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

‘Catastrophic’ threat to cancer ops at England’s third largest hospital trust

Cancer services at large hospital trust have been at ‘catastrophic’ risk of being overwhelmed, after two of its hospital sites had to suspend life-saving cancer surgeries in the last month due to COVID-19.
In its latest board papers Mid and South Essex Foundation Trust rated the “cancellation of cancer elective activity” at its highest risk level of 25 – which based on their own risk-scoring key is “catastrophic”. It said the expected consequences at this risk level include “permanent disability or death, serious irreversible health effects” and an “unacceptable… quality of service”.
The trust runs three general acute hospitals in the county. Its 2,000 plus beds make it the third largest trust in England after University Hospitals Birmingham FT and Leeds Teaching Hospitals.
The same board papers, dated 28 January, said cancer surgery at Southend University Hospital, one of three hospital sites run by the trust, “ceased on 24 December”. At a second hospital site, Mid Essex Hospital covid “hit hard just before Christmas” and elective work was “dramatically impacted with short period of life and limb only carried out on site”. This meant all P2 cancer surgery — which requires treatment in less than four weeks — did not take place. 
Both hospital sites said they hoped the independent sector could help them restart cancer surgeries this month with a focus on “long waiting and clinical urgent patients”. It is not clear how much capacity the sector has to work through waiting lists and the board papers said “some of this capacity may be reduced” because of recent changes to a new national contract for the independent sector.
Read full story (paywalled)
Source: HSJ, 29 January 2021
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New COVID-19 saliva test effective at finding symptomless cases

A new COVID-19 test that is able to detect even asymptomatic cases of the virus through saliva is being piloted  in the UK.
The new LamPORE test, developed by UK-based company Oxford Nanopore, will be tested in mobile laboratories in four areas across the country. 
It is already being used in Aberdeen, with plans to roll it out in Telford, Brent and Newbury, and results so far have shown it is even effective at detecting the virus in people who are not showing symptoms.
LamPORE will allow for additional testing capacity where it is needed for large numbers of people and be used alongside existing PCR and lateral flow test, the Department of Health and Social Care (DHSC) said.
Read full story
Source: The Independent, 28 January 2021
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Hundreds of unused vaccines

Surplus COVID-19 vaccines have been given to healthy young people in parts of England and some GPs have “run out” of eligible patients to vaccinate in the scramble to inoculate the country.
While supplies have been cut in some areas, one GP in the Midlands told the Guardian he had “hundreds of unused vaccines” which he is not allowed to use, having already inoculated all priority patients.
Other vaccination centres have taken a more liberal approach, inviting younger patients for jabs at the end of the day if they find themselves with surplus doses of the Pfizer vaccine, which has a shelf life of three days.
Currently, only four groups are eligible for vaccines in England: the over-70s, the clinically extremely vulnerable, care home residents and frontline health and social care workers.
But one 38-year-old in Sheffield in none of those groups said she was offered the jab on “the iciest day of the year” if she could get to the clinic within half an hour because of weather-related cancellations. A 24-year-old in Manchester said she’d had a spare after volunteering at a vaccination centre.
In Reading, one clinic is calling local police stations and offering surplus jabs to officers at the end of the day. Others are offering spares to frontline charity workers.
One medic in Greater Manchester told the Guardian they managed to receive their second dose of the vaccine by repeatedly turning up at their local vaccine site at the end of each day, receiving it on day three.
Read full story
Source: The Guardian, 29 January 2021
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CQC issues warning about care home staff working with Covid

Care watchdogs are investigating concerns that staff with Covid-19 have been working with care home residents as operators said absence levels are as high as 70% owing to sickness and self-isolation, increasing pressure to get staff back to work.
The Care Quality Commission has ordered several councils to investigate allegations about the practice, which puts lives at risk, and possible breaches of the Care Act relating to abuse or neglect of residents. It is understood to be dealing with fewer than 10 cases.
But the regulator has issued a warning to all care homes in England with the Department of Health and Social Care and council social services chiefs that “under no circumstances should staff who have tested positive for COVID-19, regardless of whether they are displaying symptoms or not, work in a care setting” until their self-isolation has ended.
The Rights for Residents group said on Thursday it had been contacted by a carer whose boss had asked her to return to work only a few days after a positive test because of staff shortages. She refused and no longer works for the care home.
In many homes, a quarter of staff are sick or self-isolating, with the ratio as high as 70% in some cases and operators are bringing in friends and family to try to cover shifts, said Nadra Ahmed, executive chairman of the National Care Association.
Read full story
Source: The Guardian, 28 January 2021
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NHS drops virtual assessments used to section patients

Hospital trusts in England have been told to stop using virtual assessments to section people under the Mental Health Act after a judge ruled them unlawful.
An NHS trust sought a court judgment on remote assessments after the Department of Health and Social Care issued guidance in November indicating that this method could be used as part of an evaluation during the pandemic.
Experts said that a “small but significant” number of people may have been sectioned this way.
Following the judgment, an email was sent to mental health professionals from NHS England saying “immediate action required”. It added that anyone detained via remote assessment would need to be notified.
The message read: “Stop using remote methods for any new or ongoing assessments for detention or section renewals under Part II of the Act.”
“All mental health providers should identify and reassess individuals who are currently detained under Part II of the MHA following a remote assessment as soon as possible if ongoing detention is deemed necessary.”
The government had originally advised that it believed remote assessment could be used but said only the courts could provide a definitive interpretation of the law, setting out the circumstances under which such assessments could take place.
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Source: The Guardian, 30 January 2021
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Pregnant women going for scans alone told they cannot film baby

Pregnant women attending scans and appointments alone are repeatedly being told they cannot record or take photographs of their unborn child to show their partner, according to a survey.
The poll of more than 3,450 pregnant women by the campaign group Pregnant Then Screwed found that more than half of respondents (52%) attended scans alone and were also told that they could not record or take photographs during the appointment.
NHS trusts have been warned that they could be acting unlawfully if they continue to ban partners of pregnant women accessing hospital appointments remotely. Women are repeatedly being told it is “illegal” to photograph or film their scan, despite this not being the case, said the charity Birthrights, which sought the legal advice.
“We are keen to see maternity services accommodate partners in person, in line with national guidance,” said Birthrights’ programmes director, Maria Booker. “However if this is really not possible at some hospitals during the current peak, maternity services must find other ways to ensure women feel supported and partners remain involved.”
Read full story
Source: The Guardian, 31 January 2021
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COVID-19: 'Traumatised' hospital staff need time to recover

"Traumatised" and "exhausted" medical staff need time to recover before tackling an NHS backlog, says the group representing hospitals in England.
Many staff could resign if their wellbeing is not factored into plans to cut waiting lists, NHS Providers said.
The number of people waiting more than a year for surgery rose 1,613 to 192,000 during the Covid pandemic. NHS Providers said demand for hospital beds is easing, but the pressure on intensive care units is still intense.
NHS Providers estimates that it is going to be at least a month before the NHS gets back to normal winter pressures, and trusts are concerned about the transition into the next phase of the pandemic.
Critical work that has been postponed, including a small number of urgent cancer cases, will be a priority, but there remains a need to tackle a wider backlog of routine operations alongside the vaccination programme.
NHS Providers said trusts will work as fast as possible to tackle the backlog, but leaders cannot do so at the expense of staff burnout.
Last month, a study suggested that many hospital staff treating the sickest patients during the first wave of the pandemic were left traumatised by the experience. Nearly half reported symptoms of severe anxiety, depression, post-traumatic stress disorder or problem drinking. One in seven had thoughts of self-harming or being "better off dead".
Read full story
Source: BBC News, 1 February 2021
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Urgent children’s ops routinely cancelled due to covid pressure

Dozens and potentially hundreds of urgent operations for children have been cancelled during the third wave of the covid pandemic, HSJ can reveal.
There are also concerns that national guidance for prioritising surgery “disadvantages” young people.
Several well placed sources told HSJ that urgent operations for children have been delayed in recent weeks because of covid pressures. This is because of a combination of staff being diverted to help with adults sick with covid, and space in children’s facilities — including intensive care — being taken over for adult covid care, as well as other staff being absent due to covid.
The royal college of surgeons has told HSJ that urgent children’s operations “are increasingly being cancelled around the country”.
Dozens and potentially hundreds of children’s operations rated as priority two — those which are urgent and should be carried out within a month — have been cancelled and delayed in recent weeks in the capital, according to several well placed sources. This is alongside potentially thousands of priority three operations being cancelled, which are those needing to be carried out within three months.
Read full story
Source: HSJ, 31 January 2021
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Covid: Vaccine offered to all care home residents in England, says NHS

Coronavirus vaccines have been offered to residents at every eligible care home for the elderly in England, according to health officials.
NHS England said that more than 10,000 homes had been visited by staff delivering the jab in a bid to prioritise those most vulnerable to COVID-19.
Vaccinations were postponed at a small number of homes for safety reasons during a local outbreak and some residents have not received a jab for clinical reasons.
However, staff will return to those homes as soon as possible, a spokesperson for NHS England said.
Read full story
Source: The Independent, 1 February 2021
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Maternity staff facing extreme burnout over staff shortages and longer busier shifts, warn healthcare leaders

Maternity staff are facing extreme burnout during the pandemic as staff shortages and longer, busier shift patterns lead to the workforce becoming increasingly overwhelmed, healthcare leaders warned.
Senior figures working in pregnancy services told The Independent healthcare professionals are working longer hours, covering extra shifts around the clock, and spending more time on call to compensate for increasing numbers of employees taking time off work after getting coronavirus.
Staff say stress-related absences have reached “worryingly” high levels, with junior doctors and midwives “thrown into the deep end” due to having to fill in for colleagues.
Professionals argued the coronavirus crisis will lead to a rise in doctors, nurses and midwives suffering post-traumatic stress disorder (PTSD) and other mental health issues – raising concerns staff exhaustion could curb patient safety and standards of care.
Read full story
Source: The Independent, 31 January 2021
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Gender clinic bosses at controversial NHS facility are removed after regulators highlighted a string of failures including managing patient safety risk

Bosses at the controversial NHS gender-change clinic for children have been removed after regulators highlighted a string of failures.
The management team of the Gender Identity Development Service (GIDS) in London has been 'disbanded', documents reveal. It comes weeks after the clinic, run by the Tavistock and Portman NHS Trust, was judged 'inadequate' by the Care Quality Commission.

Watchdogs said staff were afraid to raise concerns about patient safety for fear of 'retribution' from bosses. 
A report said: 'Staff did not always manage risk well. Many of the young [patients] were vulnerable and at risk of self-harm."
The management team of the Gender Identity Development Service (GIDS) in London has been 'disbanded', documents reveal. It comes weeks after the clinic, run by the Tavistock and Portman NHS Trust, was judged 'inadequate' by the Care Quality Commission.
"The size of the waiting list meant staff were unable to proactively manage the risks to patients waiting for a first appointment."
Read full story
Source: MailOnline, 31 January 2021
 
Patient Safety Learning

Patient and People Network to highlight individual needs first

Self-care, self-management, illness prevention and personal goals are a vital part of wellbeing for many patients and carers. That’s why the Professional Records Standard Body (PRSB) is building a Patient and People Network, in order to support them in influencing the information that is prioritised for care and decide how it’s shared. 
Covid has changed health and care priorities permanently and we know that digital is here to stay. Our goal is to ensure this can be done in the best way possible to maximise patient benefits and minimise any risks. To do this we have established a people priorities team, made up of patients and engagement specialists, and developed a strategy to help us deliver a programme of work that puts patient needs and priorities at its heart. We will be aiming to expand the team of patients and carers we currently work with, to address the issues that they feel are most pressing as well as work closely with our members’ and partners’ user networks. This will include challenges such as health inequalities, lack of access to information and sharing in decision-making. We appreciate that people’s information needs may be different to the professionals who treat them, but are equally important.  
Our goals will be to work with a more diverse network of people on projects and better support people in sharing their views and concerns. We will be re-evaluating current processes to ensure that topics are accessible and that people feel they can get involved and share their views in a meaningful way to support change within the system.  The new network will also offer support and training where needed. If you’re a carer or someone who has used services in the past and would like to get involved, please contact us on [email protected].  
Patient Safety Learning

Trusts could get new CQC ratings without inspection

The Care Quality Commission (CQC) could regularly change its ratings of health and care providers without inspectors visiting them, under new plans from the watchdog.
The CQC has said it wants to “move away from using comprehensive, on-site inspection as the main way of updating ratings” and instead use other sources like data and feedback from the public, to update ratings more regularly.
At present — under the tough ratings regime introduced in 2014 in the wake of the Mid Staffs inquiry findings — it cannot change a provider’s score without carrying out a full inspection.
It said in a recently published consultation that inspections “will remain an important part of how we assess quality,” but this will mostly be through more “targeted” inspections linked to significant risks to people’s safety, and the rights of vulnerable people.
During the covid pandemic, CQC has targeted its on-site inspections at services where potential risks are identified, or where improvements are needed.
Professor Ted Baker, the CQC’s chief inspector of hospitals, told HSJ the regulator wanted to move away from its current “fairly rigid” timetable of inspections in favour of a more “flexible” approach.
Read full story (paywalled)
Source: HSJ, 2 February 2021
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'They've been ignored': older people cared for at home face vaccine delays

More than 2.5 million people over the age of 80 have received their first dose of the COVID-19 vaccine, NHS England has said. But the vaccine is failing to reach thousands of elderly people who receive care in their own homes, according to a provider, because they are too frail to travel to vaccination centres or fear catching the virus if they do.
The Guardian spoke to three people who have family members over 80 still waiting to be vaccinated.
“How on earth are elderly people expected to negotiate the system if they don’t have any help?” says Amanda Elliott, 59. Her father-in-law, George Elliott, 98, of Polegate, East Sussex, is still waiting to be vaccinated. “It seems very unfair,” she says.
George, who was a glider pilot in the second world war, doesn’t feel entitled to a jab but finds the situation “puzzling”, Amanda says. He has chronic obstructive pulmonary disease (COPD), finds it very difficult to move and has a carer going into his home twice a day.
Amanda, a support worker at a school in Sutton, says George received a letter inviting him to book his vaccination online and “tried without success”. He then called to book over the phone and was offered an appointment in Brighton, Hastings or Petersfield, to which he would have difficulty travelling.
“I called the booking line on his behalf last week to find out what he should do as he is housebound. I was directed to his GP and his surgery told me they are not carrying out vaccinations and that I shouldn’t have contacted them about this. They were very unhelpful,” Amanda says.
In Kirkcaldy, Fife, 88-year-old Christina McPhee, who is housebound, is still waiting to be vaccinated. “The district nurse has to administer the vaccine to those who can’t leave their homes, but the local GP practice told me last Friday they have none allocated for those in the area,” says her niece Mary.
AdMcPhee has a tracheostomy and has carers and nurses visiting her several times a day, making her “very vulnerable” because she is high risk. Her sister, Mary’s mother, who is 82 and lives with McPhee, was able to get the vaccine because she could travel to the surgery, but there is no news about when McPhee is likely to receive hers.
Read full story
Source: The Guardian, 1 February 2021
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Hospital reports rise in pregnant Covid patients

A hospital has reported a "significant" increase in the number of pregnant women being treated for coronavirus.
New Cross Hospital, in Wolverhampton, said part of its maternity ward had been sectioned off for Covid patients. 
Nationally, the proportion of pregnant women in intensive care has almost doubled since the first wave.
The Royal College of Obstetricians and Gynaecologists said pregnant women were at no greater risk of being infected with Covid than the general public.
The Royal Wolverhampton NHS Trust's chief executive said the cause of the increase in the city was unclear.
"We're seeing a lot more pregnant women now suffering with Covid and some of them have been very, very ill," Prof David Loughton said at a regional coronavirus briefing on Friday."We have had some deaths," he continued, "so that is really sad".
An intensive care audit has shown the percentage of pregnant women aged 16-49 has almost doubled in the second wave compared to the first wave of the pandemic. Up until the end of August, 29 women in that age bracket who had been admitted with coronavirus were pregnant, compared to 103 from September to the end of January.
Recently, the intensive care unit treated two Covid-positive pregnant patients and almost 200 expectant mothers tested positive in the city during the past quarter.
Read full story
Source: BBC News, 2 February 2021
 
 
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Coroner calls for new guidance on umbilical venous catheters after baby’s death

A newborn baby died after doctors caring for him failed to realise that the umbilical venous catheter (UVC) through which he was being fed and medicated was wrongly positioned, a coroner has found.
Anna Crawford, assistant coroner for Surrey, called for guidelines from the National Institute for Health and Care Excellence (NICE) on the use of the catheters after hearing that none currently exist.
Yo Li was born extremely prematurely at St Peter’s Hospital in Chertsey on 11 January 2019 and transferred to the neonatal intensive care unit, where he was put on mechanical ventilation. A UVC was inserted but it was wrongly positioned within his liver tissue and he died four days later.
Read full story (paywalled)
Source: BMJ, 29 January 2021
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