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

Scheme launched to improve safety for frontline NHS staff

A London-wide operation has launched known as Operation Cavell, to improve the safety of NHS staff. The initiative will see a senior officer review all reports of assaults and hate crime against NHS staff.
Following a three-month pilot, the NHS, Metropolitan Police Service (MPS) and Crown Prosecution Service (CPS) have been working in partnership to launch the scheme, which aims to protect NHS staff on the frontline.
As well as senior police officer involvement, senior welfare and support staff within the NHS will be brought on board to help those who have been the victim of such crimes feel safer.
Martin Machray, Joint Regional Chief Nurse for NHS England & Improvement in London, said: “The last year of the pandemic has shone a light on the selflessness and dedication of NHS staff. All our staff should be able to come into work without fear of violence, injury or abuse. We therefore welcome the rollout of this important initiative across mental health services in London and we hope it will help protect and support our wonderful colleagues.”
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Source: National Health Executive, 16 April 2021
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Accidental overdose of hospital patients with paracetamol sparks investigation

Patients have been significantly harmed, including suffering permanent damage to their liver, after being given accidental overdoses of paracetamol in hospital.
The NHS safety watchdog the Healthcare Safety Investigation Branch (HSIB) has now launched a national investigation after a number of incidents where adults with a low bodyweight were given too much paracetamol through an infusion, or IV drip, directly into their bloodstream.
The Independent understands there were three incidents reported by NHS staff in 2020 but there have been others in earlier years including the trigger event which sparked HSIB’s probe.
Overdoses of IV paracetamol in both adults and children is a recurring problem. Safety alerts have been repeatedly issued to NHS hospitals over the problem, with one alert in 2010 highlighting more than 200 previous incidents of overdoses.
In 2011 an inquiry into the death of 19-year-old Danielle Welsh, who died from liver failure due to a sustained paracetamol overdose in June 2008, found a junior doctor who prescribed the drug did not know she weighed only 35kg. The inquiry found: “There was a prevailing culture of assumed familiarity with the administration of IV paracetamol, a familiarity derived from the common use of oral paracetamol.”
Now the independent Healthcare Safety Investigation Branch believes the problem of prescribing paracetamol without considering a patients’ weight is still going on.
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Source: The Independent, 19 April 2021
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'Urgent action' over children's mental health care

A child was twice given double the "safe" dose of a rapid tranquilizer at a hospital run by a troubled NHS trust.
The child was put at "significant risk of harm" at Telford's Princess Royal Hospital, said inspectors.
Rating children's services inadequate, they said Shrewsbury and Telford Hospital NHS Trust (SaTH) must halt seeing under 18s for acute mental health needs. The trust, in special measures, was working to "urgently address concerns".
The Care Quality Commission (CQC) carried out a targeted inspection on 24 February prompted by "concerning information" about treatment at the service run by SaTH.
The trust is currently at the centre of the largest ever inquiry into NHS maternity care.
Staff told inspectors they had seen an increase in the number of young people with "significant mental health issues" and learning disabilities over the past year.
But the services, which were rated as "requiring improvement" in November 2019, were deemed "inadequate" in four of five areas tested - for being safe, effective, responsive and well-led.
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Source: BBC News. 19 April 2021
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Dr Michael Watt: Almost 20% of patients misdiagnosed

Almost 20% of patients seen by neurology consultant Dr Michael Watt were given a wrong diagnosis, a report has found.
A review of 927 of Dr Watt's high-risk patients found 181 people received a diagnosis described as "not secure", Health Minister Robin Swann said.
He was speaking as the Belfast Trust announced the recall of a further 209 neurology patients seen and discharged by Dr Watt between 1996 and 2012.
This is the third such recall.
Dr Watt was at the centre of Northern Ireland's biggest patient recall linked to his work at Belfast's Royal Victoria Hospital.
Mr Swann said he had met patients and families affected by the recall in October last year.
"While this report is statistical in nature, it deals with individuals, their families and their experiences," he said.
"I know that many will have had their confidence in our health service shaken and I remain committed to helping restore it."
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Source: BBC News, 20 April 2021
 
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'Anger' over report into neglect death care home

The mother of a man who died after suffering neglect said she felt "extreme distress and anger" at a critical new report into his care home.
James Delaney, 37, died while he was a resident at Sapphire House in Bradwell, Norfolk, in July 2018. After an inadequate rating by the Care Quality Commission (CQC), Mr Delaney's mother said she felt lessons had not been learned from her son's death.
A spokeswoman for operator Crystal Care said it had "addressed all concerns".
Mr Delaney, who died of a diabetes-related illness, was required to take insulin twice a day, but, despite staff noting he had not taken insulin for three days, they failed to take action.
Jacqueline Lake, senior coroner for Norfolk, said at his inquest in 2019 there had been "a gross failure" by the care home to provide "basic medical attention".
The home, which houses up to five people who have a learning disability or autistic spectrum disorder, was inspected in January and February 2021 after two whistleblowers alleged that abusive practices were taking place - a claim which is being investigated by the local safeguarding team.
CQC inspectors found "people were not safe and were at risk of avoidable harm", and while risk assessments for diabetes, medicines and behaviour management existed, information was often "lacking or inaccurate".
After reading the report, Mr Delaney's mother, Roberta Conway, said her reaction was one of "extreme distress and anger". She said the coroner had "pointed out what needed to be done, and it hasn't been done".
"It cost my son his life and I don't want to see anybody else's life being wasted," she added.
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Source: BBC News, 21 April 2021
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Ageing NHS hospitals hit by sewage leaks, power failures and rat infestations

Raw sewage flooding wards, power failures, and rat infestations were just some of more than 1,200 critical incidents at NHS trusts in the past year caused by ageing equipment and crumbling infrastructure.
NHS leaders have said more investment is needed to reverse a backlog in buildings maintenance across the health service which has now reached an unprecedented £9bn. The situation is getting worse, with the backlog costs rising by 60 per cent in four years.
In some hospitals the problems have become so severe they are affecting patient care leading to wards being closed, operations delayed and in some cases posing genuine risks to safety.
Hampshire Hospitals was forced to suspend some services because of an uncontrollable rat infestation, while at East Cheshire NHS trust a power failure led to a back-up generator causing a fire triggering a second blackout. Patients had to be transferred to neighbouring hospitals and given blankets while others were given blankets to keep them warm.
In another incident at Great Western Hospitals Trust, a patient having a hip operation was left under anaesthetic “open and exposed” while staff struggled to find a vital part needed for the operation which was in a storeroom that couldn’t be opened.
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Source: The Independent, 20 April 2021
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Health secretary could prop up unsafe services with new power, say NHS leaders

New powers given to the health secretary as part of proposed legislation could make local services unsafe, NHS Providers has warned the House of Commons health select committee.
In a letter to committee chair Jeremy Hunt, seen exclusively by HSJ, the membership organisation said proposed new powers over local reconfiguration outlined in the government’s recent health white paper must include an “explicit” test that proves the intervention will not worsen patient safety.
The letter, signed by Chris Hopson and Saffron Cordery, CEO and deputy CEO respectively of NHS Providers, said: “Given the overwhelming importance of patient safety in these considerations, there should be an explicit test that use of the  [reconfiguration] power must maintain or improve safety before the power can be exercised."
“As part of the exercise of the power, the providers and integrated care system concerned, NHS England and the public should all be consulted on the relevant safety issues before the power can be exercised, with those views then made public.”
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Source: HSJ, 20 April 2021
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Trusts team up for weekend surgery drive to cut paediatric waiting times

Three acute trusts have teamed up to carry out surgical procedures on hundreds of children over several weekends as part of plans to tackle waiting lists in the region.
Trusts across the Bath and North East Somerset, Swindon and Wiltshire Integrated Care System are pooling resources to tackle long waits in paediatric oral and ear, nose and throat services.
The initiative began on the April bank holiday weekend. Thirty-eight of the longest waiters from Royal United Hospitals Bath Foundation Trust, who had been waiting up to 74 weeks for oral surgery, were treated by Salisbury FT. The other trust involved in the plans is Great Western Hospitals FT. 
More than 400 children are expected to be treated over a series of joint surgery weekends. The next, which will also focus on both oral and ENT surgery, will take place over the early May bank holiday. 
RUH’s chief executive Cara Charles-Barks told HSJ the joint surgery plans will have a “huge impact” on the region’s elective waiting lists.
Read full story (paywalled)
Source: HSJ, 21 April 2021
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Infant mortality in Birmingham 'not openly discussed'

Infant mortality is not "openly discussed" among some communities, a charity worker in Birmingham said, as the city attempts to tackle a long-standing problem.
For the last decade, Birmingham has had one of the highest rates of infant mortality in England. The city council has set up a taskforce in a bid to halve the number of deaths.
It heard rates were highest in deprived areas and among Black, Pakistani, and Bangladeshi heritage families.
Shabana Qureshi is the women wellbeing manager for the Ashiana Community Project, a charity which works to improve quality of life for those living in Sparkbrook.
Figures from the 2011 census show 87% of its population identified as being from an ethnic group other than White British, with the largest ethnic group being Pakistani. Many of women she works with, she said "don't know how to ask the right questions" and so are "not informed" about issues.
Many people in the communities they work with, she said, have low education levels and are more likely to suffer with maternity health issues, but find it difficult to access services.
"[Infant mortality] is not something that is discussed openly," she said.
"A lot of women live within extended families and are sometimes not aware of the risks, they live with these conditions and health inequalities."
She said any services which hope to tackle these problems need to involve communities, and be designed to be relatable, culturally sensitive and maintain trust.
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Source: BBC News, 22 April 2021
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NICE launches ambitious strategy to provide quicker access to new treatments and innovations

NICE will speed up patients’ access to the latest and most effective treatments, and dynamic guideline recommendations will be put in the hands of healthcare professionals more quickly under plans unveiled by NICE in its 5-year strategy launched on Monday (19 April 2021).
NICE will transform key elements of its approach to ensure efficiency and speed while maintaining robust, trusted methods.
The COVID-19 pandemic has reaffirmed the need to place science and evidence at the heart of health and care decision making and improve outcomes for all patients across the healthcare system.
Ensuring the organisation is more proactive and engaged with the life science industry earlier in the innovation pathway will allow patients to access new treatments faster.
Professor Stephen Powis, NHS England medical director, said: “Since its creation the NHS has always adapted quickly in response to new innovations, from world first transplants to more recently new cancer drugs and treatments during the pandemic which are enabling patients to get the care they need from the comfort of their own home."
“At the heart of the NHS Long Term Plan is a commitment to rollout the latest treatments to patients as soon as they are approved and so we welcome NICE’s new strategy to speed up approvals of the latest and most effective treatments.”
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Source: NICE, 19 April 2021
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End NHS staff shortages now, Boris Johnson told

Doctors, nurses and NHS bosses have pleaded with Boris Johnson to spend billions of pounds to finally end the chronic lack of staff across the health service.
The strain of working in a perpetually understaffed service is so great that it risks creating an exodus of frontline personnel, they warn the prime minister in a letter published on Wednesday.
They have demanded that the government devise an urgent plan that will significantly increase the size of the workforce of the NHS in England by the time of the next general election in 2024.
Their intervention comes after the latest NHS staff survey found that growing numbers of them feel their work is making them sick and that almost two-thirds believe they cannot do their jobs properly because their organisation has too few people.
NHS poll shows rising toll of work stress on staff health
The letter has been signed by unions and other groups representing most of the NHS’s 1.4 million-strong workforce, including the Royal College of Nursing, British Medical Association and Unison. NHS Providers and the NHS Confederation, which both represent hospital trusts, have also endorsed it, as has the Academy of Medical Royal Colleges, a professional body for the UK’s 240,000 doctors.
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Source: The Guardian, 21 April 2021
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Most new mums say NHS six-week checks fail to focus on their health

Six out of seven new mothers in England are not getting a checkup of their health six weeks after giving birth, despite such appointments becoming a new duty on the NHS last year.
Just 15% of women who have recently had a child are having a dedicated consultation with a GP to discuss their physical and mental health, according to a survey by the parenting charity National Childbirth Trust (NCT).
The requirement was introduced last year to boost maternal health and especially to try to identify women having psychological problems linked to childbirth such as postnatal depression. The appointments are separate to the established six-week check of a baby’s progress.
However, 85% of the 893 mothers in England whom Survation interviewed last month for NCT said their appointments were mainly or equally about the baby’s health and they did not get the chance to talk to the GP about their mental wellbeing.
“It is extremely disappointing to find that only 15% of new mothers are getting an appointment focused on their wellbeing and a quarter of mums are not being asked about their mental health at all,” said NCT’s chief executive, Angela McConville.
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Source: The Guardian, 22 April 2021
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Windrush scandal made ethnic minority people ‘fearful’ of using cancer services

Fears that their data would be shared with the Home Office following the Windrush scandal left some people from ethnic minorities afraid to access cancer services during the pandemic, an NHS England document has revealed.
The paper from the West Midlands Cancer Alliance said there was a “perception” the government was “accelerating immigration removals” and that, as a result, “individuals (particularly those affected by the Windrush scandal) are then fearful of accessing cancer treatment and may not participate in screening programmes for fear their information will be inappropriately shared with the Home Office”.
The news comes after figures released last week showed the fall-off in referral and treatment of Black-British patients for cancer during the early stages of the pandemic was sharper than for their White-British counterparts.
Referrals and first treatments for cancer dipped across the board in April last year.
However, by July, White patients were receiving 77 per cent of the treatment volumes they had done 12 months before. The figure for Black patients was 67 per cent. This 10 percentage point difference continued in August and September, as treatment volumes for White-British patients recovered to 83 and 91 per cent respectively. Parity was achieved from October to December 2020, the latest period for which data is available.
Read full story (paywalled)
Source: HSJ, 22 April 2021
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Influenza drug ‘good contender’ for at-home treatment against COVID-19

An antiviral typically used to treat influenza is a “good contender” for a drug that could be taken at home by people infected with COVID-19, according to a scientist who is trialling the medicine.
Favipiravir, licensed as a flu treatment in Japan since 2014, has already shown potential in reducing lung damage in hospitalised Covid patients and speeding up the time taken to clear the virus from the body.
But two UK trials, in Glasgow and London, are investigating whether the drug could be taken by people in the community before their disease has progressed, therefore keeping them out of hospital.
The government has promised to “supercharge” the search for and development of a new generation of easy-to-take, at-home drugs that can reduce transmission and quicken recovery from COVID-19.
A new taskforce, modelled on the team behind Britain’s vaccine procurement programme, is to oversee this work. It intends to deliver two effective treatments - offered in tablet form - to the public as early as autumn.
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Source: The Independent, 22 April 2021
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Royal Derby Hospital: Women's care reviewed over gynaecology concerns

Nearly 400 women who were treated by a consultant gynaecologist who "unnecessarily harmed" some patients are being invited to have their care reviewed by an independent expert.
University Hospitals of Derby and Burton NHS Trust is writing to 383 patients treated by Daniel Hay.
His conduct has been under investigation since 2019 after hospital colleagues raised concerns.
The trust has said at least eight of his patients had been harmed. It has not provided any further information on the nature of the harm.
Mr Hay worked at the Royal Derby Hospital and Ripley Hospital between 2015 and 2018.
The trust initially reviewed his patients who had undergone major surgery such as hysterectomies, before being expanded to include intermediate care, including diagnostic tests. By December, 383 former patients had been included in the review.
Now the trust has pledged to invite each one for a virtual meeting with an independent consultant gynaecologist to discuss their care outcome, starting with those who underwent major surgery.
Read full story
Source: BBC News, 22 April 2021
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CQC tells provider to inform police of staff assault on patient

Allegations of staff assaulting patients at a mental health hospital have been uncovered for a second time, one year after the Care Quality Commission (CQC) first raised concerns over potential abuse at the unit. 
The regulator criticised Broomhill Hospital in Northampton in a report issued this week after inspectors found details of three alleged assaults by staff against patients. The unit is run by independent sector provider St Matthew’s Healthcare, but treats NHS patients.
In May 2020, the CQC placed the hospital into special measures amid concerns it was failing to protect patients against abuse. Patients had raised concerns to inspectors over poor staff attitudes and made allegations that two had physically assaulted patients. 
A second inspection this year was triggered by further whistleblowing concerns from patients and staff.
Following the most recent inspection, which took place this February, the CQC has again raised warnings about staff allegedly assaulting patients. The staff members involved in all three incidents were dismissed and the CQC has asked the provider to inform the police of one incident.
According to the report: “Staff had not always treated patients with compassion and kindness… [or] been discreet, respectful, and responsive when caring for patients. Two patients told us that their experience in the hospital was ‘terrible’. Two different patients told us that they had observed staff shout at patients. Another patient described Broomhill as ‘the worst hospital they had been in’, adding that they were not happy with the care provided.”
Read full story (paywalled)
Source: HSJ, 22 April 2021
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