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

Unsafe maternity care has cost the NHS £8.2bn in 15 years

Negligent maternity care in the NHS has cost taxpayers an “eye-watering” £8.2bn over the past 15 years, The Independent reveals.
Ministers face calls to urgently increase spending to ensure maternity units are safe for women and babies by providing adequate staffing levels, training and equipment.
New data, obtained by The Independent from NHS Resolution, which handles clinical negligence costs for the service, reveals that total payments made following settled cases and legal costs rose from £271m in 2006-07 to an estimated £920m in 2020-21.
The number of maternity claims being made by families has almost doubled in the past decade, rising from 391 in 2009-10 to 765 in 2019-20.
Recent maternity scandals at the Shrewsbury and Telford Hospital Trust, East Kent Hospitals University Trust and at hospitals in Nottingham have all had common themes around poor culture, a lack of honesty and not enough staff or equipment.
The Department of Health and Social Care is exploring how it can make changes to the UK clinical negligence system to reduce the costs to the taxpayer. Health minister Nadine Dorries told MPs on the Commons health committee in February that the reforms would look “across the NHS… not just maternity, at how issues of no-blame, no-fault compensation and clinical negligence are treated”.
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Source: The Independent, 20 September 2021
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Entire Covid shielding programme quietly axed for good on day of Cabinet reshuffle

The entire Covid shielding programme has been “closed” for good in an announcement slipped out at night during a Cabinet reshuffle.
Clinically extremely vulnerable people will “not be advised to shield again” in future despite fears of a huge winter wave, said the statement uploaded to the government website last week.
Furious charities today raised fears disabled and immunosuppressed people will be “cast adrift” - while others will feel “yet again forgotten by the government”.
Some 3.8million vulnerable people were advised to shield during England’s third lockdown, going outside only for exercise or health appointments. That guidance was paused on 1 April and on July 19 people were told they could follow the same rules as the rest of the population.
But the ‘Shielded Patient List’ was retained for future use and ex-shielders were given special tips, such as only meeting vaccinated people.
Last night, however, the government announced there will no longer be “centralised guidance” for clinically extremely vulnerable people.
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Source: Mirror, 16 September 2021
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Mental health hospital in Suffolk closed after 'unacceptable' care

A mental health hospital in Suffolk has been closed after inspectors found it was failing to protect patients from harm and abuse.
St John's House in Palgrave, near Diss, was previously rated inadequate by the Care Quality Commission (CQC). A further inspection of the 49-bed hospital found the care was "unacceptable" and "insufficient progress had been made regarding patient safety".
The company that runs the hospital, Partnerships in Care, part of the Priory Group, has now decided to close the site.
Stuart Dunn, CQC head of inspection for mental health and community services, said: "Our latest inspection of St John's House found an unacceptable service where insufficient improvements had been made to protect patients from harm and abuse and the number of safety incidents remained high."
"Staff weren't responding appropriately to patients who were self-harming, with one patient not being sent to hospital quickly enough after swallowing a foreign object, despite complaining of abdominal pain.
"We reviewed CCTV footage and found staff were sometimes asleep when they should have been observing patients to make sure they were safe. This was all the more concerning as we identified this as a concern during the previous two inspections of this service, demonstrating a lack of improvement to keep patients safe.
"Incidents of restraint remained high and not all staff had the right training to carry it out safely. In addition, staff were not following hospital policy when using soft handcuffs with patients during safety incidents."
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Source: ITV News, 17 September 2021
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Scottish Hospitals Inquiry to begin to investigate problems at flagship hospitals

An inquiry will begin hearing evidence on Monday into problems at two flagship Scottish hospitals that contributed to the death of two children.
The Scottish Hospitals Inquiry is investigating the construction of the Queen Elizabeth University Hospital (QEUH) campus in Glasgow and the Royal Hospital for Children and Young People and Department of Clinical Neurosciences in Edinburgh.
The inquiry was ordered after patients at the Glasgow site died from infections linked to pigeon droppings and the water supply, and the opening of the Edinburgh site was delayed due to concerns over the ventilation system.
Earlier this year, an independent review found the death of two children at the QEUH were at least in part the result of infections linked to the hospital environment.
The review investigated 118 episodes of serious bacterial infection in 84 children and young people who received treatment for blood disease, cancer or related conditions at the Royal Hospital for Children at the campus. It found a third of these infections were “most likely” to have been linked to the hospital environment.
The inquiry will aim to determine how issues at the two hospitals relating to ventilation, water contamination and other matters impacted on patient safety and care and whether this could have been prevented.
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Source: The Herald, 20 September 2021
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Failure to update Covid symptom list ‘is killing people’, leading researcher warns

The Government’s out-of-date advice on Covid symptoms that should trigger a PCR test could be causing around 20,000 cases a day and needs to be changed urgently, a leading researcher has warned.
Speaking with Pulse, Professor Tim Spector, who heads the ZOE Covid study at King’s College London said the picture is ‘now fairly clear’ that the most common symptoms among those now testing positive are nothing like when the pandemic began.
‘It’s the wrong message and it’s not a joke, it’s killing people,’ he told Pulse.
The ZOE Covid study was first launched in March 2020 and tracks infections using an app with millions of users.
According to the app, the traditional symptoms of cough, shortness of breath, and fever rank way down the list in vaccinated adults and unvaccinated children.
Instead the virus is presenting more like a regular cold with runny nose, headache, sneezing and sore throat leading the way. ‘One in two people with a positive PCR test across the country lack any of the three government approved symptoms,’ he said. ‘We’re missing lots of cases.’
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Source: Pulse, 17 September 2021
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‘Worrying failings’ in the administration of the NHS maternity charging programme

Maternity Action’s new research has found worrying failings in the administration of the NHS charging programme, leaving vulnerable women anxious and fearful about debts they cannot pay and deterring them from attending for care.
Maternity Action’s new report Breach of Trust: a review of the implementation of the NHS charging programme in maternity services in England details how the implementation of the government’s NHS charging ‘overseas visitors’ programme within NHS Trusts poses a significant risk to migrant women’s health and wellbeing.
The government insists that women who are vulnerable are adequately protected because the regulations make certain vulnerable groups exempt from NHS charging, such as refugees, asylum seekers, women who have been victims of modern slavery. The government have also stated that all maternity care should be deemed ‘immediately necessary’ and not refused due to an inability to repay.
However the report has found that these legal safeguards are simply not working upon implementation in Trust settings. Many migrant women living in the UK are put at risk because they are deterred from accessing essential maternity care.
Read full story
Source: Maternity Action, 16 September 2021
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Winners of HSJ Patient Safety Awards 2021 revealed

Last night’s HSJ Patient Safety Awards celebrated the innovative work of frontline NHS teams in a year when the challenge and necessity of keeping the public safe had never been greater.
Patient Safety Team of the Year was St Luke’s Cancer Centre and the pharmacy team from Royal Surrey Foundation Trust, who achieved ambitious change to reduce the risk of covid infections of cancer patients.
This year saw the introduction of the Improving Care for Children and Young People Initiative of the Year which was won by Humber Teaching FT and Hull CCG for their Humber Sensory Processing Hub. Website
The Patient Safety Awards celebrate the teams at the frontline pushing the boundaries of patient safety and driving cultural change to minimise risk, enhance quality of care and ultimately save lives.
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Source: HSJ, 21 September 2021
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Troubled maternity wards still jeopardising patients, watchdog warns

Babies and mothers are at risk of injury and death because too many maternity units have not improved care despite a string of childbirth scandals, a Care Quality Commission (CQC) report has warned.
In a highly critical report published on Tuesday, the CQC voiced serious concern that lessons are not being learned and that many incidents involving patients’ safety are still not being recorded.
Some hospitals have been “too slow” to take the steps needed to make labour and birth safer, despite multiple inquiries, reports and recommendations to do so, it said.
The CQC also found other persistent weaknesses in maternity care, including tension and difficulties between obstetric doctors and midwives and poor oversight of risks to patients during an in-depth inspection of maternity care at nine hospitals in England. The NHS has been criticised for major maternity scandals involving poor care, which sometimes persisted for many years, at trusts such as Morecambe Bay, East Kent and Shrewsbury and Telford.
The government, NHS leaders and patients have pressed the NHS in England to overhaul maternity safety to reduce the number of babies being left brain-damaged or dead and mothers injured or dead as a result of poor care during childbirth.
The watchdog also criticised hospitals for doing too little to seek the views from black, minority ethnic and poorer communities about how to improve their experience of giving birth. Black women are four times more likely to die in childbirth than white women, and Asian women twice as likely.
“We know that many maternity services are providing good care, but we remain concerned that there has not been enough learning from good and outstanding services,” said Ted Baker, the regulator’s chief inspector of hospitals.
Read full story
Source: The Guardian, 21 September 2021
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Overprescribing of medicines must stop, says government

Many patients are being prescribed unnecessary and even harmful treatments, a new report warns.
The review, in England, suggests one-tenth of items dispensed by primary care are inappropriate or could be changed. Around 15% of people take five or more medicines a day - some are to deal with the side-effects of the others.
The government is appointing a prescribing tsar to help with the issue and stop waste.
Overprescribing can happen when:
a better alternative is available but not given the medicine is appropriate for a condition but not the individual patient a condition changes and the medicine is no longer appropriate the patient no longer needs the medicine but continues to be prescribed it. Chief pharmaceutical officer for England, Dr Keith Ridge, said: "Medicines do people a lot of good and this report is absolutely not about taking treatment or services away from people where they are effective. But medicines can also cause harm and can be wasted."
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Source: BBC News, 22 September 2021
Patient Safety Learning

Leaked national survey reveals steep fall in support for staff wellbeing

Leaked results from a national survey of NHS staff has revealed a sharp drop in those who believe their health and wellbeing is being supported by their employer.
The People Pulse is a national, monthly survey launched in 2020. It enables provider and commissioner organisations to monitor the NHS workforce’s health and wellbeing.
According to a snapshot of the results recorded between May and August seen by HSJ, there was a drop of 9.6 percentage points in “perceptions of wellbeing support”, with “positivity” sitting at 57.3%.
Almost a quarter of the survey respondents reported a “negative” experience of health and wellbeing support.
The survey results also revealed almost a third of respondents said they wanted to speak up about a specific issue during the pandemic, especially on issues of staff safety, health and wellbeing, but they did not because they feared repercussions or believed nothing would happen.
Read full story (paywalled)
Source: HSJ, 21 September 2021
Sam

Damning report published into death of baby born to teenager in prison cell

A catalogue of failures among prison and health professionals has been highlighted in an investigation report into the death of a teenager’s baby after she gave birth alone in her cell at the largest women’s prison in Europe.
The Prisons and Probation Ombudsman published the devastating report into the events in September 2019 at HMP Bronzefield in Ashford, Middlesex on Wednesday. The case was first revealed by the Guardian and the baby’s death triggered 11 separate inquiries.
The report details a disturbing series of events that culminated with the young woman, who cannot be named, being in “constant pain” on the night of 26 September and eventually passing out while giving birth.
According to the report the teenager "appeared to have been regarded as difficult and having a ‘bad attitude’ rather than as a vulnerable 18-year-old, frightened that her baby would be taken away”. Failings included:
There was confusion among different health professionals about her due date. The day before her baby was born she told a prison nurse she would kill herself or someone else if the baby was taken away from her, but this information was not adequately shared. On 26 September she was put on extended observation, meaning she should have been regularly checked but this did not happen. She rang the bell twice at 8.07pm and 8.32pm that day. A call was connected then immediately disconnected at 8.45pm. She did not press the bell again. Checks by prison officers at 9.27pm and 4.19am revealed “nothing untoward”. It was left to two prisoners to alert staff to the fact that there was blood in her cell at 8.21am on 27 September. Prisons and Probation ombudsman Sue McAllister said: “Ms A gave birth alone in her cell overnight without medical assistance. This should never have happened. Overall, the healthcare offered to Ms A in Bronzefield was not equivalent to that she could have expected in the community.”
The publication of the report has triggered multiple calls for an end to the imprisonment of pregnant women from the Royal College of Midwives, NGOs and academics in the field. 
Read full story
Source: The Guardian, 22 September 2021
Sam

Blood inquiry: Former cabinet minister says AIDS advice was "regrettable"

It was "regrettable" that the government said there was "no conclusive proof" AIDS could be transmitted by blood products in 1983, a public inquiry has heard.
Giving evidence, former secretary of state Lord Fowler said it would have been better to add that it was likely NHS treatment could be contaminated. But he said he didn't think the change would have made a crucial difference.
Survivors have accused ministers of playing down the risks at the time.
It's thought around 3,000 haemophiliacs died of AIDS and hepatitis C after being treated with a blood-clotting product called Factor VIII in the 1970s and 1980s.
Groups representing families of those affected by the scandal claim the use of the phase "no conclusive proof" minimised the danger from blood products at the time.
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Source: BBC News, 22 September 2021
Sam

‘Devastated’ doctors warn trust CEO of ‘extremely unsafe situation’

Consultants at a major tertiary centre have written to their chief executive, warning services are in ‘an extremely unsafe situation’ and calling for elective work to be diverted elsewhere.
Surgeons and anaesthetists at the former Brighton and Sussex University Hospitals Trust — now part of University Hospitals Sussex Foundation Trust — said: “We are devastated to report that the care we aspire to is not being provided at UHS… we are forced to contemplate that it is not safe to be open as a trauma tertiary centre and we feel elective activity must be proactively diverted elsewhere.”
The letter from BSUH’s anaesthetist and surgical consultant body is dated yesterday and was sent to UHSussex chief executive Dame Marianne Griffiths. The Royal Sussex County Hospital in Brighton — part of the trust — is the major trauma centre for the South East coast, from Chichester to parts of Kent.
In the letter, seen by HSJ, the consultants claimed a shortage of theatre staff is leading to “clinical safety issues, gross operational inefficiencies and burnout within our remaining depleted staff groups”. 
Read full story (paywalled)
Source: HSJ, 21 September 2021
Sam

Endometriosis: 'I thought I would die from period blood loss'

A woman with stage 4 endometriosis said she was told she needed to "be more positive" before her diagnosis - despite heavy blood loss and pain.
Anna Cooper, from Newbridge, Wrexham, started her periods at 11 and by the time she turned 14, her mother was pushing for a referral.
Since then she has had 13 surgeries, with a 14th due in the coming months.
She said: "It is not taken seriously enough. It seems to be that we are just not being heard at the minute."
Watch video
Source: BBC News, 9 September 2021
Sam

Children’s NHS mental health referrals double in pandemic

Record numbers of children and young people are seeking access to NHS mental health services, figures show, as the devastating toll of the pandemic is revealed in a new analysis.
In just three months, nearly 200,000 young people have been referred to mental health services – almost double pre-pandemic levels, according to the report by the Royal College of Psychiatrists.
Experts say the figures show the true scale of the impact of the last 18 months on children and young people across the country.
“These alarming figures reflect what I and many other frontline psychiatrists are seeing in our clinics on a daily basis,” said Dr Elaine Lockhart, the college’s child and adolescent faculty chair. “The pandemic has had a devastating effect on the nation’s mental health, but it’s becoming increasingly clear that children and young people are suffering terribly.”
Read full story
Source: The Guardian, 23 September 2021
Sam

NHS Scotland's 'biggest crisis' in five charts

Scotland's Health Secretary Humza Yousaf says the NHS is facing the "biggest crisis" of its existence.
There's a shortage of beds, the demand for ambulances is soaring and waits in accident and emergency departments are getting longer.
On top of that, COVID-19 admissions have been rising fast as the number of infections in Scotland spiralled at the end of the summer.
BBC News share five charts illustrating the enormous pressures currently being felt by NHS Scotland.
Read full story
Source: BBC News, 23 September 2021
Sam
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