Skip to content

News

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

Doctor: We're getting self-harming 10-year-olds in A&E

The pandemic has had a deep impact on children, who are arriving in A&E in greater numbers and at younger ages after self-harming or taking overdoses, writes Dr John Wright of Bradford Royal Infirmary.
Children are a lost tribe in the pandemic. While they remain (for the most part) perplexingly immune to the health consequences of COVID-19, their lives and daily routines have been turned upside down.
From surveys and interviews carried out for the Born in Bradford study, we know that they are anxious, isolated and bored, and we see the tip of this iceberg of mental ill health in the hospital.
Children in mental health crisis used to be brought to A&E about twice a week. Since the summer it's been more like once or twice a day. Some as young as 10 have cut themselves, taken overdoses, or tried to asphyxiate themselves.
There was even one child aged eight.
Lockdown "massively exacerbates any pre-existing mental health issues - fears, anxieties, feelings of disconnection and isolation," says A&E consultant Dave Greenhorn.
Read full story
Source: BBC News, 2 February 2021
Patient Safety Learning

UK hospitals failing to follow guidelines on group B Strep

Failures to follow national guidelines to prevent group B Strep infections in newborn babies is leading to a postcode lottery of care and opportunities to stop deadly infections being missed, a new report has found. Nearly 90% of hospitals in the UK are not using the recommended test for GBS carriage – which costs around £11- despite clear guidance issued by the Royal College of Obstetricians and Gynaecologists (RCOG) and Public Health England (PHE) that the test can significantly decrease false-negative results.
Group B Strep is the UK’s most common cause of severe infection in newborn babies, causing sepsis, pneumonia, and meningitis. Approximately 800 babies a year in the UK develop group B Strep infection in their first 3 months of life, 50 babies will die, with another 70 survivors left with life-changing disabilities. Most of these infections could be prevented.
Only a tiny number of NHS Trusts are following the key new recommendations around giving pregnant women information on group B Strep, offering testing to some pregnant women, and following Public Health England guidelines on testing for group B Strep. As a result, pregnant women face a postcode lottery, potentially receiving significantly different care from recommended practice.
Read full story
Source: Group B Strep Support, 1 February 2021
Patient Safety Learning

NHS in London asked to plan for ‘possible covid surge later in 2021’

The NHS’s London regional team has told its integrated care systems (ICS) to draw up plans for ‘another possible [covid-19] surge later in 2021’, HSJ has learned.
The guidance, dated February 2021 says: “Later in March/early April we will ask for systems to begin to plan for a possible wave 3 covid surge.”
The NHS England and Improvement London presentation adds: “[The] purpose of the critical care de-surge plan [is to] ensure that the… bed base can expand safely in the event of a 3rd covid surge and/or other major incident/event.”
Any surge in covid cases is likely to be caused by new variants of the virus, such as those originating in Brazil and South Africa, which are more resistant to vaccines, becoming dominant in the UK. At present government advisers think this is unlikely and that even if this scenario did arise, it will be possible to modify vaccines to combat the new strain.
The guidance sets out three other “strategic goals” the ICSs should address. But it has “surprised” senior figures from outside London who were waiting for the national framework for tackling the NHS’ growing elective waiting list expected later this month.
The presentation said the other key goals were to: ensure “staff get… immediate rest and respite”; set out plans to “desurge critical care”; and plan for elective recovery.
Read full story (paywalled)
Source: HSJ, 3 March 2021
Patient Safety Learning

Oxford vaccine could substantially cut spread

The Oxford-AstraZeneca vaccine could lead to a "substantial" fall in the spread of the virus, say scientists.
The impact of Covid vaccines on transmission has been a crucial unknown that will dramatically shape the future of the pandemic.
The study, which has not been formally published, also showed the vaccine remained effective while people waited for a second dose. It was 76% effective during the three months after the first shot. 
The UK, amid global debate and in sharp contrast to other countries, is prioritising giving the first dose to as many people as possible. The idea is to save more lives by giving more people some protection, but it means people will have to wait around three months for the booster instead of three weeks.
This study - on 17,000 people in the UK, South Africa and Brazil - showed protection remained at 76% during the three months after the first dose. This rose to 82% after people were given the second dose.
Prof Andrew Pollard, from the Oxford Vaccine Trial, said: "These new data provide an important verification of the interim data that was used by more than 25 regulators including the MHRA and EMA to grant the vaccine emergency use authorisation."
"It also supports the policy recommendation made by the Joint Committee on Vaccination and Immunisation for a 12-week prime-boost interval, as they look for the optimal approach to rollout."
The report does not tackle the impact of the new variants on how well the vaccines work.
Read full story
Source: BBC News, 2 February 2021
 
 
Patient Safety Learning

Covid patients given early warning home oxygen monitors by paramedics

Coronavirus patients who call an ambulance but are not yet sick enough to go to hospital are being given new home oxygen monitoring kits to help spot those who may deteriorate earlier.
Across the Thames Valley region, thousands of patients will be given the kits which include a pulse oximeter device to monitor blood oxygen levels, a diary to track their symptoms and advice on what to do if they become sicker.
South Central Ambulance Service Trust (SCAS) has become the first ambulance service in the country to launch the scheme after research showed a small drop in oxygen levels among some patients could be an early warning sign of serious complications.
Patients with pneumonia and non-Covid lung conditions often experience shortness of breath before a drop in oxygen levels. But with coronavirus, patients can suffer what has been called ‘silent hypoxia’ where their oxygen levels can fall before the patient becomes breathless and calls for help.
Read full story
Source: The Independent, 2 February 2021
Patient Safety Learning

Some of those most at risk are still not on the Covid vaccine priority list

With the first phase of the UK’s vaccination programme now fully under way, the government’s self-congratulatory tone suggests all clinically vulnerable groups are soon in line for protection. There’s certainly reason to be positive: millions of people are on their way to safety. But look a little closer and many high-risk people are struggling to access the vaccine.
When the vaccine was first introduced last year, the Joint Committee on Vaccination and Immunisation (JCVI) put shielders – or the “clinically extremely vulnerable” (CEV) – as low as sixth on the priority list, behind older people with no underlying health conditions. It resulted in the baffling situation where a marathon-running 65-year-old was given priority for the vaccine over a 20-year-old with lung disease who needs oxygen support. The government U-turned after pressure, moving CEV people up to fourth spot behind healthy over-75s.
These are complex calculations, but there are still fears some will miss out. Some young disabled people who don’t meet the government’s narrow criteria of CEV and are worried they won’t be prioritised at all.
Shielders – many of whom are of working age and live with children – also have extra risk factors compared with older people. As the British Medical Association said this month, we need a more sophisticated vaccine delivery that takes into account circumstantial factors such as race, health inequality and employment. I’ve received many messages from shielders who are terrified of being forced out to work, or of schools reopening before they get their vaccine.
There are also those with learning disabilities to consider. Currently, only older people with a learning disability, those who have Down’s syndrome or people who are judged as having a severe learning disability are on the priority list. This means that people with a mild or moderate learning disability aren’t prioritised at all. This is despite the fact all people with learning disabilities have a death rate six times higher than the general population. Young adults with a learning disability are 30 times more likely to die of Covid than young adults in the general population.
Read full story
Source: The Guardian, 3 February 2021
Patient Safety Learning

Multiple whistleblowers flag ‘heartbreaking’ incidents at major trust

Clinicians within a major teaching hospital’s cancer services have raised multiple concerns over patient safety, which they believe have resulted from badly planned service changes in response to the covid crisis.
HSJ has spoken to several staff members who have worked in the haematology speciality at University Hospitals Birmingham Foundation Trust since last June, when the services underwent significant changes to free up capacity for coronavirus patients.
This involved most haematology services at Heartlands Hospital in east Birmingham moving to the trust’s main Queen Elizabeth Hospital site in Edgbaston.
The staff, who all wished to remain anonymous, told HSJ the transfer happened at just one week’s notice and was poorly planned. Once implemented, they said QEH’s newly enlarged service suffered from extreme staffing shortages, leading to several “never events”, such as patients being given the wrong blood type.
In one resignation letter, a nurse who had transferred to QEH told managers patients’ “basic care needs are not being met”.
The nurse said most shifts were understaffed, with examples of three nurses looking after 30 patients and added in the resignation letter: “I am witnessing strong and knowledgeable colleagues breaking down on each shift.
“Furthermore, never events are happening at an alarming rate, necessary resources are commonly unavailable and communication between all levels of seniority is poor…"
Read full story (paywalled)
Source: HSJ, 2 February 2021
Patient Safety Learning

People with learning disabilities dying at a greater rate from coronavirus

People with a learning disability must be urgently prioritised for the coronavirus vaccine, charities have warned as new data shows they are almost twice as likely to die from the virus than the general population.
The latest data for learning disability deaths shows 80% of deaths in the week to 22 January were linked to COVID-19. This compares to just 45% in the general population.
The charity Mencap said everyone with a learning disability should be prioritised for the vaccine.
According to its analysis of deaths reported to the Office for National Statistics and the national Learning Disabilities Mortality Review programme, the proportion of deaths among the learning disabled has been increasing every week since November when it was just above 35%.
Harry Roche, an ambassador at Mencap who has a learning disability, said: “The death rate for 18- to 34-year-olds with a learning disability is 30 times higher than the rest of the population. I’m 32 years old and have a learning disability – this statistic scares me. I’m calling on Boris Johnson and Matt Hancock to rethink and prioritise everyone with a learning disability. We are too often forgotten, don’t ignore us now.”
Read full story
Source: The Independent, 3 February 2021
Patient Safety Learning

Long Covid Minister needed to respond to growing crisis

Press release 3 February 2021
The charity Patient Safety Learning and patient group Long Covid Support are calling for the creation of a dedicated Minister for Long Covid to take a coordinated, multi-stakeholder approach to this issue.[1]
Long Covid patients are people with confirmed or suspected Covid-19 who continue to struggle with prolonged, debilitating and sometimes severe symptoms months later.[2] Statistics indicate that there are currently hundreds of thousands of people living with Long Covid in the UK, with at least one in 10 people still experiencing symptoms 12 weeks after initial infection.[3]
While there has been some progress to put in place support for people with Long Covid, there remains a complex spectrum of issues that need to be addressed. These are summarised in a blog, published by Patient Safety Learning and Long Covid Support today, calling for the UK Government to make urgent and significant improvements in their response to Long Covid.[4]
Claire Hastie of the Long Covid Support, said:
“Almost one year on from when many first fell ill, people with Long Covid are simply not getting the help they need. There is an urgent need to increase the pace and scale of the response to help the hundreds of thousands of people affected (including children). This needs to be driven by a dedicated minister with the power to affect change.”
Helen Hughes, Chief Executive of Patient Safety Learning, said:
“People living with Long Covid have too often been left ‘joining the dots’ trying to understand how they can access safe, quality treatment and support and what they can do to improve their health. Clinical advice and access to further investigations has been inconsistent, leaving many feeling abandoned, confused and understandably concerned for their future health outcomes.
Long Covid not only impacts people’s physical and mental health, but also their ability to work and their economic circumstances. We believe the appointment of a Minister for Long Covid would help to provide leadership, accountability and a coordinated response to these challenges.”
Notes to editors:
[1] Patient Safety Learning is a charity and independent voice for improving patient safety. We harness the knowledge, insights, enthusiasm and commitment of health and social care organisations, professionals and patients for system-wide change and the reduction of avoidable harm.
[2] The symptoms for those with Long Covid vary greatly but many are experiencing rashes, shortness of breath, neurological and gastrointestinal problems, abnormal temperatures, cardiac symptoms and extreme fatigue.
[3] Office for National Statistics, The prevalence of Long Covid symptoms and Covid-19 complications, 16 December 2020. https://www.ons.gov.uk/news/statementsandletters/theprevalenceoflongcovidsymptomsandcovid19complications
[4] Patient Safety Learning and Long Covid Support, Long Covid Minister needed to respond to the growing crisis, 3 February 2020. https://www.patientsafetylearning.org/blog/long-covid-minister-needed-to-respond-to-growing-crisis
Sam

Report reveals digital health technology must be accessible for all

To be successful digital health technology must be accessible to all while still maintaining the human aspects of healthcare, a new report has said.
‘Digital Health during the Covid-19 Pandemic: Learning Lessons to Maintain Momentum’ draws on research and case studies of good practice in digital health during the pandemic.
The aim of the report is to offer policy recommendations to help ensure the UK capitalises on the potential of digital health to the benefit of patients, the NHS and the UK, after the crisis subsides.
The report, launched by the Patient Coalition for AI, Data and Digital Tech in Health, with support from patient organisations and the Royal Colleges of Nursing and Radiologists, highlights that uptake of digital health technologies has been limited, while patient experience of technologies including video conferencing and mobile apps has been mixed.
While patients strongly believe in the value of digital health, there are still significant concerns about using it, particularly around data collection and sharing.
A number of key organisations gave their support to the report. This included the likes of the British Heart Foundation, Patient Safety Learning and the Royal College of Nursing.
Read full story
Source: Digital Health, 3 February 2021
Patient Safety Learning

Covid coughing study suggests NHS staff at far greater risk than thought

The NHS has been urged to rethink safety for thousands of frontline staff after new research suggested that Covid patients’ coughing is putting them at far greater risk of catching the virus than previously thought.
The study found that coughing generated at least 10 times more infectious “aerosol” particles than speaking or breathing – which could explain why so many NHS staff have fallen ill during the pandemic.
The research has led to fresh demands that anyone caring for someone with Covid-19, or suspected Covid-19, should be provided with the most protective equipment – including FFP3 respirator masks – and that hospital ventilation should be improved.
Health workers are up to four times more likely to contract coronavirus than the general population, with infection rates among those on general hospital wards approximately double those of intensive care unit (ICU) staff – who do have access to the most protective PPE.
Read full story
Source: The Guardian, 3 January 2021
Patient Safety Learning

Care homes still breaking Covid rules despite fatal outbreaks, inspectors say

Care homes in England operated by profitable chains have been branded unsafe by inspectors, who found serious failures in efforts to control the spread of coronavirus in its latest wave.
In the last month 40% of care homes inspected by the Care Quality Commission in England were judged to be inadequate or in need of improvement. Several handling fatal coronavirus outbreaks were revealed to have broken laws meant to keep residents safe.
Some of the worst failings uncovered in reports filed in the last month include CCTV showing PPE being used wrongly on 63 occasions in one home, infected residents mixing in communal areas with Covid-free residents, chronic staff shortages, and a care home manager continuing to work after showing Covid symptoms.
The spate of problems relates to a small minority of care homes but coincides with a tripling of fatalities linked to the virus among care residents in England and Wales.
Read full story
Source: 4 February 2021
Patient Safety Learning

Can digital technology help embed a strong patient safety culture?

Within a few months of joining Great Ormond Street Hospital Foundation Trust as medical director, Mat Shaw became its chief executive. Heading up the organisation clearly brought with it new responsibilities and challenges, yet he says on one important issue there was little difference between the two roles – namely, the focus on patient safety and enabling clinicians to offer the best possible care for patients.
“I lived through the time when all notes were on paper, when you had five, six volumes of thousands of pages. I lived through that time when it was very difficult to actually know what information to collect, and from where you should collect it, to make decisions around patients. And I recognise we don’t always do the right thing based on those systems.
“So for me it’s been tremendously important to try and bring a system in, and the digital tools which are needed, to make care kinder and also safer, with better outcomes for patients. In our new strategy, digital is front and centre in a way that it’s never been before, because I consider this agenda so important to how we treat patients.”
Read full story
Source: HSJ (paywalled), 3 February 2021
 
Patient Safety Learning

Study reveals extent of Covid vaccine side effects

About one in three people recently given a Covid vaccine by the NHS report some side-effects.
None was serious - a common one was some soreness around the injection site, the UK researchers who gathered the feedback found.
Experts say the findings, from about 40,000 people - mostly healthcare workers - are reassuring for the millions having the vaccines now.
The Zoe app team from King's College London found:
37% experienced some local "after-effects", such as pain or swelling near the site of the injection, after their first dose, rising to about 45% of the 10,000 who had received two doses 14% had at least one whole-body (systemic) after-effect - such as fever, aches or chills - within seven days of the first dose, rising to about 22% after the second dose These after-effects get better within a few days. All of the medical trials and real-world experiences so far suggest the vaccines are safe and effective.
Read full story
Source: BBC News, 4 February 2021
Patient Safety Learning

Gosport hospital deaths: Families 'need Hillsborough-style inquests'

Relatives of patients who died after receiving "dangerous" levels of painkillers at Gosport War Memorial Hospital have called for new inquests. 
An inquiry found 456 patients died after being given opiate drugs at the hospital between 1987 and 2001, but no charges have ever been brought.
Four families told the BBC they have requested judge-led "Hillsborough-style" hearings with a jury. The Attorney General's Office said it was reviewing the application.
Police began a fresh inquiry in 2019 into 700 deaths after the Gosport Independent Review Panel found there was a "disregard for human life" at the hospital in Hampshire.
Coroner-led inquests in 2009 found drugs administered at the hospital contributed to five deaths.
However, lawyers representing some of the families told the BBC more wide-ranging inquests similar to those that examined the events of the Hillsborough disaster should be undertaken.
Read full story
Source: BBC News, 5 February 2021
Patient Safety Learning

Hospitals prepare for increase in children suffering rare disease triggered by Covid

Hospitals across the country are preparing for a significant increase in children needing treatment for a rare disease triggered by coronavirus.
Paediatric departments across the NHS are recalling children’s nurses who have been redeployed to help care for adult patients as well as freeing up specialist intensive care beds to be ready for more cases of the rare condition first identified after the first wave last year.
Because of how widespread COVID-19 infections have become in the last month, with the numbers of patients in hospital peaking at almost 40,000, experts believe they will see a larger number of children affected by the disease called Paediatric Multisystem Inflammatory Syndrome (PIMS).
Modelling by London’s Evelina Children’s Hospital, which treated around 110 children with PIMS during the first wave of the virus, suggested for every 200 adults admitted to hospital across London, there was one child admitted with PIMS at the Evelina.
This modelling cannot be used to predict admissions across the country, but paediatric experts believe they will begin to see a larger number of children with the condition with a peak expected in the next three weeks.
It is thought COVID-19 triggers an inflammatory response among a very small minority of children – of all children infected with COVID-19, less than half of one per cent went on to develop PIMS.
Those that do suffer severe inflammation in their blood vessels and can have damage to their heart. Symptoms of PIMS include a rash, fever and abdominal pain.
Read full story
Source: The Independent, 4 February 2021
Patient Safety Learning
Registered address: Patient Safety Learning, China Works SB203, 100 Black Prince Road Vauxhall, London, SE1 7SJ

Account

Navigation

Search

Search

Configure browser push notifications
Chrome (Android)
  1. Tap the lock icon next to the address bar.
  2. Tap Permissions → Notifications.
  3. Adjust your preference.
Chrome (Desktop)
  1. Click the padlock icon in the address bar.
  2. Select Site settings.
  3. Find Notifications and adjust your preference.