC News, 30 November 2020
Patient Safety Learning

Major concerns over funding and staffing of new ‘long covid’ clinics

There are serious concerns over the funding and staffing numbers available for new ‘long-covid’ clinics, while patient groups ‘remain in the dark’ over their locations.
Last month, NHS England announced there would be 40 clinics around the country, to start opening at the end of November, with £10m of funding to cover set-up and operational costs until March 2021.
But several speakers at HSJ’s inaugural virtual respiratory forum last week said there were still uncertainties and concerns about the capacity to provide the clinics.
Dr Jon Bennet, a respiratory consultant and chair of the British Thoracic Society, said staffing the respiratory rehabilitation services within the clinics would be challenging, as “there isn’t at the moment sufficient capacity”.
Read full story (paywalled)
Source: HSJ, 29 November 2020
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Nearly half of trusts report no BAME staff in top management tier, HSJ investigation reveals

Nearly 100 trusts have no ‘very senior managers’ (VSM) who are declared to be from a black, Asian or minority ethnic background, HSJ analysis has revealed.
According to data obtained from every NHS provider in England, 96 out of 214 (45%) did not have any VSMs declared as being from a BAME background.
This includes several large providers, such as The Newcastle upon Tyne Hospitals Foundation Trust — where around 9 per cent of the workforce and 15 per cent of the city’s population are BAME — and Liverpool University Hospitals FT.
Jon Restell, chief executive of the Managers in Partnership trade union, said the underrepresentation of BAME staff in leadership positions has “dangerously damaged” the NHS’ response to coronavirus, labelling it the “ultimate wake-up call”.
Read full story (paywalled)
Source: HSJ, 30 November 2020
Patient Safety Learning

Cumbria hospitals must take 'rapid' action on patient safety

Two hospitals in Cumbria must take "rapid" action "to keep people safe", the health watchdog has announced.
There had been "escalating" concerns about Carlisle's Cumberland Infirmary and the West Cumberland Hospital in Whitehaven, the Care Quality Commission (CQC) said.
North Cumbria Integrated Care (NCIC) has been issued with a warning.
The trust, which was already rated as requiring improvement, admitted the pace of change had been "too slow". The warning notice requires the organisation "to take action to minimise the risk of patients being exposed to harm".
During checks in August and September, inspectors found:
Emergency department patients "were not always receiving timely and appropriate" treatment Significant delays in admitting people to wards "Insufficient numbers" of qualified, competent and experienced staff Professor Ted Baker, chief inspector of hospitals, said "rapid improvements" were needed.
Read full story
Source: BBC News, 27 November 2020
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