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

Alert over hospital air devices after 120 ‘never events’

NHS trusts are to be told to remove devices linked to more than 120 never events caused by ‘unconscious errors’.
A national patient safety alert from NHS England which urges trusts to remove all air flowmeters from wall medical gas outlets. It is likely to be published next month.
The alert comes after 121 never events in the last three years involved staff members accidentally connecting patients to air instead of oxygen. This number is close to 10% of all never events recorded during that period.
These types of never events have been recorded by 57 NHS organisations during 2018-19, 2019-20 and 2020-21.
The incidents took place mostly on medical wards and in emergency departments. They occurred despite NHSE issuing a patient safety alert in 2016, which recommended removing the flowmeters from wall outlets when not in active use.
According to NHSE documents - seen by HSJ - the never events often went undetected “for some time”, even when other staff responded to deteriorating patients or took over their care. The regulator concluded this makes it more likely that there have been other unreported incidents.
Read full story (paywalled)
Source: HSJ, 17 May 2021
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Long Covid symptoms ease after vaccination, survey finds

COVID-19 vaccines tend to alleviate the symptoms of long Covid, according to a large survey of more than 800 people that suggests mRNA vaccines, in particular, are beneficial.
Although COVID-19 was initially understood to be a largely respiratory illness from which most would recover within a few weeks, as the pandemic wore on increasing numbers of people reported experiencing symptoms for months on end. There is no consensus definition of the condition of these people who have symptoms ranging from chronic fatigue to organ damage, let alone a standardised treatment plan.
As vaccines hit the mainstream, concerns arose that vaccination could precipitate relapses or a worsening of symptoms. But conversely, anecdotal reports suggested that vaccines helped some people with long Covid.
The analysis, which is yet to be peer reviewed, was conducted on the basis of a survey of 812 people (mostly white, female participants) with long Covid in advocacy groups in the UK and internationally who were contacted via social media. The participants (a small proportion of whom also said they had ME/CFS) were asked to wait at least a week after their first dose to avoid their responses conflating with side-effects of the vaccine.
In general, those who received mRNA vaccines (Pfizer/BioNTech or Moderna) reported more improvements in symptoms, compared with those who got an adenovirus vaccine (Oxford/AstraZeneca). In particular, those who received the Moderna vaccine were more likely to see improvements in symptoms such as fatigue, brain fog and muscle pain, and less likely to report a deterioration, the analysis found.
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Source: The Guardian, 18 May 2021
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‘GP said I might be blocked up. At hospital they told me I was heading towards sepsis’

Monica Evans's initial misdiagnosis could have proved life-threatening – and she is just one of many to have suffered during pandemic.
Since The Telegraph began reporting on the struggles of patients around the country to access GP services during the pandemic, they have been inundated with messages and letters.
There have been multiple stories of serious misdiagnoses made after telephone consultations with doctors that took place in lieu of face-to-face assessments; of interminable waits to get through to practices on jammed phone lines; and of lengthy delays while worried patients have waited for referrals to be made.
Those who shared their experiences have also shared their fury, frustration, fear and dismay. Some who could afford to have felt they had no option but to turn to private healthcare, unable to obtain the help they needed from an NHS struggling with Covid and all its knock-on effects. Others have been left with nowhere to turn. 
GPs have spoken, too, about their dissatisfaction with a system that has discouraged face-to-face consultations. 
Amid an outpouring of anger from both patients and doctors, NHS England yesterday rowed back on plans for "total triage" of patients to keep them out of surgeries whenever possible. But for many the damage has already been done.
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Source: The Telegraph, 13 May 2021
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Ambulance crews in England to use iPads to assess accident and stroke victims

Ambulance crews will start using iPads to send photographs of accident and stroke victims to specialist hospital doctors so that they can make rapid diagnoses and save some patients a trip to A&E.
NHS England is giving 30,000 iPads to regional ambulance services to help paramedics decide what care to give and whether to take someone to hospital or treat them at the scene.
The tablet computers will be a vital link between ambulance crews and hospital consultants, whose digital interaction will make treatment faster and better, NHS England said.
For example, the devices will let paramedics show an A&E department how badly injured patients have been in a road traffic crash, so that they can prepare for their arrival. They will also allow crews access to patients’ medical records to help them build a better picture of their health.
“Ambulance crews have been at the forefront of the pandemic, routinely dealing with life-and-death situations and often first on scene to treat and diagnose critically ill patients,” said Sir Simon Stevens, NHS England’s chief executive. “These devices are another tool for our highly skilled paramedics and ambulance technicians as they continue to respond to the country’s most critically ill and injured patients.”
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Source: The Guardian, 18 May 2021
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Social care cuts mean thousands with dementia taken to A&E, charity says

Tens of thousands of people with dementia are taken to hospital each year for emergency admission because inadequate social care has left them unprotected from infections, falls and dehydration, an investigation has found.
There has been a 27% increase over a four-year period in avoidable illnesses and injuries caused by failures in care for those living with dementia, according to the Alzheimer’s Society.
“This news comes just under a week after the Queen’s speech frustratingly made only a brief mention of the prime minister’s promise nearly two years ago to deliver a clear plan for social care reform, a devastating blow for the 850,000 people living with dementia, worst hit by coronavirus,” said Kate Lee, chief executive officer at Alzheimer’s Society.
The charity found that nearly two-thirds of dementia emergency admissions could have been avoided. It blames cuts in social care budgets and warned that worse is to come.
Launched to mark Dementia Action Week, the charity’s investigation also found that nearly three-quarters of family carers said loved ones with dementia had experienced preventable medical issues because of lack of support. One in nine had been taken to hospital.
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Source: The Guardian, 17 May 2021
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Unpublished hospital patient safety reports exposed

Serious patient safety issues are being buried in confidential hospital reports, BBC Panorama has found.
Freedom of Information requests revealed 111 reports, written by medical royal colleges, which NHS trusts have a duty to share. Eighty reports were given to the BBC but only 26 had been shared in full with regulators, and 16 published.
The Department of Health would not comment on whether it might change the law to ensure publication.
Since the 2015 Morecambe Bay maternity scandal in which 11 babies and a mother died, NHS Trusts are supposed to publish summaries of external reviews, and share them with the regulator.
An earlier review into the hospital had previously identified concerns but had not been made public.
Dr Bill Kirkup, who led a 2015 investigation into the Morecambe Bay scandal, said Panorama's findings were a "great disappointment".
"People should know that there is something that is important enough to be looked at and they should know what the results of that scrutiny are. I can't understand what the rationale would be for withholding the existence of a report or the findings of the report. These are important matters of accountability in the public service."
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Source: BBC News, 19 May 2021
   
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Google AI tool can help patients identify skin conditions

Google has unveiled a tool that uses artificial intelligence to help spot skin, hair and nail conditions, based on images uploaded by patients.
A trial of the "dermatology assist tool", unveiled at the tech giant's annual developer conference, Google IO, should launch later this year, it said.
The app has been awarded a CE mark for use as a medical tool in Europe.
A cancer expert said AI advances could enable doctors to provide more tailored treatment to patients.
The AI can recognise 288 skin conditions but is not designed to be a substitute for medical diagnosis and treatment, the firm said.
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Source: BBC News, 18 May 2021
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Alarm raised years before hospital’s ‘inadequate’ rating

Multiple concerns were being raised about an inpatient hospital for several years before it was rated ‘inadequate’ by the Care Quality Commission (CQC), HSJ has learned.
Huntercombe Hospital in Maidenhead, which provides NHS-funded mental healthcare for children, was put into special measures in February after an inspection raised serious concerns over the apparent over-use of medication to sedate patients, among other issues. It has since received a further warning notice.
The unit, which predominantly treats female patients, had previously been rated “good” by the CQC in 2016 and 2019.
Five former patients and four parents have now told HSJ of poor care and practices at the unit between 2016 and 2020. Two of the families raised concerns directly to Huntercombe, as well as NHS England, local authorities and the local community provider, Berkshire Healthcare FT.
Read full story (paywalled)
Source: HSJ, 18 May 2021
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NHS was ‘overwhelmed’ in January surge, study finds

The NHS “was largely overwhelmed” at the height of the UK’s Covid second wave in January, according to a study.
New research published in Anaesthesia, a journal of the Association of Anaesthetists, revealed the scale of the pressure on hospitals during the pandemic and how stretched some units were.
Based on surveys of all NHS hospitals, with more than half responding, the study found almost a third of anaesthetists were redeployed to look after critically ill patients, leaving 42% of operating theatres closed.
This meant operations, including for cancer and emergency surgery patients, had to be cancelled.
The research, by Professor Tim Cook, a consultant in anaesthesia and intensive care at the Royal United Hospitals Bath Foundation Trust, said: “Three-quarters of critical care units were so expanded that planned surgery could not be safely resumed. At all times, the greatest resource limitation was staff.”
It is thought the findings are an underestimate of how bad the situation really was in some hospitals because the busiest units were less able to respond to the survey.
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Source: The Independent, 19 May 2021
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US physician gets 59-year sentence for unneeded patient surgeries, $20M fraud

A Virginia gynaecologist has been sentenced to 59 years in prison for a fraud scheme that caused insurance programmes to lose more than $20 million, according to the U.S. Justice Department. 
Javaid Perwaiz was sentenced after being convicted last November of 52 counts of healthcare fraud and false statements related to a scheme in which he performed medically unnecessary surgeries, including hysterectomies and improper sterilisations, on his patients. 
From about 2010 to 2019, Dr. Perwaiz often falsely told his patients that they needed the surgeries because they had cancer or could avoid cancer, prosecutors said. Additionally, evidence showed Dr. Perwaiz falsified records for his obstetric patients to induce labor early to ensure he was reimbursed for the deliveries and violated Medicaid's required 30-day waiting period for elective sterilisation procedures by backdating records to make it appear that he had complied with the waiting period. Dr. Perwaiz also billed insurance companies for diagnostic procedures that he only pretended to perform at his office, prosecutors said. 
"Motivated by his insatiable and reprehensible greed, Perwaiz used an arsenal of horrifying tactics to manipulate and deceive patients into undergoing invasive, unnecessary and devastating medical procedures," Raj Parekh, acting U.S. attorney in the Eastern District of Virginia, stated. "In many instances, the defendant shattered their ability to have children by using fear to remove organs from their bodies that he had no right to take."
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Source: Becker's Hospital Review, 18 May 2021
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Baby death raises questions over maternity care

Beth and Dan Wankiewicz want answers about why their baby son Clay died last year, shortly after his birth at Doncaster Royal Infirmary. Despite a low-risk pregnancy, the family say Clay died from multiple skull fractures.
Doncaster and Bassetlaw NHS Foundation Trust said "the provision and delivery of high-quality" care is a priority.
The BBC has found a 2016 review flagging concerns about the hospital's maternity care was never published. The report - one of scores of unpublished reports discovered by a Freedom of Information request by BBC's Panorama programme - highlighted significant patient safety concerns.
Beth Wankiewicz was admitted to hospital last July, but after a day of labour her baby had still not been born. With no consultant doctor on site, a junior doctor made two attempts to deliver the baby with forceps, after getting advice on the phone.
Father, Dan, remembers the second attempt with forceps being much more vigorous "which was a bit of a shock".
The family say there was a further delay before they had a Caesarean section. Their baby had to be pushed back up the birth canal into the womb for the C-section to be performed.
"I think after about 10 minutes, we both looked at the clock, and we said it's not looking good," said Dan.
Around 20 minutes after their son was born, despite attempts to resuscitate him, they were told he had died.
The following day they say a midwife told them she was being pressurised by other staff to say Clay had been stillborn, but she was sure he had been born alive, and she had heard a heartbeat.
The family now believe this was to avoid scrutiny and the need for a coroner's inquest, which doesn't happen with still births.
Read full story
Source: BBC News, 19 May 2021
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Breast implant victims to receive compensation

More than 2,500 women who were victims of the PIP breast implant scandal should receive compensation, a French appeal court has decided.
It also upheld an earlier judgement finding German company TUV Rheinland, which awarded safety certificates for the faulty implants, negligent.
The case in Paris involved 540 British women, who said they suffered long-term health effects.
The results could have far-reaching implications for other victims.
Jan Spivey is one of the women in the case. She was given PIP implants after she had a mastectomy due to breast cancer.
She developed sore and aching joints, chest and back pain, fatigue, severe headaches and anxiety. Once removed it was clear her implants had been leaking silicone into her body.
She says the implants have had a massive impact on her mental health.
"My PIP implants from 20 years ago are still impacting on my life and my health and my wellbeing, even today."
Read full story
Source: BBC News, 19 May 2021
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Almost a fifth of nurses say a negative workplace culture forced them to leave profession

Almost a fifth of nurses who left the profession cited a negative workplace culture as a reason for leaving along with almost a quarter saying they were under too much pressure.
The nursing regulator, the Nursing and Midwifery Council (NMC) warned there could be an exodus of registered nurses after the coronavirus pandemic in its latest annual report.
Despite a record number of nurses and midwives joining the profession across the UK, the NMC said pressure on frontline nurses could drive many away.
In a survey of 5,639 nurses who left the register between July 2019 and June 2020, the NMC found that after retirement as the most common reason for leaving, almost a quarter of nurses (23%) said they left their jobs because of "too much pressure", leading to stress and poor mental health.
A total of 18% blamed a negative workplace culture as the reason to leave.
The NMC report warned: “These issues existed before the pandemic, and may well outlast it, further disrupting an already fatigued nursing and midwifery workforce. If not addressed, this could have a significant impact on the number of people we report leaving our register over the next year and beyond.”
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Source: The Independent, 20 May 2021
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Glan Clwyd: Vascular overhaul 'must be undone' over safety risks

Changes to vascular services in north Wales must be reversed urgently after a report highlighted safety risks, campaigners warned.
Services were centralised from Ysbyty Gwynedd to Ysbyty Glan Clwyd - about 30 miles away - in April 2019.
An independent report, by the Royal College of Surgeons, highlights bed shortages and confusion over staffing levels.
Betsi Cadwaladr health board said it was making urgent changes to services.
In the report, commissioned by BCUHB after patients and staff raised fears about the new service, the Royal College of Surgeons makes nine "urgent recommendations to address patient safety risks".
The report sets out issues, including too many patients being transferred to the hub hospital at Glan Clwyd, and a lack of vascular beds leading to frequent delays in transfers. The report also refers to a lack of clarity regarding the availability of consultant vascular surgeons.
Read full story
Source: BBC News, 20 May 2021
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NHS warned multiple times that imaging shortages may kill

Coroners have warned the NHS nearly a dozen times in recent years that a lack of imaging capacity could lead to more deaths, HSJ can reveal.
Five of these warnings followed deaths at a single site, Tameside General Hospital in Greater Manchester. The most recent case concerned a patient that died after developing covid during a prolonged wait for an MRI scan.
Sir Mike Richards last year warned in a major report for NHS England about the lack of imaging equipment, and the Royal College of Radiologists has highlighted national shortages of radiology staff on numerous occasions in recent years.
HSJ combed through more than 100 prevention of future death reports and responses published between 2018 and 2021 in an effort to quantify harm linked to these shortages.
Of dozens of reports mentioning imaging issues, including software problems, poor note-taking and incorrect interpretation of results, HSJ identified 11 cases where coroners specifically warned either the trust or system concerned, and/or NHS England or the Department for Health and Social Care, that capacity issues could lead to future deaths.
In some of the cases, coroners concluded that shortages likely contributed to a patient’s death. 
Read full story (paywalled)
Source: HSJ, 20 May 2021
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Covid: Stillbirth and prematurity risks may be higher

A large UK study suggests having coronavirus around the time of birth may increase the chance of stillbirths and premature births - although the overall risks remain low.
Scientists say while most pregnancies are not affected, their findings should encourage pregnant women to have jabs as soon as they are eligible.
The majority are offered vaccines when they are rolled out to their age group.
The study appears in the American Journal of Obstetrics and Gynecology. The research, led by the National Maternity and Perinatal Audit, looked at data involving more than 340,000 women who gave birth in England between the end of May 2020 and January 2021.
Researchers say a higher risk of stillbirth and prematurity, as well as a greater chance of having a Caesarean section, remained even once factors such as the mother's age, ethnicity, socio-economic background and common health conditions were taken into account.
Babies born to women who tested positive were more likely to need special neonatal intensive care because they were born early and needed more support - rather than being infected with coronavirus itself.
Professor Asma Khalil, co-author of the paper, said it was important for women and healthcare workers to be aware of the potential risks.
Read full story
Source: BBC News, 21 May 2021
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