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

Major trust forced to restrict chemotherapy amid staff shortages

A major acute trust in the East Midlands has been forced to restrict how much chemotherapy it is able to offer due to staff shortages.
Nottingham University Hospitals Trust confirmed in a statement its chemotherapy service has been affected by long-term staff sickness and staff vacancies. 
A trust spokeswoman said: “We continue to provide chemotherapy to patients who benefit most from the treatment and the small number of patients affected have been contacted directly by their specialist cancer team and offered support.”
She added: “We are recruiting to posts as well as working with neighbouring NHS and private providers to ensure that any delays are minimal.”
The trust added all its patient care decisions adhered to national guidance aimed at helping chemotherapy centres categorise and prioritise treatments when these situations arise.
The Nottingham Post first reported the difficulties facing the trust, suggesting the restrictions would specifically affect palliative care patients who receive chemotherapy at NUH’s City Hospital site.
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Source: HSJ, 23 September 2021
Sam

Watchdog warns its powers will be weakened by Health and Care Bill reforms

The health service ombudsman has warned he will ‘be in no position to investigate’ the behaviour of another watchdog under the government’s health service reforms.
Rob Behrens, the Parliamentary and Health Service Ombudsman, said plans to create a “closed safe space” for the information provided by clinicians to the Healthcare Safety Investigation Branch (HSIB) will mean a reduction in his powers and he will not be able to hold HSIB to account.
Mr Behrens, speaking at HSJ’s Patient Safety Congress, said that although coroners would be able to access information gathered by HSIB investigations under the reforms, the ombudsman would not be able to access this “safe space” without the permission of the High Court.
The reforms would see HSIB become a new statutory independent organisation, the Health Service Safety Investigations Body, and prohibit the disclosure of “protected material” such as information or documents obtained during investigations.
However, this prohibition of disclosure would not apply to information required by coroners, ordered by the High Court or necessary to investigate an offence or address a “serious and continuing” safety risk to a patient or the public.
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Source: HSJ, 22 September 2021
Sam

ICS leaders must have courage to put quality first, says CQC chief inspector

The Care Quality Commission’s (CQC) outgoing chief inspector of hospitals has called on integrated care system leaders to be ‘courageous’ in putting quality first.
Speaking at the HSJ’s Patient Safety Congress, Ted Baker implored ICS leaders to not focus solely on financial and operational targets, although he also acknowledged “there is a lot of pressure to meet [those] targets”.
In his speech yesterday, he said: “It’s often taken really courageous leaders to put quality first ahead of financial targets and operational targets… You have to be courageous to do that and I think some of the leaders of the ICSs, they need to be that courageous.
“They need to focus on quality and safety within an [ICS] and not, if you like, go down the kind of NHS path of focusing on financial and operational targets.
“If we can do that, we can have a really transformative effect on integrated care across [the] system. I suppose that’s what I’m asking for: courage from all of us to tackle some of the cultural issues in the NHS."
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Source: HSJ, 22 September 2021
Sam

Mental health unit death raises coroner fears

A coroner has raised concerns about how a family was allowed to bring a restricted item that contributed to a man's death into a mental health unit.
Joshua Sahota, 25, died as a result of asphyxia and psychosis in Bury St Edmunds, Suffolk, on 9 September 2019.
Suffolk coroner Nigel Parsley said Mr Sahota's relatives were not told the item they brought in when visiting was on a restricted list.
The NHS trust which runs the unit said it had improved its internal processes.
Mr Sahota, from Kennett in Cambridgeshire, was taken to the Wedgewood Unit on the West Suffolk Hospital site three weeks before his death as his mental health had declined. 
Insufficient staffing levels contributed to his death, an inquest jury at Suffolk Coroner's Court concluded.
Other factors included insufficient observations and one-to-one processes, no clear and concise risk assessments, being slow to develop a care plan and the absence of a documented crisis plan.
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Source: BBC News, 21 September 2021
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Cancer backlog could take a decade to clear

It could take more than a decade to clear the cancer-treatment backlog in England, a report suggests.
Research by the Institute for Public Policy Research (IPPR) estimated 19,500 people who should have been diagnosed had not been, because of missed referrals. 
If hospitals could achieve a 5% increase in the number of treatments over pre-pandemic levels, it would take until 2033 to clear the backlog. However, if 15% more could be completed, backlogs could be cleared by next year.
Between March 2020 and February 2021, the number of referrals to see a specialist dropped by nearly 370,000 on the year before, a fall of 15%.
Behind these figures are thousands of people for whom it will now be too late to cure their cancer, the report, with the CF health consultancy, warns.
And it estimates the proportion of cancers diagnosed while they are still highly curable - classed as stage one and two - has fallen from 44% before to pandemic to 41%.
IPPR research fellow Dr Parth Patel said: "The pandemic has severely disrupted cancer services in England, undoing years of progress in improving cancer survival rates.
"Now, the health service faces an enormous backlog of care, that threatens to disrupt services for well over a decade. We know every delay poses risks to patients' chances of survival."
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Source: BBC News, 24 September 2021
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Return of the common cold: infections surge in UK as autumn arrives

The return of schools and the arrival of autumn means common colds and other respiratory infections are firmly on the rise, spreading coughs and sneezes, more severe illnesses, and prompting some to report their worst colds ever.
According to Public Health England, there is no particularly nasty new virus doing the rounds, but as cases rise, experts warn that people can expect more frequent infections and more serious symptoms now the UK is emerging from lockdown.
Common colds and other respiratory tract infections tend to ramp up in September when the schools go back and autumn arrives, but after 18 months of social distancing and mask wearing, many people are thought to have weaker immune defences to protect themselves against the onslaught of respiratory viruses.
With reduced immunity across the board, people may fall ill with viruses they would normally have fended off with little trouble, or develop co-infections that make them feel more poorly. This is particularly likely if the viruses that have been kept at bay by anti-Covid measures all bounce back at once.
“We don’t know what we’re going to see with common colds this season,” said Prof Ronald Eccles, former director of the Common Cold Centre at Cardiff University. “We’re seeing this increase now, but the whole system has been knocked out of kilter by the fact that we’ve been socially distancing and wearing masks, and children have not had that immunity over the past year or so.”
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Source: The Guardian, 24 September 2021
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TikTok video of IUD removal at home prompts warning from health authorities

A TikTok user who went viral with a video of herself removing her implanted birth control device has prompted calls among sexual health experts for better monitoring of social media platforms.
In a video which has gained over 178,000 likes, TikTok user Mikkie Gallagher is filmed performing a ‘DIY IUD removal’ wearing medical gloves, writing on top of the post: “A lot easier than I thought TBH,” and “Catch of the day: Mirena IUD, 2 inches”.
An intrauterine device (IUD) is inserted into the uterus to prevent pregnancy and sometimes assist in relieving period pain. They usually need to be taken out every five to 10 years depending on the type. Women can choose when to have them removed.
Family Planning Victoria CEO, Claire Vissenga, said she found it very concerning that “DIY could pass as healthcare or professional assistance”.
“... it’s just a ridiculous thing to do. Removing an IUD potentially does physical damage, and could complicate contraception,” says Vissenga
Family Planning medical director, Kathleen McNamee, said 80% of DIY IUD removals failed, leading to GP or emergency visits.
“If the person dislodges the IUD in a failed attempt, it could no longer be effective as a contraceptive method and result in an unwanted pregnancy,” she said.
Read full story
Source: The Guardian, 24 September 2021
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Hospitals consider ‘risky’ dilution of ICU nursing ratios

NHS trusts in London are looking to dilute their intensive care nurse-to-patient ratios due to workforce shortages, according to a leading critical care nurse.
Nicki Credland, chair of the British Association of Critical Care Nurses, told HSJ’s Patient Safety Congress that trust leaders in London have discussed relaxing the ratios from one nurse per patient, to one nurse per 1.75 patients.
ICU staffing ratios have been intermittently diluted throughout the covid pandemic, but this has previously been used as a temporary measure.
Ms Credland, a keynote speaker at the event on Tuesday, suggested some trusts are now looking at a permanent shift away from one-to-one care. She added: “What we are seeing now is that certain trusts in the country are doing exactly what we were worried about."
“Starting to move away from those [guidelines for the provision of intensive care services] standards that we have, that protect both us as nurses but also protect the patient’s safety as well."
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Source: HSJ, 24 September 2021
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‘Horrendous’ patient death after staff mistake physical injuries for mental health condition

A patient died from a serious spinal injury after emergency staff incorrectly attributed his physical condition to his mental health issues, an inquest heard.
Robert Walaszkowski, who had been detained at a secure mental health unit run by North East London Foundation Trust in October 2019, suffered a serious injury after running into a door on the unit.
Staff from London Ambulance Service did not suspect a spinal injury and he was taken to the emergency department at Queen’s Hospital in Romford with a suspected head injury. An inquest heard he did not receive a spinal examination and imaging of the spine, despite this being required due to the nature of his injury and presentation.
He was discharged from A&E the following day, and was then placed on the floor of a private patient transport vehicle, to be transported back to the mental health unit, Goodmayes Hospital. He arrived at the hospital unresponsive. He never recovered consciousness and died of his injuries a month later.
An inquest jury has recorded a narrative conclusion and found that neglect contributed to Robert’s death.
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Source: HSJ, 24 September 2021
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Labour launches bid to end NHS ‘culture of secrecy’ and improve safety following care scandals

Labour is to push for key changes to the government’s NHS reforms, with new laws on transparency in the NHS and a demand for safe staffing levels on hospital wards, following a series of scandals relating to failures in patient care.
Amendments to the government’s Health and Care Bill will also include plans for the investigation of stillbirths by medical examiners, and for limits on the power of the health secretary to interfere in investigations.
Labour’s shadow health secretary Jonathan Ashworth believes the changes – which also include giving local NHS regions the ability to object to some spending limits if they consider them to pose a risk to patient safety – will attract the support of Conservative MPs.
In an exclusive interview with The Independent ahead of the Labour Party conference in Brighton, Mr Ashworth said it was vital that the NHS learned from mistakes and improved its record on safety, which he said could only be achieved through greater transparency.
“Patient safety has been forgotten in this bill. The patient voice has been ignored. Patients are like the ghosts in the machine,” he said.
“The bill is going through parliament, and we are putting down amendments to improve it as best we can. We want to put in the bill a framework to deliver greater patient safety, because after all, it should be the golden thread running through every aspect of healthcare delivery."
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Source: The Independent, 26 September 2021
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Milly Main: Criminal investigation over hospital deaths

Police have launched a criminal investigation into a number of deaths at a Glasgow hospital, including that of 10-year-old Milly Main. It comes as a separate public inquiry into the building of several Scottish hospitals is being held.
Milly's mother recently told the inquiry her child's death was "murder".
A review in May found an infection which contributed to Milly's death was probably caused by the Queen Elizabeth University Hospital environment.
The Crown Office and Procurator Fiscal Service has now instructed police to investigate the deaths of Milly, two other children and 73-year-old Gail Armstrong at the Glasgow campus. It is understood the probe could lead to criminal charges or a fatal accident inquiry.
A spokesperson said: "The investigation into the deaths is ongoing and the families will continue to be kept updated in relation to any significant developments."
The Crown Office added that it was committed to supporting the Scottish Hospitals Inquiry and "contributing positively" to its work.
Read full story
Source: BBC News, 26 September 2021
 
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'Vigilante treatments': Anti-vaccine groups push people to leave ICUs

Anti-vaccine Facebook groups in the United States have a new message for their community members: Don’t go to the emergency room, and get your loved ones out of intensive care units.
Consumed by conspiracy theories claiming that doctors are preventing unvaccinated patients from receiving miracle cures or are even killing them on purpose, some people in anti-vaccine and pro-ivermectin Facebook groups are telling those with COVID-19 to stay away from hospitals and instead try increasingly dangerous at-home treatments, according to posts seen by NBC News over the past few weeks.
Some people in groups that formed recently to promote the false cure ivermectin, an anti-parasite treatment, have claimed extracting Covid patients from hospitals is pivotal so that they can self-medicate at home with ivermectin. But as the patients begin to realize that ivermectin by itself is not effective, the groups have begun recommending a series of increasingly hazardous at-home treatments, such as gargling with iodine, and nebulizing and inhaling hydrogen peroxide, calling it part of a “protocol.”
The messages represent an escalation in the mistrust of medical professionals in groups that have sprung up in recent months on social media platforms, which have tried to crack down on Covid misinformation. And it’s something that some doctors say they’re seeing manifest in their hospitals as they have filled up because of the most recent delta variant wave.
Those concerns echo various local reports about growing threats and violence directed toward medical professionals in the US. In Branson, Missouri, a medical center recently introduced panic buttons on employee badges because of a spike in assaults. Violence and threats against medical professionals have recently been reported in Massachusetts, Texas, Georgia and Idaho.
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Source: NBC News, 24 September 2021
 
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Fears over NHS plan to close all local ambulance stations in London

NHS bosses plan to shut every local ambulance station in London, prompting fears that patients could be harmed if 999 crews take longer to reach them, the Guardian can reveal.
The London ambulance service (LAS) has started a controversial programme to close all 68 ambulance stations and replace them with 18 new “ambulance deployment centres” or “hubs”.
A patient group has criticised the plan as “dangerous” and MPs are worried that having fewer ambulance stations around the capital could mean patients wait longer to get to hospital.
“This move to shut every ambulance station in London could cause significant harm to patients because of the delays that will take place in getting to them,” said Malcolm Alexander, the chair of the LAS Patients’ Forum, a non-statutory watchdog, and Hackney Healthwatch, a government-funded statutory body that scrutinises NHS services in the east London borough.

“We have come across many situations where people have suffered harm because ambulances have taken too long to get there. It looks like this is quite dangerous from the point of view of patient safety.”
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Source: The Guardian, 25 September 2021
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Trusts struggle with growing backlog of uninvestigated incidents

The backlog of serious clinical incidents that need investigating is building up throughout the NHS, due to the impact of coronavirus and emergency service pressures.
Concerns have been raised by commissioners in some areas over the delays. Meanwhile, patients and families who have been harmed are waiting longer to see their cases resolved and the organisations involved are not learning the lessons taught by care failures as quickly as they should. 
Staff redeployment or absences due to COVID-19 are among the reasons why many investigations are being delayed. As result, trusts are attempting to recruit additional investigators to manage their backlogs.
Tina Ivanov, the trust’s director of quality governance, said: “Learning from serious incidents when they occur is an important part of our improvement culture.
“We are increasing the number of trained investigators at the trust and have brought in additional resource to help complete the outstanding investigations. The reasons for the increase in outstanding serious incidents include staff absences and clinical pressures.”
Read full story (paywalled)
Source: HSJ, 27 September 2021
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NHS waits: More people feeling forced into private healthcare

"To be put in a position where you're basically begging off people, it's infuriating."
Last October, 12-year-old Hayden Kildea was diagnosed with severe scoliosis, a condition where the spine twists and curves to the side. Left untreated, it can become a dangerous and life-limiting condition.
The Kildeas, who live in Strabane, Northern Ireland, say they were told Hayden would need urgent surgery - but that because of the backlog caused by the pandemic, he would have to wait more than two years.
His mum Shauna found a clinic in Turkey that was able to carry out the operation immediately, but it would cost £50,000 - money the family didn't have. So in the summer, they turned to crowdfunding and campaigning to raise the money.
Millions of people across the UK are currently on NHS waiting lists - in Northern Ireland there are over 465,000 people, while in England, 5.6m are queuing for treatment.
Data shared with BBC Panorama shows that on average, waiting lists have grown by 50% in the most deprived parts of England since the start of the pandemic, compared with nearly 35% in the most affluent areas.
The research, conducted by the King's Fund, also shows that people on waiting lists in poorer areas are nearly twice as likely as those in wealthier areas to wait more than one year for treatment.
The Health and Social Care Board in Northern Ireland said patient demand continued "to exceed capacity across a range of specialties". It added: "As a result, even before the pandemic, the number of people waiting longer than the target waiting times was increasing."
Read full story
Source: BBC News, 27 September 2021
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COVID-19 bereaved families group hopes PM will 'take us seriously' at meeting

The co-founder of a coronavirus bereaved families group has said he hopes Boris Johnson will "at long last... take us seriously" when he meets them at Number 10 today.
Matt Fowler said it is vital the prime minister understand the need to start a public inquiry as soon as possible.
Mr Johnson will meet members of the Covid-19 Bereaved Families for Justice group today - more than a year after promising to meet people whose loved ones had died.
They will share how their family members caught the disease and died, and repeat calls for a public inquiry to get priority.
The group plans to raise issues with the PM such as the disproportionate effect of COVID on some ethnic groups, transmission of the disease on public transport and in the workplace, the impact of late lockdowns, and failures to learn from the first wave.
Boris Johnson previously said the inquiry would start in spring 2022.
Read full story
Source: Sky News, 28 September 2021
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