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

Coroners warned of mental health care failings in dozens of inquests

Shortfalls in mental health services and staffing have been flagged as concerns in dozens of inquests since 2015, the Observer has revealed, with coroners issuing repeated warnings over patients facing long waiting lists or falling through gaps in service provision.
The Observer has identified 56 mental health-related deaths in England and Wales from the start of 2015 to the end of 2020 where coroners identified a lack of staffing or service provision as a “matter of concern”, meaning they believed “there is a risk that future deaths could occur unless action is taken”.
Coroners issue Reports to Prevent Future Deaths (PFD) when they believe action should be taken to prevent deaths occurring in future, and send them to relevant individuals or organisations, who are expected to respond. In one case, a woman referred to psychotherapy services had still not received any psychotherapy by the time she died 11 months later. In another, someone had endured a seven-month wait for a psychological assessment.
Alison Cobb, senior policy and campaigns officer at the mental health charity Mind, said: “It’s shocking that so many should lose their lives because there isn’t enough capacity in mental health services to provide adequate care. These prevention of future deaths notices are meant to inform better ways of working, and it’s especially concerning that similar stories are repeating over and over again.”
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Source: The Guardian, 5 September 2021
Coroner's reports on the hub
Sam

Hospital-acquired infection caused one-in-five covid deaths at several trusts

More than one in five ‘covid deaths’ were both probably hospital-acquired, and caused at least in part by the virus, at several trusts, according to analysis released to HSJ.
HSJ obtained figures from more than 30 trusts which have looked in detail at cases where patients died after definitely, or probably, catching covid in hospital. 
Thirty-two acute trusts provided HSJ with robust data, out of the total 120 in England. Across all 32, they had recorded 3,223 covid hospital deaths which were either “definitely” or ‘probably’ nosocomial — making up around 17% of their total reported 19,020 hospital deaths.
The trusts said 2,776 of the 3,223 deaths also had covid listed on their death certificate, either as an “immediate cause” or as a contributory factor. That constitutes about 15% of all the hospitals’ covid deaths, and 86% of the nosocomial deaths.
When approached by HSJ, these trusts said they followed robust infection control practices, and that high community covid prevalence, and covid admissions, were the main cause of hospital-acquired infection. Some trusts also cited their ageing infrastructure.
Read full story (paywalled)
Source: HSJ, 6 September 2021
 
Sam

NHS gender identity clinic whistleblower wins damages

A child safeguarding expert who faced vilification after raising concerns about the safety of children undergoing treatment at a London NHS gender identity clinic has won an employment tribunal case against the hospital trust.
Sonia Appleby, 62, was awarded £20,000 after an employment tribunal ruled the NHS’s Tavistock and Portman trust’s treatment of her damaged her professional reputation and “prevented her from proper work on safeguarding”.
Appleby, an experienced psychoanalytical psychotherapist, was responsible for protecting children at risk from maltreatment.
The tribunal heard evidence she raised concerns about the treatment of increasing numbers of children being referred to the trust’s Gender Identity Development Service (Gids). The service in Hampstead has been at the heart of a controversy over its treatments, including the provision of drugs known as puberty blockers to children as young as 10.
The tribunal heard evidence that after she raised the concerns, instead of addressing them, the trust management ostracised her and attempted to prevent her from carrying out her safeguarding role, by sidelining her. Appleby said the management’s action amounted to a “full-blown organisational assault”.
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Source: The Guardian, 4 September 2021
Sam

What has caused the NHS blood tube shortage?

Becton Dickinson (BD), which manufactures most of the blood tubes used by the NHS, has alerted NHS England and NHS Improvement (NHSE/I) to a global shortage of some of its products, including two types of blood tubes: those with a yellow or purple top.
BD says that the COVID-19 pandemic created the most unpredictable demand it has seen in the past 70 years. The company says that it has also been difficult for customers to predict the types and quantities of blood tubes they will be using from month to month, which affects manufacturers’ abilities to meet demand. “Adding to the issue are global transportation delays that have resulted in more products being tied up in transportation than is normal, creating additional delays in deliveries,” BD said in a statement. “Raw material suppliers are also challenged to keep up with demand for materials and components.”
In the UK, BD has been authorised to import blood tubes that are approved for use in other regions of the world, including the United States. It plans to deliver nine million of these additional blood tubes to the NHS for immediate distribution. 
Read full story (paywalled)
Source: BMJ, 3 September 2021
Sam

Hospital admits liability for baby’s death after ignoring mother’s concerns

A hospital has admitted liability for the death of a baby who was delivered stillborn three days after his mother’s complaints of fluid loss and severe pain were dismissed as wetting the bed.
Jacob Jackson could have been born healthy, Shrewsbury and Telford hospital trust (Sath) has accepted, if it had arranged an earlier delivery in October 2018 as his mother, Charlotte, had suggested.
The incident happened 18 months after an external review had been ordered into serious maternity failings at the trust, which are now known to be the biggest maternity scandal in the history of the NHS.
Charlotte said: “It makes me feel sick to my stomach that they knew there were problems – this sort of thing had been going on for decades. We keep getting fed the same lines that ‘lessons have been learned’. If lessons had been learned parents and babies wouldn’t be going through this.”
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Source: The Guardian, 6 September 2021
Patient Safety Learning

GP staff facing abuse from patients over cancelled blood tests

GP surgery staff are facing abuse from patients who are “angry and upset” that their blood test has been cancelled because of the NHS-wide chronic shortage of sample bottles.
“Patients are angry when we ring them up and say, ‘Sorry we can’t do your blood test after all’. A lot of people are quite angry and concerned about their own health,” Dr David Wrigley, the deputy chair of council at the British Medical Association, said.
“Patients are quite rightly upset and some get quite aggressive as well. They are worried because they don’t know what the implications of their cancelled test are for their health.”
GP practices in England had begun cancelling appointments because the NHS’s main supplier could not deliver stocks as planned for one to two weeks because of “unforeseen road freight challenges”. 
NHS England has responded to the shortage of blood sample bottles by telling GPs to cancel all but clinically urgent blood tests and hospitals to cut back the tests they do by at least 25%. 
Read full story
Source: The Guardian, 6 September 2021
Patient Safety Learning

Healthy baby terminated by hospital in mix-up with sick twin

Doctors at a hospital in Birmingham mistakenly terminated a healthy unborn baby in a procedure instead of its sickly twin.
The unidentified mother decided to abort one of the fetuses because it was suffering from restrictive growth, which increases the chances of stillbirth and puts the healthy baby at risk. During the procedure at Birmingham Women's and Children's NHS Foundation, surgeons accidentally terminated the wrong twin.
The 2019 incident emerged in a Freedom of Information Act survey of hospital blunders.
Dr Fiona Reynolds, chief medical officer at Birmingham Women's and Children's NHS Trust, said: "A full and comprehensive investigation was carried out swiftly after this tragic case and the findings were shared with the family, along with our sincere apologies and condolences."
"The outcome of that thorough review has led to a new protocol being developed to decrease the likelihood of such an incident happening again."
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Source: The Independent, 6 September 2021
 
Patient Safety Learning

Increased ambulance handover delays threatening patient safety

A new snapshot survey by the Royal College of Emergency Medicine has found that in August 2021 half of respondents stated that their Emergency Department had been forced to hold patients outside in ambulances every day, compared to just over a quarter in October 2020 and less than one-fifth in March 2020.
The survey, sent out to Emergency Department Clinical Leads across the UK, also found that half of respondents described how their Emergency Department had been forced to provide care for patients in corridors every day, while nearly three-quarters said their department was unable to maintain social distancing every day.
One-third said that the longest patient stay they had had in their Emergency Department was between 24 and 48 hours, with 7% reporting the longest stay to be more than 48 hours.
Dr Ian Higginson, Vice President of the Royal College of Emergency Medicine, said: “It is shocking to see the extent of the challenges faced by Emergency Departments across the UK. Holding ambulances, corridor care, long stays – these are all unconscionable practices that cause harm to patients. But the scale of the pressures right now leaves doctors and nurses no options. We are doing all we can to maintain flow, maximise infection prevention control measures, and maintain social distancing. Our priority is to keep patients safe, and ensure we deliver effective care quickly and efficiently, but it is extremely difficult right now."
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Source: The Royal College of Emergency Medicine, 6 September 2021
Patient Safety Learning

Northern Ireland health system "one step from chaos"

"Bodies would have been piling up" if the Covid vaccine had not been available, the director of intensive care at Belfast City Hospital has said.
Dr George Gardiner, a consultant, also said his biggest fear would be having to stop routine cancer surgery. He has called for an end to "tribal politics" in Northern Ireland to allow transformation of the health service, so that cancer and coronavirus can be tackled in tandem.
He said the system was currently "one step from chaos" and warned hospitals will not cope with winter if Covid numbers continue to rise.
"We need to get everyone who can take a vaccine to take it now before the winter pressures are on us," Dr Gardiner added.
"The cancer surgery that we are doing at the minute is life saving. A few more Covid admissions, which could be prevented, will cause us to stop operating because we simply haven't got the capacity to do both."
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Source: BBC News, 7 September 2021
Patient Safety Learning

Nurse shortage ‘delaying treatment for 21% of UK cancer patients’

More than 600,000 cancer patients in the UK are facing treatment delays or missing out on vital support because of a shortage of specialist nurses, a new report from Macmillan Cancer Support reveals.
One in five of all those living with cancer (21%) are lacking dedicated support. The NHS is suffering from a “shocking” shortfall of 3,000 specialist nurses in England alone, according to the analysis by Macmillan Cancer Support.
As a result, cancer patients are struggling with medication, having hospital appointments cancelled because there are not enough staff or experiencing devastating delays to chemotherapy. In some cases, patients are ending up in A&E.
Patricia Marquis, England director of the Royal College of Nursing, warned the workforce crisis was having a “devastating impact” on people living with cancer. “Expertise built up over many years is lost very quickly and it is patients who pay the price, as this report shows,” she added.
Read full story
Source: The Guardian, 8 September 2021
Patient Safety Learning

Covid in Scotland: Can in-person GP appointments ever fully return?

Community doctors in Scotland have told the BBC they cannot imagine returning to normal face-to-face service with current levels of demand.
Allowing more patients to see their GP in person is a top priority for the government's NHS Recovery Plan. But as the country tries to emerge from the pandemic, surgeries are seeing unprecedented pressure to catch up with patients.
The health secretary has confirmed that new guidance should allow practices to see more people in person. But greater use of telephone and video appointments, brought in when the pandemic hit, is going to continue.
Dr Begg has been a GP for 25 years. He says they won't go back to business as usual, the way they worked before.
"In person consultations are really important, to examine people, to give injections, to remove lesions, all of these. I think a flexible approach is what we need. It's what we were planning to do before the pandemic anyway; a flexible mix of phone call, video and in-person consulting where it is appropriate."
Dr Begg says the new ways of working are essential to deal with the huge number of requests they get.
"There is a demand, capacity gap and indeed there was before the pandemic. We are seeing at last more students come through medical school and more people finally coming to join general practice training, but this is going to take at least ten years to turn things around."
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Source: BBC News, 7 September 2021
Patient Safety Learning

Why vaccinating all teens is a difficult decision

The UK's vaccine advisory body has decided not to recommend vaccines for healthy 12-15-year-olds, but it will offer vaccines to thousands more children with underlying health problems.
Ministers will now seek more advice on extending the rollout based on factors such as school disruption.
There is general agreement that this was a really tricky call to make. Bur The Joint Committee on Vaccination and Immunisation (JCVI) has focused squarely on the health benefits of vaccination to children themselves - not on the impact to their schooling or other people.
Children's risk from Covid isn't zero but the chances of them becoming seriously ill from Covid are incredibly small. Deaths among healthy children are extremely rare - most have life-limiting health conditions.
That means there needs to be a clear and obvious advantage to giving them a jab. However, a very rare side-effect of the Pfizer and Moderna vaccines has made that calculation a lot more complicated.
Paul Hunter, professor of medicine at University of East Anglia, says there's been intense pressure on the JCVI and he can understand why they are being cautious.
"I don't know what the answer is - I'm very close to the fence on this. There's not enough data to be absolutely certain."
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Source: BBC News, 4 September 2021
Patient Safety Learning

New body to tackle health disparities

Following a government announcement, a new body set to tackle health disparities in the UK will launch on Friday 1 October.
The Office for Health Improvement and Disparities (OHID) aims to tackle health inequalities across the country and will be co-led by newly appointed Deputy Chief Medical Officer (DCMO), Dr Jeanelle de Gruchy.
The OHID will play a vital role in the Department of Health and Social Care, driving the prevention agenda throughout the government to minimise health disparities, many of which have been exacerbated by the pandemic, and improve the public’s health.
Unfortunately, health disparities around the UK are austere. For example, a woman living in Blackpool will on average live 16 fewer years in good health than a woman born in Brent, London.
The government is also aware that ethnicity can impact health and health outcomes.
Health disparities can consequently undermine a person’s ability to work and live a long, healthy and independent life, whilst putting pressure on the NHS, social care and other public services.
Read full story
Source: National Health Executive, 7 September 2021
Patient Safety Learning

Covid-positive care home staff work amid shortage

A care home owner has said she was "forced" to ask two staff with Covid-19 to work because of a staff shortage.
The Caledonia home in Holyhead, Anglesey, said 11 of its 12 residents had Covid and the two staff only cared for residents who were also positive.
Ann Bedford said Anglesey council and an agency had both been unable to provide emergency cover for staff who were sick or isolating. After speaking to social services, it was agreed the staff could work.
"I have never known a situation as bad as we faced over the last weekend. As a matter of course we have contingency plans in place to cope in emergencies but even these buckled under the strain," she said.
"My heart sinks when I think about the weeks and months ahead. We felt abandoned and alone. I called on social services for help but they were facing their own emergencies."
"The shortage of carers on Anglesey is at dangerous levels and is being intensified by the pandemic."
Read full story
Source: BBC News, 8 September 2021
Patient Safety Learning

Unvaccinated health and care workers in England could be redeployed

Health and care sector workers in England who decline to be fully vaccinated could be moved to back-office roles, a UK government minister has suggested, as a consultation on plans to mandate COVID-19 and flu vaccinations was launched.
The six-week consultation process will take views on whether vaccine requirements should apply for health and wider social care workers – those in contact with patients and people receiving care.
It would mean only those who are fully vaccinated, unless medically exempt, could be deployed to deliver health and care services.
Speaking on Times Radio, Helen Whately, the minister for care, said the government was working with care homes and other settings to see if workers who refused the vaccine could be redeployed.
She said: “You can look at whether there are alternative ways somebody could be deployed, for instance, in a role that doesn’t involve frontline work, or doesn’t involve being physically in the same setting as the patient – whether it’s, for instance, working on 111, something like that."
But she suggested that people who refused to get vaccinated against coronavirus should not work in social care.
Speaking on Sky News, Whately said care homes had been hit particularly hard by Covid, and added: “The reality is that one of the best ways we can protect people living in care homes is through making sure that staff are vaccinated.”
Read full story
Source: The Guardian, 9 September 2021
Patient Safety Learning

Concern raised over death of five patients seen remotely by GPs

Patients being assessed remotely in general practice, rather than face-to-face, has been raised as a risk in reports on five deaths by a single coroner since the pandemic hit.
Senior coroner for Greater Manchester Alison Mutch has written five prevention of future deaths reports highlighting concerns that doctors were missing details in telephone appointments which may have been spotted, had the patient been seen in person. The reports cover a variety of conditions, including covid, a broken femur, and anxiety and depression.
In March 2020, NHS England guidance instructed GPs to adopt a “total triage” approach, where face-to-face appointments should generally only follow a phone, video or digital consultation. But, in May, NHSE wrote to GPs to ask them to “ensure they are offering face to face appointments”, adding remote appointments “should be done alongside a clear offer of appointments in person”.
There have been growing calls in the media for increased face-to-face appointments, while, in March 2021, a report by Healthwatch concluded: “While telephone appointments are convenient for some, others are worried that their health issues will not be accurately diagnosed.”
Maureen Baker, former chair of the Royal College of GPs and Patient Safety Learning trustee told HSJ she was “not aware pre-pandemic of any major concerns with remote consulting”, adding: “It’s not that things don’t go wrong. They do, but things can and do go wrong in face-to-face consultations as well.”
“Many practices have been using remote consulting very successfully for many years [but for GPs introducing remote consultations during the pandemic] the concern is that practices will have had to change and implement it very quickly.”
Read full story (paywalled)
Source: HSJ, 9 September 2021
You may also be interested in a recent blog from Trish Greenhalgh: 'Why remote consultation with a doctor is difficult – and how it can be improved'
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