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

A third of stillbirths in Cwm Taf maternity units 'could have been prevented', review finds

A third of stillbirths at two south Wales hospitals could have been prevented with better care or treatment, an investigation has concluded.
It emerged two years ago that more than 60 women suffered the heartbreak of a stillbirth at at the Royal Glamorgan, Llantrisant, and Prince Charles Hospital, Merthyr Tydfil, and that many of these were never reported or investigated.
An independent panel set up by the Welsh Government to oversee improvements in these maternity units has now concluded that many of these babies could have been saved.
It looked at whether the care provided to women and their babies between January 2016 and September 2018 fell below the standards expected. The failures were split into different levels of severity, known in the report as "modifiable factors".
Their investigation looked at 63 stillbirths between January 1, 2016, and September 30, 2018, and discovered that 21 (33%) of them had at least one "major modifiable factor", meaning the stillbirth could potentially have been avoided.
More than half (59%) of the 63 had at least one "minor modifiable factor" while in three-quarters (76%) of them "wider learning" was required. In only four of the 63 stillbirths the panel found no modifiable factors.
The panel also discovered that "areas for learning" were identified in 59 of the 63 episodes of care reviewed.
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Source: Wales Online, 5 October 2021
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Patient Safety Learning

First new treatment for sickle cell in 20 years

The first new sickle-cell treatment in 20 years will help keep thousands of people out of hospital over the next three years, NHS England has said.
Sickle-cell disease is incurable and affects 15,000 people in the UK.
And the National Institute for Health and Care Excellence said the hope of reducing health inequalities for black people, who are predominantly affected and often have poorer health to start with, made the drug worth recommending.
It called it "an innovative treatment".
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Source: BBC News, 5 October 2021
Sam

Health secretary to act on racial bias in effectiveness of medical devices

Sajid Javid has said medical device manufacturers should check their products work well for people of all ethnic backgrounds, citing problems that those with dark skin have experienced when using pulse oximeters.
Several studies have found oximeters are not as good at identifying hypoxia in people with darker skin. The devices have been widely used during the covid pandemic to monitor people at risk of deteriorating at home. They are meant to trigger a response when needed. Official guidance was updated this summer to encourage caution in their use. 
The health and social care secretary has identified health inequalities as one of his priorities. He gave the issue as an example of racial bias in healthcare when speaking at the Conservative party conference on Tuesday evening.
He said: “It turned out that pulse oximeters, all of them that exist in the world, were giving often the wrong reading for people with dark skin, because they were designed by companies where basically all they were thinking about were white people. Why is that? Because the companies, their market was white countries with a majority of white people.”
Mr Javid, who has a British Pakistani background, continued: “They just weren’t thinking whether these things could work on people with a skin colour like mine or just darker skin, and that’s not right.
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Source: HSJ, 6 October 2021
Sam

Symptoms to watch for as 10% of secondary pupils suffer long Covid

More than one in ten secondary school pupils and over a third of school staff who had COVID-19 have suffered ongoing symptoms, figures suggest.
The most common symptom reported by staff and pupils was weakness/tiredness, while staff were more likely to experience shortness of breath than pupils, according to a small study of schools in England.
The survey from the Office for National Statistics (ONS) estimates that about 35.7% of staff and 12.3% of secondary school pupils with a previously confirmed Covid-19 infection reported experiencing ongoing symptoms more than four weeks from the start of the infection.
Among those experiencing ongoing symptoms, 15.5% of staff and 9.4% of secondary school pupils said their ability to carry out day-to-day activities had been significantly reduced.
Geoff Barton, general secretary of the Association of School and College Leaders, said: “This survey data reveals the largely hidden long-term effects of Covid on both students and school and college staff.
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Source: Wales Online, 28 September 2021
Sam

Women have struggled to get help with the menopause for decades but it’s about to change

HRT used to be a dirty word. Now it’s a battle cry. Women will begathering in Parliament Square in London later this month to support the menopause bill to demand free prescriptions for hormone replacement therapy in England. The bill could help thousands more women to access this life-changing treatment and will put the menopause under the microscope.
For years, a combination of medical sexism, hysterical reporting and outdated science has held women back from asking for the health care they need. HRT replenishes the oestrogen, progesterone (and sometimes testosterone) that women lose when having the menopause. As a result of previous misleading reports linking the treatment to a risk of breast cancer and dementia, HRT has long been considered controversial.
Last week, however, a BMJ paper studying more than 100,000 HRT users over two decades in the UK found that there was no overall association between hormone replacement and an increased risk of developing dementia. Meanwhile, the science lumping the many different types of HRT together in one “causes-breast-cancer” basket is being questioned by menopause experts.
A sexist, ageist culture has kept the menopause – and the stigma associated with it – hidden for decades. In a TUC survey of 4,000 women, 85% said the menopause affected their working life. Many women have lost their health, jobs, relationships and even their lives at the time of their menopause, when rates of suicide peak.
But now, Labour MP Carolyn Harris is pushing the second reading of her menopause bill through parliament later this month. Aside from making HRT free in England (it’s already free in Scotland and Wales), the bill will also cover broader issues around menopause rights and education, particularly in the workplace.
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Source: The Guardian, 6 October 2021
Patient Safety Learning

"I have never seen this level of abuse"

The abuse of staff at GP surgeries has "no place in the NHS", a healthcare boss has said, following complaints it has risen during the pandemic.
Dr Joanne Watt, GP chairwoman of the Northamptonshire Clinical Commissioning Group (CCG), said she understood patients' frustrations as surgeries battle with increased demand.
But she said the reports of abuse were "extremely upsetting and demoralising".
A receptionist told the BBC she had "never seen this level of abuse".
Claire, who works at Harborough Field surgery in Rushden and has been employed by the NHS for 34 years, said staff were being verbally abused on a daily basis and it was "becoming the norm and it shouldn't be". "We work within the rules we're given. It's very upsetting, we've been reduced to tears," she said.
The latest NHS staff survey found one in three staff claimed to have experienced at least one incident of bullying, harassment or abuse from service users, their relatives or other members of the public, in the year to March 2021.
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Source: BBC News, 7 October 2021
Patient Safety Learning

Historic go-ahead for malaria vaccine to protect African children

Children across much of Africa are to be vaccinated against malaria in a historic moment in the fight against the deadly disease.
Malaria has been one of the biggest scourges on humanity for millennia and mostly kills babies and infants. Having a vaccine - after more than a century of trying - is among medicine's greatest achievements.
The vaccine - called RTS,S - was proven effective six years ago.
Now, after the success of pilot immunisation programmes in Ghana, Kenya and Malawi, the World Health Organization says the vaccine should be rolled out across sub-Saharan Africa and in other regions with moderate to high malaria transmission.
Dr Tedros Adhanom Ghebreyesus, director-general of the WHO, said it was "a historic moment".
"The long-awaited malaria vaccine for children is a breakthrough for science, child health and malaria control," he said. "[It] could save tens of thousands of young lives each year."
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Source: BBC News, 6 October 2021
Patient Safety Learning

Inquest hears evidence of mistakes in Nightingale patients’ care

An inquest into the death of a London bus driver at London’s Nightingale Hospital during the first wave of coronavirus has heard evidence about equipment mistakes which may have harmed patients.
Kishorkumar Patel, aged 58, was one of the first patients to be admitted to the field hospital at London’s Excel Conference Centre in April last year.
An inquest at East London Coroner’s Court was told doctors and nurses were forced to work “leanly” because of limited staff and ventilators to help patients breathe.
Mr Patel is one of 10 patients who had the wrong filter used on the ventilator machines which it is thought triggered a cardiac arrest in Mr Patel, a father of six.
A serious incident report identified 10 patients were affected by the use of the wrong filter, with three said to have been harmed as a result. 
Read coroner's report
Read full story
Source: The Independent, 6 October 2021
Patient Safety Learning

More than one million waiting for mental health treatment with one in 10 doctor posts empty

One in 10 posts for consultant psychiatrists in England are vacant with growing waiting times for people needing mental health treatment, experts have warned.
A census of the current situations across England by the Royal College of Psychiatrists has found there is just one psychiatrist for every 12,567 people in England.
Health service bosses at NHS England have acknowledged there are an estimated 1.5 million people who are waiting for mental health support amid fears the situation will worsen as the effects of the Covid pandemic become clear. This is on top of the 5.6 million patients waiting for routine operations and treatments for physical illness.
The Royal College said there was a shortage of 568 empty consultant posts in the NHS out of a total of 5,367 which it said meant patients would have to wait longer for treatment. In total there are 4,500 full time consultants working in the NHS.
The highest rates of unfilled positions are in the fields of addiction, eating disorders and child and adolescent psychiatry.
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Source: The Independent, 6 October 2021
Patient Safety Learning

Better diagnosis of FASD in children needed

An adoptive mother is calling for the NHS to improve its diagnosis for children exposed to alcohol in the womb, so their families can be helped.
Amanda Boorman's two sons have Foetal Alcohol Spectrum Disorder (FASD) but they were not diagnosed correctly. She said: "This is a brain and body condition that is lifelong so really the professionals need to step up."
Foetal Alcohol Spectrum Disorder (FASD) covers the various health and mental issues which can affect children.
A spokesperson for the Department for Health and Social Care said: "We are committed to reducing future cases of Fetal Alcohol Spectrum Disorder (FASD) and we have asked NICE [National Institute for Healthcare Excellence] to produce a Quality Standard in England for FASD to help the health and care system improve diagnosis and care of those affected.
"We have also published England's first Fetal Alcohol Spectrum Disorders Health Needs Assessment to improve the lives of families living with it and increase understanding amongst clinicians and policy makers."
Mrs Boorman, from Brent Knoll in Somerset, said: "There's no way an adoptive parent should ever have to go to a chief executive of a hospital and say 'what is your strategy for diagnosing FASD?' What needs to happen is that clinical commissioning groups, the boards of those, chief executives in hospitals, directors of children's services, social care and education need to be much more proactive."
"What we've seen is reactive or just not really knowing - it's complete ignorance."
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Source: BBC News. 7 October 2021
 
Sam

NHS needs to learn lessons from negligence cases

The costs of clinical negligence cases have been falling for the past two years, according to the last two NHS Resolution annual reports, and we need an open debate about the true facts regarding this litigation.
Specialist lawyers and their experience of dealing with an array of claims have something valuable to add to the debate around the failures of patient-safety learning across the whole of the health service.
The problem is that claims are not seen for the learning opportunities that they present. In addition, assessment of lessons regarding safety is disjointed across the NHS into numerous separate trusts.
That is why specialist claimant legal firms in this field have come together to use their experience of litigation to propose a beneficial scheme.
Fixation on costs could backfire as specialist law firms may leave the field, says Paul Rumley, chairman of the Society of Clinical Injury Lawyers and a partner at the law firm Royds Withy King. "It is better for the government and MPs to look at our scheme and continue with the success of current collaboration, while assessing wider structural reform of the NHS to deliver more co-ordinated lessons around patient safety."
Read full story (paywalled)
Source: The Times, 7 October 2021
Patient Safety Learning

Flu deaths could hit 60,000 in worst winter for 50 years, say experts

Flu deaths could be the worst for 50 years because of lockdowns and social distancing, health chiefs have warned, as the NHS launches the biggest ever flu vaccination drive.
More than 35 million people will be offered flu jabs this winter, amid concern that prolonged restrictions on social contact have left Britain with little immunity.
Officials fear that this winter could see up to 60,000 flu deaths – the worst figure in Britain since the 1968 Hong Kong Flu pandemic – without strong uptake of vaccines.
There is also concern about the effectiveness of this year’s jabs, because the lack of flu last year made it harder for scientists to sample the virus and predict the dominant strains.
Health chiefs said the measures introduced over the past 18 months to protect the country against coronavirus would now put the public at greater risk of flu.
The NHS has already begun the rollout of flu jabs and COVID-19 boosters. Health chiefs will urge everyone eligible to take up their chance, with the launch of a major campaign today to drive take-up.
Read full story
Source: The Telegraph, 8 October 2021
Sam

'Life-saving' continuity of care at risk in the UK, GPs warn

Continuity of care in general practice reduces use of out-of-hours care, acute hospitalisations and mortality, researchers have shown - as GP leaders warned staff shortages and heavy workload means it is becoming harder to deliver in the UK.
Long-lasting personal continuity with a GP is 'strongly associated with reduced need for out-of-hours services, acute hospitalisations, and mortality', according to a study by researchers in Norway.
An association lasting more than 15 years between a patient and a specific GP reduces the probability of any of these factors by 25-30%, the study published in the British Journal of General Practice found.
The researchers said 'promoting stability among GPs' should be a priority for health authorities, and warned that continuity of care was under pressure.
The findings come as general practice in the UK faces intense pressure amid a shortage of GPs and intense workload after more than 18 months of the COVID-19 pandemic.
Responding to the findings, RCGP chair Professor Martin Marshall said: "Continuity of care is highly valued by patients and GPs and our teams alike. It is what allows us to build relationships with our patients, often over time, and this study builds the strong evidence base of its benefits for patients and the NHS."
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Source: GP Online, 4 October 2021
Sam

Major NHS trust downgraded by care watchdog amid safety fears

One of the largest hospital trusts in England has been downgraded by the care watchdog amid safety fears and criticism that bosses did not act on staff concerns.
The Care Quality Commission (CQC) said it found bedpans covered in faeces, urine and hair during 10 visits to wards at University Hospitals Birmingham Trust in June.
Staff in A&E told inspectors they were put under pressure to nurse patients in corridors. At one stage 20 ambulances were queuing outside Heartlands Hospital with patients waiting outside.
The CQC said staff felt “disconnected from leaders” who didn’t show an understanding of the pressures they were under.
Consultants to the regulator staff were experiencing fatigue and they felt executives at the trust “were no longer interested in staff welfare”.
In its inspection report, the CQC said staff did not always clean equipment and said labels for when items were last cleaned were being applied incorrectly.
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Source: The Independent, 8 October 2021
Sam

Ambulance handover delays at A&E are putting patients at risk

Between April 2020 and March 2021 there were approximately 185,000 ambulance handovers to emergency departments throughout Wales. However, less than half of them (79,500) occurred within the target time of 15 minutes.
During that period there were also 32,699 incidents recorded where handover delays were in excess of 60 minutes, with almost half (16,405) involving patients over the age of 65 who are more likely to be vulnerable and at risk of unnecessary harm.
Data published by the Welsh Government highlighted that in December 2020 alone, a total of 11,542 hours were lost by the ambulance service due to handover delays. This figure has been rising sharply and has now reached pre-pandemic levels once again.
Inspectors said these delays have consistently led to multiple ambulances waiting outside A&E departments for excessive amounts of time, unable to respond to emergencies within their communities.
"These delays have serious implications on the ability of the service to provide timely responses to patients requiring urgent and life-threatening care," the report stated.
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Source: Wales Online, 7 October 2021
Patient Safety Learning

WHO report highlights global shortfall in investment in mental health

The World Health Organization’s (WHO) new Mental Health Atlas paints a disappointing picture of a worldwide failure to provide people with the mental health services they need, at a time when the COVID-19 pandemic is highlighting a growing need for mental health support.
The latest edition of the Atlas, which includes data from 171 countries, provides a clear indication that the increased attention given to mental health in recent years has yet to result in a scale-up of quality mental services that is aligned with needs. 
Issued every three years, the Atlas is a compilation of data provided by countries around the world on mental health policies, legislation, financing, human resources, availability and utilization of services and data collection systems. It is also the mechanism for monitoring progress towards meeting the targets in WHO’s Comprehensive Mental Health Action Plan.
“It is extremely concerning that, despite the evident and increasing need for mental health services, which has become even more acute during the COVID-19 pandemic, good intentions are not being met with investment,” said Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization. “We must heed and act on this wake-up call and dramatically accelerate the scale-up of investment in mental health, because there is no health without mental health.”
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Source: WHO, 8 October 2021
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