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

Huge covid death rate among vulnerable patients who have to travel to hospital

Dialysis patients who must travel to hospital are nearly four times as likely to die of covid than those aged over 80, but so far have not been prioritised for receiving vaccination, HSJ has learned. 
UK Renal Registry data shows that, from March to November 2020, 3.3% of all in-centre haemodialysis patients have died from covid (662 deaths out of a population of 20,000). This figure compares to a death rate of approximately 0.7% in all those aged over 80 and 1.8% in over 90s.
Although the government classifies dialysis patients as clinically extremely vulnerable to COVID-19, not all patients are able to receive dialysis at home and those receiving inpatient treatment still need to travel to dialysis clinics, either in main hospital buildings or smaller satellite clinics, three times a week.
At present the Joint Committee on Vaccine and Immunisation COVID-19 vaccine prioritisation list ranks all dialysis patients at priority level four, alongside all other shielding patients and those aged over 70. Priority one covers all care home residents and staff, while priority two covers all over 80s and frontline health workers.
The Renal Association wrote to Public Health England and JCVI over the weekend to ask for a change in vaccine prioritisation but, at the time of writing, has not received a response. 
Read full story (paywalled)
Source: HSJ, 9 December 2020
Patient Safety Learning

People who suffer from ‘significant’ allergic reactions should not take Covid vaccine, UK regulators warn

The UK’s drug regulator has warned that people with have a history of “significant” allergic reactions should not receive the Pfizer-BioNTech vaccine.
The Medicines and Healthcare products Regulatory Agency (MHRA) issued the warning after two NHS staff members who were administered with doses on Tuesday both suffered an allergic reaction.
NHS England said all trusts involved with the vaccination programme have been informed.
Dr June Raine, chief executive of the MHRA, said the regulatory body was examining the cases.
“We know from the very extensive clinical trials this wasn’t a feature," she told a parliamentary committee on Wednesday. 
"But if we need to strengthen our advice now that we’ve had this experience in the vulnerable populations - the groups that have been selected as a priority - we get that advice to the field immediately.”
Read full story
Source: The Independent, 8 December 2020
Patient Safety Learning

COVID-19 has not led to an increase in stillbirths, data confirms

Coronavirus has not caused an increase in stillbirths despite fears it could do so, Government data suggests.
The Office for National Statistics (ONS) published data on Monday showing that the stillbirth rate decreased from 4.0 stillbirths per 1,000 total births in 2019, to 3.9 in the first three quarters (January to September) of 2020, in line with the long-term trend.
The data comes amid fears that coronavirus can impact pregnancy and the stillbirth rate.
Read full story
Source: The Telegraph, 8 December 2020
Patient Safety Learning

Covid: NHS staff sickness has 'huge impact' on care

One in 10 staff at some Welsh health boards are off sick or self-isolating, BBC Wales has been told.
The NHS Confederation said staffing problems were having a "huge impact".
It said the overall NHS Wales absence rate was between 8% and 9%, but some services have up to half their staff absent.
Monthly absence rates in December are usually about 5%, but Aneurin Bevan, Cwm Taf Morgannwg and Betsi Cadwaladr health boards have rates of about 10%.
Welsh NHS Confederation director Darren Hughes told Wales Live the NHS was in "the same storm but different parts will definitely be in different boats", with absence rates higher in areas hit hardest by coronavirus.
Read full story
Source: BBC News, 10 December 2020
Sam

Cancer patient gets coronavirus after sharing ward with Covid sufferer

A hospital has apologised after an elderly cancer patient tested positive for coronavirus, having been left in a ward with another patient suffering from COVID-19 for several days.
The Aneurin Bevan University Health Board, which serves the Royal Gwent Hospital in Newport, Wales, has confirmed that it is dealing with an outbreak of the virus at the hospital.
It comes after Lesley Pook accused the hospital of “locking” her father James ‘Jim’ Pook and others in a ward with a coronavirus patient and “waiting for them all to develop symptoms”.
Read full story
Source: The Independent, 9 December 2020
Patient Safety Learning

Number of people on NHS waiting lists hits 12-year high

At least 162,000 patients are waiting more than a year for routine NHS operations, the highest number for more than 12 years.
Latest statistics from NHS England show 162,888 people were waiting over 52 weeks for hospital treatment in October this year.
The total NHS waiting list for routine treatments at the end of October had reached 4.4 million with more than a third of patients waiting over 18 weeks – the NHS target for waiting times from referral to treatment.
Earlier this year health think tanks had predicted the waiting list could hit 10 million, but NHS England said this had not come to pass because of the work of hospitals and NHS staff to keel waiting lists lower than they were last year.
The median waiting time was just over 11 weeks, NHS England said 
Some experts have warned of hidden demand for NHS surgeries with many patients yet to be referred to treatment because of the covid pandemic.
A spokesperson for NHS England, said: “Although Covid hospitalisations almost doubled during November, for every Covid inpatient the NHS treated, hospitals managed to treat five other inpatients for other health conditions. With cancer referrals and treatments now back above usual levels, our message remains that people should continue to come forward for care when they need it."
Read full story
Source: The Independent, 10 December 2020
Patient Safety Learning

Caroline Criado Perez demands end of NHS Covid partner ban after having miscarriage alone

A prominent feminist campaigner and writer has described in devastating detail how she was left feeling “humiliated and alone” as she was forced to deal with a miscarriage without her partner.
Caroline Criado Perez, the author of Invisible Women, called on NHS trusts to allow partners to attend medical appointments, scans and emergencies in maternity services, because the refusal to do so was “traumatising an already traumatised woman”. She added: “It needs to stop, now.”
At the start of the coronavirus crisis, the majority of NHS trusts began preventing partners from accompanying pregnant women to the majority of maternity appointments, and reports suggest this is still the case in many areas.
In September the Guardian revealed that three-quarters of NHS trusts were not allowing birth partners to support women throughout their whole labour, despite being told by the NHS and Boris Johnson to urgently change the rules on visiting.
According to a November survey by the campaign group Pregnant Then Screwed (PTS), 82% of respondents said their local hospital had restrictions in place (for labour or scans), while 90% said that these restrictions were having a negative impact on their mental health.
Read full story
Source: The Guardian, 9 December 2020
Patient Safety Learning

NHS urged to publish delayed report on hospital 'witch-hunt'

The NHS is under pressure to publish a delayed review into a bullying scandal at Matt Hancock’s local hospital that involved senior clinicians being asked to provide fingerprint samples in a “witch-hunt” for a whistleblower.
The “rapid review” into West Suffolk hospital, which Hancock had to recuse himself from because of his friendship with the boss at the trust, was ordered in January and had been due for completion in April. Its publication was put back to this month because of the coronavirus pandemic. But it is now not expected until spring.
The Doctors’ Association UK suspects the conclusions are being sat on because they make embarrassing reading for the trust’s chief executive, Steve Dunn, described by Hanock as a “brilliant leader”.
A consultant who chairs the hospital’s medical staff committee wrote to the NHS’s regional director for the east of England, Ann Radmore, last week warning that senior medics felt the hospital could not move on until the review was published.
The NHS East insists the review will be published as soon as possible, but a source confirmed this is likely to be “spring next year”.
Patient Safety Learning

Rural NHS trusts struggle to reduce waiting lists

NHS patients in rural areas of England face extra long waits for treatment, according to a study.
The Nuffield Trust think-tank says urban areas benefited most from measures put in place to help the NHS cope with the coronavirus pandemic. Researchers found rural hospitals now faced an uphill challenge when it came to restoring services to normal.
NHS England says that funding reflects the higher costs of delivering care in rural communities.
The Nuffield Trust report says while the number of Covid cases in rural areas was lower than in big urban centres, the pandemic's impact on services has been much greater. It says the coronavirus crisis highlighted pre-existing problems facing rural trusts.
For example, it can be hard to recruit and retain doctors and nurses who are willing to work in smaller hospitals, which means trusts rely more heavily on expensive agency staff to fill gaps in rotas. This, in turn, has a detrimental effect on the finances of hospital trusts which struggle to balance the books.
In addition, rural trusts often have only a limited capacity to treat any extra patients as they are often already very busy.
Read full story
Source: BBC News, 11 December 2020
Sam

Shrewsbury maternity scandal: NHS plans ‘early warning’ system to spot future care mistakes

Health chiefs are designing an “early warning” system to detect and prevent future maternity care scandals before they happen, a health minister has said.
Patient safety minister Nadine Dorries said she hoped the system would highlight hospitals and maternity units where mistakes were being made earlier.
The former nurse also revealed the Department of Health and Social Care was drawing up a plan for a joint national curriculum for both midwives and obstetricians to make sure they had the skills to look after women safely.
During a Parliamentary debate following the publication of a report into the Shrewsbury and Telford Hospital care scandal, the minister was challenged by MPs to take action to prevent future scandals.
The former health secretary, Jeremy Hunt, warned the failings at the Shropshire trust, where dozens of babies died or were left with permanent brain damage, could be repeated elsewhere.
He said: “The biggest mistake in interpreting this report would be to think that what happened at Shrewsbury and Telford is a one-off — it may well not be, and we mustn't assume that it is.”
Ms Dorries said: “Every woman should own her birth plan, be in control of what is happening to her during her delivery and I really hope ... this report is fundamental in how it's going to reform the maternity services across the UK going forward.
Read full story
Source: The Independent, 11 December 2020
Sam

Actions in Donna Ockenden Review must be acted upon immediately by all maternity services say RCOG and RCM

Strong leadership, challenging poor workplace culture, and ringfencing maternity funding are key to improving safety. That’s the message from two leading Royal Colleges as they respond to the independent review of maternity services at Shrewsbury and Telford NHS Trust led by Donna Ockenden.
The RCOG and the Royal College of Midwives (RCM) have today welcomed the Ockenden Review and its recognition of the need to challenge poor working relationships, improve funding and access to multidisciplinary training and crucially to listen to women and their families to improve learning and to ensure tragedies such as those that have happened at Shrewsbury and Telford NHS Trust never occur again. 
The Colleges have said that the local actions for learning and the immediate and essential actions laid out in this report must be read and acted upon immediately in all Trusts and Health Boards delivering maternity services across the UK.
Commenting, Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, said: 
“This report makes difficult reading for all of us working in maternity services and should be a watershed moment for the system. Reducing risk needs a holistic approach that targets the specific challenges of fetal monitoring interpretation and strengthens organisational functioning, culture and behaviour."
Read press release
Source: RCOG, 10 December 2020
Sam

Reflections on the initial findings of the Ockenden Review

Patient Safety Learning Press Release
10th December 2020
Today the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust published its first report on its findings.[1] The report made recommendations for actions to be implemented by the Trust and “immediate and essential actions” for both the Trust and the wider NHS.
The Review was formally commissioned in 2017 to assess “the quality of investigations relating to new-born, infant and maternal harm at The Shrewsbury and Telford Hospital NHS Trust”.[2] Initially it was focused on 23 cases but has been significantly expanded as families have subsequently contacted the review team with their concerns about maternity care and treatment at the Trust. The total number of families to be included in the final report is 1,862. These initial findings are drawn from 250 cases reviewed to date.
This is another shocking report into avoidable harm.
We welcome the publication of these interim findings and the sharing of early actions that have been identified to make improvements to patient safety in NHS maternity services. We commend the ambition for immediate responses and action.
Reflecting on the report, there are a number of broad patient safety themes, many of which have been made time and time again in other reports and inquiries.
A failure to listen to patients
The report outlines serious concerns about how the Trust engaged and involved women both in their care and after harm had occurred. This was particularly notable in the example of the option of having a caesarean section, where there was an impression that the Trust had a culture of wanting to keep the numbers of these low, regardless of patients’ wishes. They commented:
“The Review Team observed that women who accessed the Trust’s maternity service appeared to have little or no freedom to express a preference for caesarean section or exercise any choice on their mode of deliver.”
It also noted a theme in common with both Paterson Inquiry and Cumberlege Review relating to the Trusts’ poor response to patients raising concerns.[3] The report noted that “there have also been cases where women and their families raised concerns about their care and were dismissed or not listened to at all”.
The need for better investigations
Concerns about the quality of investigations into patient safety incidents at the Trust is another theme that emerges. The review reflected that in some cases no investigation happened at all, while in others these did take place but “no learning appears to have been identified and the cases were subsequently closed with it deemed that no further action was required”.
One of the most valuable sources for learning is the investigation of serious incidents and near misses. If these processes are absent or inadequate, then organisations will be unable to learn lessons and prevent future harm reoccurring. Patient Safety Learning believes it is vital that Trusts have the commitment, resources, and frameworks in place to support investigations and that the investigators themselves have the right skills and training so that these are done well and to a consistently high standard. This has not formed part of the Report’s recommendations and we hope that this is included in their final report.
Lack of leadership for patient safety
Another key issue highlighted by the report is the failure at a leadership level to identify and tackle the patient safety issues. Related to this one issue it notes is high levels of turnover in the roles of Chief Executive, executive directors and non-executive directors. As part of its wider recommendations, the Report suggests trust boards should identify a non-executive director who has oversight of maternity services.
Good leadership plays a key role in shaping an organisations culture. Patient Safety Leadership believes that leaders need to drive patient safety performance, support learning from unsafe care and put in place clear governance processes to enable this. Leaders need to be accountable for patient safety.
There are questions we hope will be answered in the final report that relate to whether leaders knew about patients’ safety concerns and the avoidable harm to women and their babies. If they did not know, why not? If they did know but did not act, why not?
Informed Consent and shared decision-making
The NHS defines informed consent as “the person must be given all of the information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead”.[4] The report highlights concerns around the absence of this, particularly on the issue of where women choose as a place of birth, noting:
“In many cases reviewed there appears to have been little or no discussion and limited evidence of joint decision making and informed consent concerning place of birth. There is evidence from interviews with women and their families, that it was not explained to them in case of a complication during childbirth, what the anticipated transfer time to the obstetric-led unit might be.”
Again this is another area of common ground with other recent patient safety reports such as the Cumberlege Review.[5] Patient Safety Learning believes it is important that patients are not simply treated as passive participants in the process of their care. Informed consent and shared decision making are vital to respecting the rights of patients, maintaining trust in the patient-clinician relationship, and ensuring safe care.
Implementation for action and improved patient safety
In its introduction, the report states:
“Having listened to families we state that there must be an end to investigations, reviews and reports that do not lead to lasting meaningful change. This is our call to action.”
Responding with an official statement in the House of Commons today, Nadine Dorries MP, Minister for Mental Health, Suicide Prevention and Patient Safety, did not outline a timetable for the implementation of this report’s recommendations.
In 2020 we have seen significant patient safety reports whose findings have been welcomed by the Department of Health and Social Care but where there has subsequently been no formal response nor clear timetable for the implementation of recommendations, most notably the Paterson Inquiry and Cumberlege Review.
Patient Safety Learning believes there is an urgent need to set out a plan for implementing the recommendations of the Ockenden Report and these other patient safety reports. Patients must be listened to and action taken to ensure patient safety.
[1] Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Emerging findings and recommendations form the independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, 10 December 2020. https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2020/12/ockenden-report.pdf
[2] Ibid.
[3] The Right Reverend Graham Jones, Report of the Independent Inquiry into the Issues raised by Paterson, 2020. https://assets.publishing.serv...; The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020. https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf
[4] NHS England, Consent to treatment, Last Accessed 16 July 2020. https://www.nhs.uk/conditions/consent-to-treatment/
[5] Patient Safety Learning, Findings of the Cumberlege Review: informed consent, Patient Safety Learning’s the hub, 24 July 2020. https://www.pslhub.org/learn/patient-engagement/consent-and-privacy/consent-issues/findings-of-the-cumberlege-review-informed-consent-july-2020-r2683/
Sam

Hospital acquired covid infections hit record high

The number of COVID-19 infections likely to have been acquired in hospital are rising again for the first time in three weeks and their proportion of all cases has reached record levels for the second wave, HSJ can reveal.
NHS England data covering the week to 6 December (the latest available) shows 1,787 COVID-19 cases were acquired in-hospital – a rise of almost 14% on the week before. The number of hospital-acquired, or “nosocomial”, infections had been falling since the week to 15 November, when 1,794 were recorded.
This week, hospital acquired covid infections amounted to 21% of the 8,337 new cases which were recorded in hospitals – the highest proportion in the second wave. On 6 December alone, 24% of infections had probably been acquired in hospital rather than the community.
Read full story (paywalled)
Source: HSJ, 11 December 2020
Patient Safety Learning

GPs say rule change makes covid vaccine programme ‘unfeasibly challenging’

Coronavirus vaccinations at GP practices will now take ‘twice as long’ after regulators announced new rules just days before the jabs are rolled out across primary care.
The Medicines and Healthcare products Regulatory Agency announced patients would have to be observed for 15 minutes after they received the vaccine. This came after two people had severe allergic reactions to the Pfizer/BioNTech vaccine.
Primary care directors told HSJ the change means they have had to overhaul plans in their primary care networks and, in some areas, the vaccine programme will be “unfeasibly challenging” to deliver.
Sources told HSJ workforce plans are being overhauled, while vaccines risk being wasted because of the additional time constraints. There have been claims some practices may drop the vaccination programme altogether, as they lack capacity to carry out 15-minute observations for each patient.
One primary care director, who spoke to HSJ anonymously, said: “For us, we now need additional space for an observation area. It also makes it more difficult to efficiently flow through the vaccines as the actual vaccination process might take a few minutes, but the through flow of patients will be limited by the 15-minute wait.”
They added: “The vaccine now taking at least twice as long to do creates logistical problems. Not insurmountable but there nonetheless."
Read full story (paywalled)
Source: HSJ, 11 December 2020
Patient Safety Learning

Royal Derby Hospital: Gynaecologist investigation affects 382 women

The number of women involved in an investigation into a consultant gynaecologist who "unnecessarily harmed" patients has risen to 382.
University Hospitals of Derby and Burton NHS Foundation Trust has written to another 110 women who were treated by Daniel Hay.
Mr Hay is under investigation after eight women treated by him were found to have been "unnecessarily harmed". The latest women have been told there are "no concerns" for their health.
Staff at the Royal Derby Hospital raised concerns about the consultant's care in late 2018. An initial review of 58 cases involving Mr Hay identified the eight lapses of care for which he and the trust have apologised.
A broader investigation was launched and another 135 women, who had undergone surgery, were contacted to say their care was being reviewed.
In September the trust wrote to a further 79 women who had received intermediate care.
It has now said 110 more women, all outpatients at Ripley Hospital between April 2017 and July 2018, have now been contacted.
Dr Magnus Harrison, executive medical director, said: "We have widened the review to a specific outpatient clinic... to understand the care being provided there. We are doing this proactively, rather than in response to any specific concerns, so that the review is as thorough as possible."
"Each of the women have been informed that there are no concerns regarding their current health."
Read full story
Source: BBC News, 11 December 2020
Patient Safety Learning

England’s Covid test and trace relying on inexperienced and poorly trained staff

England’s test and trace service is being sub-contracted to a myriad of private companies employing inexperienced contact tracers under pressure to meet targets, a Guardian investigation has found.
Under a complex system, firms are being paid to carry out work under the government’s £22bn test and trace programme. Serco, the outsourcing firm, is being paid up to £400m for its work on test and trace, but it has subcontracted a bulk of contact tracing to 21 other companies.
Contact tracers working for these companies told the Guardian they had received little training, with one saying they were doing sensitive work while sitting beside colleagues making sales calls for gambling websites.
One contact-tracer, earning £8.72 an hour, said he was having to interview extremely vulnerable people in a “target driven” office that encouraged staff to make 20 calls a day, despite NHS guidance saying each call should take 45 to 60 minutes.
Another call centre worker, who had no experience in healthcare or emotional support, said she suffered a nervous breakdown during an online tutorial about phoning the loved ones of coronavirus victims in order to trace their final movements.
Read full story
Source: The Guardian, 14 December 2020
Patient Safety Learning
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