Skip to content

News

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

Staff frightened to speak about NHS trust bullying

A culture of bullying and racial discrimination has been found at a hospital trust, according to an inspection report.
The Care Quality Commission (CQC) said there was a bullying culture across Nottingham University Hospitals (NUH) Trust, with many staff too frightened to speak up. The trust has been told it requires improvement as a result of the report.
NUH said it was working to address the concerns.
The report said a number of the bullying cases were directly attributable to racial discrimination.
It said the trust's latest staff survey showed the organisation was above average for black, Asian and minority ethnic staff experiencing bullying.
Sarah Dunnett, the CQC's head of hospital inspection, said they were told of bullying incidents that had not been addressed.
"We were concerned about the culture of bullying across the trust with many staff being too frightened to speak up," she said.
She said the CQC would "monitor the service closely" to ensure changes were made.
Read full story
Source: BBC News, 15 September 2021
Patient Safety Learning

Opioid pain relief 'soared during pandemic' for some patients

The use of opioids for pain relief soared during the pandemic as some patients waited longer for surgery, according to new research.
The University of Aberdeen team focused on more than 450 patients due to have hip or knee replacement surgery.
They said waiting times for these procedures increased by an average of 90 days and that the numbers of patients using opioids while waiting for surgery increased by 40% compared to pre-pandemic levels.
The research, published in the BMJ Quality and Safety, looked at data collected from 452 NHS patients from the north east of Scotland.
The university's Luke Farrow, who led the research, said alternative ways of managing severe arthritis pain needed to be found "urgently" for those waiting for this kind of surgery.
Read full story
Source: BBC News, 15 November 2021
Patient Safety Learning

Being visible on wards and understanding frontline staff is “critical” for hospital leaders

A retiring chief executive was “astonished” how many junior doctors had never met the senior directors of their hospitals — and stressed how being visible on the wards is “critical” to good leadership.
Karen Partington, who has this month stepped down after 10 years leading Lancashire Teaching Hospitals Foundation Trust, said she had made it her mission to understand the feelings and motivations of frontline staff.
In an interview with HSJ, she was asked if being visible and spending significant time talking to frontline staff is the most important bit of advice she would give a first-time chief executive.
She said: “In my personal opinion, it’s critical. How can CEOs be compassionate leaders without understanding the daily pressures faced by the whole team?"
“My executive team and I [would] meet regularly with our junior doctors and do a ‘you said, we did’ session, which really helped us to change their experiences for the better. But it was also an opportunity to ensure our frontline colleagues understood the environment they were working in as well. I have always found that when people understand ‘why’, [then] they will come up with the solutions."
Read full story (paywalled)
Source: HSJ, 14 September 2021
Patient Safety Learning

Children harmed by mental health service failings

Young people cared for by an NHS mental health service "came to harm" because of its failings, inspectors said.
The care provided by Essex Partnership University NHS Foundation Trust (EPUT) has been rated "inadequate" by the Care Quality Commission (CQC). It has now been stopped from admitting new patients after inspectors found "serious concerns" in the children and adolescent mental health services.
EPUT said it had increased staffing levels and had been coaching staff.
The inspection was prompted by a serious incident and concerning information received about safety and quality, the CQC said.
Inspectors visited, unannounced, in May and June and looked at the Larkwood and Longview wards at the St Aubyn Centre in Colchester and the Poplar Adolescent Unit at Rochford Hospital.
The CQC found observations were not always carried out safely and patients "had been harmed as a result of the poor practices", which included patients self-harming.
It said these incidents were not always reported or dealt with appropriately.
Read full story
Source: BBC News, 15 September 2021
Patient Safety Learning

Patient groups, Royal Colleges, medical charities and industry launch new Patient Coalition for AI, Data and Digital Tech in Health

A new coalition with members from Royal Colleges, health charities (including Patient Safety Learning) and patient groups has come together to ensure the interests of patients are at the heart of the development of policy in digital health technology.
The Patient Coalition for AI, Data and Digital Tech in Health is the first coalition to unite such a diverse range of stakeholders from across the health policy landscape in order to champion the patient perspective in this field.
Currently, not enough is being done to ensure that patients are included in the evolving policy discussions surrounding the development, implementation or evaluation of digital health technologies in the UK. In fact, there is limited understanding of what patients actually want from digital health. The danger is that these technologies end up as something done ‘to’ patients rather than ‘with’ and ‘for’ them. 
In addition to providing a forum for discussion, this Coalition will act as an independent campaigning coalition, taking forward joint pieces of work and engaging actively to help influence Government and NHS policy on the use of digital technology in healthcare. The goal will be to ensure patient interests are at the forefront of ongoing media and policy discussions surrounding digital health tech, and being incorporated into the policymaking process. The goal is to cultivate the necessary policy conditions to enable the UK to capitalise on new digital health technologies to the benefit of patients and the NHS.
Issues Coalition members have committed to tackling include:
Examining health inequalities and calling for the prioritisation of access to digital health. Sharing best patient-centric practice in digital health. Ensuring the patient perspective is embedded in policy and government strategies.    The Coalition’s objectives for the next year are to:
Promote understanding of the patient experience of digital health Ensure patients receive the support needed to access digital health tech Inform policymakers on what good practice looks like. The Coalition will continue to engage proactively with policymakers, health agencies and others to help inform digital health policy. It will campaign for policies such as:
Ensuring all patients have access to digital health technology, regardless of where they are in the country Providing patients with the choice of how they receive care, and empowering them to make that decision for themselves Prioritising digital assurance so that patients feel confident when engaging with digital health technologies that they are using products that have been approved by the NHS Ensuring there are clear regulations for the collection, sharing and use of patient data. Read the full press release on the Patients Association website. 
Read the Coalition's first report: Digital Health during the Covid-19 Pandemic: Learning Lessons to Maintain Momentum.
Source: Patients Association, 15 September 2021 
Patient Safety Learning

Pandemic changes affected maternity care for women who had stillbirths

Changes to maternity services during the pandemic, including the mandatory redeployment of midwives and doctors to care for infected patients, may have affected the care given to women who had stillborn babies, a Healthcare Safety Investigation Branch (HSIB) investigation has found.
The safety watchdog launched an investigation after the number of stillbirths after the onset of labour increased between April and June 2020. During the three months there were 45 stillbirths compared to 24 in the same period in 2019.
The HSIB launched a probe examining the care of 37 cases. Among its findings the watchdog said staffing levels were affected because of the NHS response to the pandemic.
In its report it said this “influenced normal work patterns and the consistency and availability of clinicians.”
As an example, in one maternity unit the staffing numbers were short by three midwives due to sickness and redeployment. In another consultant presence was reduced overnight.
During the pandemic both the Royal College of Midwives and the Royal College of Obstetricians criticised NHS trusts for redeploying maternity staff when mothers continued to need services regardless of the pandemic.
HSIB said none of the women in its report were recorded as having the virus, but it found the pressures and changes as a result of the pandemic may have affected the care they received.
The study stressed that the proportion of consultations undertaken remotely was not known and "the impact of remote consultations is not clear from this review".
Read full story
Source: The Independent, 16 September 2021
Patient Safety Learning

Call for investigation of menstrual changes after Covid jabs

Changes to periods and unexpected vaginal bleeding after having a Covid vaccine should be investigated to reassure women, says a leading immunologist specialising in fertility.
Writing in the BMJ, Dr Victoria Male, from Imperial College London, said the body's immune response was the likely cause, not something in the vaccines. There is no evidence they have any impact on pregnancy or fertility.
The UK's regulator has received more than 30,000 reports of period problems. These include heavier than usual periods, delayed periods and unexpected bleeding after all three Covid vaccines, out of more than 47 million doses given to women in the UK to date.
After reviewing the reports, the Medicines and Healthcare products Regulatory Agency (MHRA) says it "does not support a link" between Covid vaccines and the symptoms.
However, writing in an opinion piece in the BMJ, Dr Male says "robust research" into reports of period problems would help to counter misinformation around the vaccines.
"Vaccine hesitancy among young women is largely driven by false claims that COVID-19 vaccines could harm their chances of future pregnancy. Failing to thoroughly investigate reports of menstrual changes after vaccination is likely to fuel these fears."
"If a link between vaccination and menstrual changes is confirmed, this information will allow people to plan for potentially altered cycles," she said.
Read full story
Source: BBC News, 16 September 2021
Patient Safety Learning

Increase in number of patients accidentally exposed to ionising radiation in Irish hospitals last year

76 people were unintentionally exposed to ionising radiation in Irish hospitals in 2020, according to the Health and Information Quality Authority (HIQA). This figure represents an 11% increase on the total reported in 2019.
HIQA today published an overview report on the 'increase in accidental and unintended exposure to ionising radiation events notified to HIQA in 2020.
Under the European Union (Basic Safety Standards for Protection against dangers arising from Medical Exposure to Ionising Radiation) Regulations 2018 and 2019, HIQA is the competent authority for patient protection in relation to medical exposure to ionising radiation in Ireland.
In its 2019 report — its first such publication — HIQA expressed hope that the areas of improvement it identified "would help reduce the likelihood of such events and drive quality improvements in safety mechanisms for medical exposures in Ireland."
Despite this, eight more accidental exposure incidents were recorded in 2020 than in the previous year.
Human error was identified as the main cause of accidental exposure in 58% of the incidents, however, HIQA determined that other factors likely contributed to these.
Some 34% of the incidents involved the wrong patient being exposed to ionising radiation. HIQA said these exposures occurred at varying points along the medical exposure pathway.
It stressed that the number of unintended exposure to ionising radiation incidents last year was small compared with the total number of procedures carried out, estimated to be in the region of three million.
Read full story
Source: Irish Examiner, 15 September 2021
Patient Safety Learning

1 in 500 Americans have died of COVID-19

At a certain point, it was no longer a matter of if the United States would reach the gruesome milestone of 1 in 500 people dying of COVID-19, but a matter of when. A year? Maybe 15 months? The answer: 19 months.
The burden of death in the prime of life has been disproportionately borne by Black, Latino, and American Indian and Alaska Native people in their 30s, 40s and 50s.
“So often when we think about the majority of the country who have lost people to covid-19, we think about the elders that have been lost, not necessarily younger people,” said Abigail Echo-Hawk, executive vice president at the Seattle Indian Health Board and director of the Urban Indian Health Institute. “Unfortunately, this is not my reality nor that of the Native community. I lost cousins and fathers and tribal leaders."
The pandemic has brought into stark relief centuries of entwining social, environmental, economic and political factors that erode the health and shorten the lives of people of colour, putting them at higher risk of the chronic conditions that leave immune systems vulnerable to the coronavirus. Many of those same factors fuel the misinformation, mistrust and fear that leave too many unprotected.
Many people don’t have a physician they see regularly due in part to significant provider shortages in communities of colour. If they do have a doctor, it can cost too much money for a visit even if insured. There are language barriers for those who don’t speak English fluently and fear of deportation among undocumented immigrants.
“Some of the issues at hand are structural issues, things that are built into the fabric of society,” says Enrique W. Neblett Jr., a University of Michigan professor who studies racism and health.
Read full story (paywalled)
Source: The Washington Post, 15 September 2021
Patient Safety Learning

Major survey reveals ‘best and worst’ A&Es for patient satisfaction

A survey of almost 50,000 patients by the Care Quality Commission (CQC) found people’s experiences of emergency departments improved in 2020, compared to the last time the poll was conducted in 2018.
On a scale of one to 10, the regulator found 33% of patients scored their overall experience as 10, compared to 29% in 2018. Eighty-eight per cent of patients scored their care at six or higher, compared to 85% three years ago.
However, overall satisfaction levels declined at around 20 providers. 
Ted Baker, CQC’s chief inspector of hospitals, said: “This year’s survey shows some encouraging improvements with trust and confidence in clinicians, perceptions of cleanliness and overall experience all performing better than in previous years…
“However, the scope for further improvement remains. Access to emotional support, help with pain relief and information provided at discharge were all areas where some people surveyed were less positive.”
Read full story (paywalled)
Source: HSJ, 16 September 2021
Patient Safety Learning

Three deaths and ‘severe harm’ at trust with treatment delays

At least three people died and more came to ‘severe harm’ after treatment delays across three specialties at one hospital trust, new reports have revealed.
King’s College Hospital Foundation Trust commissioned harm reviews due to problems with a lack of capacity and poor management of waiting lists in endoscopy, dermatology and ophthalmology pre-pandemic. Most of the problems relate to the trust’s southern site, Princess Royal University Hospital, and took place before the current executive team took over.
The most recent board papers revealed a review of 614 cases at the PRUH’s endoscopy service found seven cases of “serious harm”. This category includes death and the document revealed three patients had died. 
The review also “highlighted delays in endoscopy leading to delayed diagnoses of cancer” in 2018-19 and 2019-20.
Investigators also found a dermatology patient came to “severe harm” after being lost to follow-up twice by the trust.
Read full story (paywalled)
Source: HSJ, 17 September 2021
Sam

Long Covid less common than feared - ONS study

One in 40 people with coronavirus has symptoms lasting at least three months, Office for National Statistics figures suggest.
In April, an ONS report put the proportion at about one in every 10. The latest, large and comprehensive analysis suggests long Covid may be less common than previously thought.
But the condition is not fully understood and still has no universally agreed definition, leading to different studies producing different figures.
However, like many other reports, the analysis suggests women, 50- to 69-year-olds and people with other long-term health conditions are the most likely to have symptoms of long Covid 12 weeks after a Covid infection.
People with high levels of virus in their body when testing positive are also more likely to have long Covid, the analysis suggests.
Read full story
Source: BBC News, 17 September 2021
Sam

Military to be called in to help Scottish ambulance crews

The Scottish government has asked the MoD for military assistance for the country's ambulance service.
Nicola Sturgeon said health services were dealing with the most challenging combination of circumstances in their history due to the COVID-19 pandemic.
Opposition politicians have highlighted a series of serious ambulance delays, including one where a man died after a 40-hour wait. They said this should not be happening in Scotland in 2021.
Ms Sturgeon said her government was looking at a range of plans to deal with the significant challenges facing the health services, with the detail of a request for military assistance being considered.
Investigations are ongoing into several cases reported in the media on Thursday, including one where a Glasgow pensioner died after a 40-hour wait for an ambulance.
The Herald newspaper reported that the family of 65-year-old Gerard Brown were told that he could have survived had help arrived sooner.
Mr Brown's GP - who is said to have repeatedly warned 999 call handlers that the patient's status was critical - was quoted as describing the crisis engulfing the Scottish Ambulance Service as being like "third world medicine".
The Scottish Ambulance Service is investigating the circumstances of the case, and said it will be "in contact with Mr Brown's family directly to apologise for the delay".
Read full story
Source: BBC News, 16 September 2021
Sam

Life expectancy in England falls to lowest level in a decade

Life expectancy in England has fallen to its lowest level since 2011, a Public Health England (PHE) report has said. Deaths were 1.4 times higher than expected between 21 March 2020 and 2 July 2021, according to the report’s findings.
The increase, largely driven by the pandemic the report said, resulted in a life expectancy decrease of 1.3 years in males, to 78.7, and a 0.9 year decrease in females, to 82.7 years - the lowest life expectancy since 2011.
Life expectancy inequality is also widening between people in the most and least deprived areas. The gap in male life expectancy between the most and least deprived areas in England is 10.3 years in 2020, which is a year higher than the 2019 level. Similarly for females, this same gap was 8.3 years in 2020, 0.6 years greater than in 2019.
The PHE report said the inequality gap reached its highest since it began recording data on deprivation linked life expectancy over two decades ago.
Its report stated: “This demonstrates that the pandemic has exacerbated existing inequalities in life expectancy by deprivation.
Read full story
Source: The Independent, 16 September 2021
 
Sam

Folic acid to be added to UK flour to help prevent birth defects

Folic acid is to be added to UK flour to help prevent spinal birth defects in babies, the government will announce.
Women are advised to take the B vitamin - which can guard against spina bifida in unborn babies - before and during pregnancy, but many do not. It is thought that adding folic acid to flour could prevent up to 200 birth defects a year.
Mandatory fortification - which the government ran a public consultation on in 2019 - would see everybody who ate foods such as bread getting more folic acid in their diets.
Neural tube defects, such as spina bifida (abnormal development of the spine) and anencephaly, a life-limiting condition which affects the brain, affect about 1,000 pregnancies per year in the UK. Many babies diagnosed with spina bifida survive into adulthood, but will experience life-long impairment.
Kate Steele, chief executive of Shine, a charity providing specialist support for people affected by spina bifida and hydrocephalus and which has campaigned for mandatory fortification of flour for more than 30 years, said she was "delighted" by the decision.
"In its simplest terms, the step will reduce the numbers of families who face the devastating news that their baby has anencephaly and will not survive," she said. "It will also prevent some babies being affected by spina bifida, which can result in complex physical impairments and poor health."
Read full story
Source: BBC News, 20 September 2021
Patient Safety Learning

Service rated ‘good’ despite ‘weaknesses in culture’

A trust’s maternity services were rated ‘good’ despite an independent report finding ‘weaknesses in the culture’ and ‘defensive and fractious’ behaviours, HSJ has learned.
As previously reported, former staff at Sandwell and West Birmingham Hospital Trust had raised concerns with the Care Quality Commission (CQC) over what they described as a “toxic management culture” and “unsafe” staffing levels in the trusts maternity service. Particular concerns were raised around community midwifery services.
This prompted an unannounced inspection by the CQC in May, which found “low morale and negative culture” in the services. However, the CQC ultimately concluded the trust was taking positive steps to address the problems and rated its maternity services “good” overall, as well as for leadership and safety.
Some frontline staff in the service have questioned those findings, however, and pointed to an independent review which was conducted in the early months of 2021.
This review, carried out by independent consultant Debbie Graham and seen by HSJ, concluded there was “evidence of weaknesses in the culture; evidenced in the behaviours of some staff which appears to go unaddressed; a lack of strong, visible leadership; a lack of a shared vision; the finding that some staff have a fear of ‘speaking up’; and poor communication systems.”
Read full story (paywalled)
Source: HSJ, 20 September 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.