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

160,000 risk harm each year from ambulance handover delays

Ambulance handover delays could harm 160,000 patients a year, 12,000 of them severely, according to a structured clinical review of cases by service bosses earlier this year.
The Association of Ambulance Chief Executives examined a sample of 470 cases where handover to A&E was delayed for an hour or more on 4 January this year. The review, whose findings were shared with HSJ, involved every mainland ambulance service in England.
It found that 85% of those who waited more than an hour suffered potential harm, with nine per cent potentially severely harmed. 
Extrapolated across an entire year, using levels of delays up to September 2021, this suggests 160,000 patients are potentially harmed annually. Patients who waited the longest for handover were at greatest risk of some level of harm, and the risk of severe harm more than tripled for those waiting more than four hours compared with those waiting for 60 to 90 minutes.
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Source: HSJ, 14 November 2021
 
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Germany’s doctors call for clear rules to “break chains of infection” as cases soar

Politicians and doctors in Germany have called for urgent action to control the spread of COVID-19 after a record number of cases were reported on 11 November.
Germany had 50 196 new confirmed Covid cases on 11 November, up from 39 676 cases on 10 November and 9658 on 1 November, showed figures from the Robert Koch Institute. A total of 235 Covid related deaths were reported on 11 November, up from 23 on 1 November.
Speaking in the Bundestag, Germany’s lower house of parliament, the federal vice chancellor, Olaf Scholz, said that immediate steps must be taken to “winterproof” Germany against what is being described as the nation’s fourth wave of Covid-19. Scholz will meet next week with the prime ministers of Germany’s 16 states to discuss new measures to fight the pandemic.
“The virus is still with us and threatens the health of citizens,” Scholz said, adding that efforts must be intensified to convince unvaccinated Germans to become fully vaccinated and encourage those already vaccinated to have the booster shot."
Everything must be done, he said, to ensure “that millions of citizens get a booster—that is the task of the next weeks and months.”
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Source: BMJ, 12 November 2021
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New children’s obesity clinics to open after pandemic shone ‘harsh light’ on crisis

NHS England is set to launch 15 new specialist clinics for children living with severe obesity after the Covid pandemic shone a ‘harsh light’ on the crisis among vulnerable young people.
Obesity currently affects one in five children in the UK. Each year, around one thousand children between the age of two to 18-years-old, and their family members, will benefit from the pilot scheme.
The scheme will also offer access to dietitians, psychologists, specialist nurses, social workers, youth workers and a children’s doctor.
Amanda Pritchard, chief executive of the NHS in England, described the coronavirus pandemic said: “The pandemic has shone a harsh light on obesity - with many vulnerable young people struggling with weight gain during the pandemic.
“Left unchecked, obesity can have other very serious consequences, ranging from diabetes to cancer.
“This early intervention scheme aims to prevent children and young people enduring a lifetime of ill-health.
“The NHS Long Term Plan committed to take more action to help children and young people with their physical and mental health and these new services are a landmark moment in efforts to help them lead longer, healthier and happier lives.”
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Source: The Independent, 15 November 2021
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NHS bosses advise all hospitals to review security after Liverpool blast

NHS chiefs are advising all hospitals to review their security arrangements in the wake of Sunday’s terrorist incident at Liverpool Women’s hospital, the Guardian can reveal.
NHS England is finalising new guidance to send to all 213 health trusts in England, which between them provide services at more than 500 hospital sites.
It will tell them to check that their security measures are adequate and also to ensure that their staff know what to do and how to stay safe if their hospital is targeted by terrorists.
It is being finalised and will be sent imminently to hospital bosses, who are still taking in the implications of the taxi explosion outside Europe’s largest maternity hospital.
Many hospitals have beefed up their security over the last year in response to numerous incursions by Covid deniers and anti-lockdown activists and the growing abuse of frontline staff.
But Sunday’s incident has prompted NHS England to write to all trusts urging them to take any steps needed to ensure they are protected.
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Source: The Guardian, 16 November 2021
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"Animals treated better": Patient made to sleep on hospital floor

A patient suffering a mental health crisis was made to sleep overnight on the floor of an NHS hospital because it had no spare beds, The Independent has learned.
On Sunday, Mr Ben Ashcroft was given a mattress on the floor at Barnsley Hospital where he had been admitted after waiting for 36 hours at a different mental health hospital.
He described the situation as being “treated like a prisoner”, adding: “An animal is treated better than this. I’m poorly and you think this acceptable to put me in room like this. This all I have in room. Rather be in prison.”
Mr Ashcroft was detained, earlier in the week, under the Mental Health Act at Calderdale Royal Hospital, in West Yorkshire.
But this hospital had no beds available and transferred him to another site in Barnsley where he was taken to a room with just a mattress.
In a statement to The Independent, the trust said demand for beds over the weekend was “exceptionally high” adding “with this level of demand we took short-term measures to ensure all our service users were kept safe”.
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Source: 15 November 2021
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Major COVID-19 booster trial looks at how best to improve immunity against coronavirus in vulnerable people

Researchers have launched a major clinical trial investigating whether people on long-term immune-suppressing medicines can mount a more robust immune response to COVID-19 booster jabs by interrupting their treatment.
The VROOM trial will have implications for people on immune-suppressing medicines, who are among the millions of clinically vulnerable patients advised to ‘shield’ during the pandemic. The study is funded by an NIHR and the Medical Research Council (MRC) partnership, and led by a team at the University of Nottingham.
Approximately 1.3 million people in the UK are prescribed the immune-suppressing drug methotrexate for inflammatory conditions such as rheumatoid arthritis, and skin conditions such as psoriasis. Many of them were among the 2.2 million clinically extremely vulnerable people advised to shield during the first phase of the pandemic, depending on specialist advice and on their risk factors.
While methotrexate is effective at controlling these conditions and has emerged as first line therapy for many illnesses, it reduces the body’s ability to generate robust responses to flu and pneumonia vaccines.
Researchers will recruit 560 patients currently taking methotrexate, to investigate whether taking a two week break in this drug immediately after they receive the COVID-19 booster jab improves their immune response to vaccination, while preventing flare-ups of their long-term illness. The study will take between one to two years to complete. All participants will have had the Pfizer-BioNTech vaccine as their third jab, as part of the national vaccination programme against COVID-19.
Professor Andy Ustianowski, NIHR Clinical Lead for the COVID-19 Vaccination Programme and Joint National Infection Specialty Lead, said: “Although the vaccine rollout has saved many lives and helped drive down the effects of the pandemic, there are still groups of vulnerable people who can’t always mount robust immunity against the virus. "
“It’s important to establish if people can safely improve protection from their booster jabs by taking a break from their immune-supressing medicines, and this pivotal study will help develop our understanding of immune responses in people taking this widely prescribed medicine."
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Source: NIHR, 12 November 2021
Sam

Artificial Intelligence plan to reduce harm to pregnant black women

Researchers are to use artificial intelligence (AI) in the hope of reducing risk to pregnant black women.
Loughborough University experts are to work with the Healthcare Safety Investigation Branch (HSIB) to identify patterns in its recent investigations.
Research has suggested black women are more than four times more likely to die in pregnancy or childbirth than white women in the UK.
The researchers plan to look at more than 600 of HSIB's recent investigations into adverse outcomes during pregnancy and birth.
The research team will develop a machine learning system capable of identifying factors, based on a set of codes, that contribute to harm during pregnancy and birth experienced by black families. These include biological factors, such as obesity or birth history; social and economic factors such as language barriers and unemployment; and the quality of care and communication with the mother.
It will look at how these elements interact with and influence each other, and help researchers design ways to improve the care of black mothers and babies.
Dr Patrick Waterson, from the university, who is helping to lead the project, said: "Ultimately, we believe the outcomes from our research have the potential to transform the NHS's ability to reduce maternal harm amongst mothers from black ethnic groups."
He added that in the longer term, the research could improve patient safety for all mothers.
Read full story
Source: BBC News, 17 November 2021
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Hidden pandemic of antibiotic-resistant infections, health officials warn

UK health officials are warning of a "hidden pandemic" of antibiotic-resistant infections if people fail to act responsibly after Covid.
Cold symptoms will be more common this winter, with social mixing - but taking antibiotics is not the answer. This could encourage harmful bacteria to evade treatment and put everyone's health at risk, the UK Health Security Agency says.
One in five people with an infection in 2020 had an antibiotic-resistant one. And if the bacteria causing their infection no longer responds to treatment with these common medicines, this can cause serious complications and lead to hospital admission.
Antibiotics should be taken or prescribed only when really needed, for example to treat bacterial infections such as sepsis, meningitis or pneumonia. They can also help protect against infection during chemotherapy, Caesarean sections and other common surgeries.
However they are sometimes prescribed to treat coughs, earache and sore throats, on which they have little or no effect.
UKHSA chief medical adviser Dr Susan Hopkins said antimicrobial resistance was a "hidden pandemic" and it was important "we do not come out of Covid-19 and enter into another crisis".
Serious antibiotic-resistant infections "will rise once again if we don't act responsibly", she added.
"As we head into winter, with increasing amounts of respiratory infections in circulation, it is important to remember that antibiotics are not needed for many cold-like symptoms.
"Stay at home if you feel unwell," she said.
"Taking antibiotics when you do not need them only puts you and your loved ones at more risk in the future, so please listen to your GP, nurse, dentist or pharmacist's advice."
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Source: BBC News, 17 November 2021
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‘Bullying, intimidation and reprisals’ undermined patient care at trust, review concludes

A ‘culture of distrust’ between consultants and the use of incident reporting as a tool of ‘reprisal’ impacted patient care at a trust’s cardiology department, a review has concluded.
An external review undertaken for Hull University Teaching Hospitals Trust has made a series of recommendations after looking into allegations of bullying and several examples of poor care within its cardiology services.
In a report published in the trust’s board papers, the Royal College of Physicians reported a “perceived tendency to downplay clinical incidents, and, to undermine those who wanted to raise patient safety issues”.
It added: “We met a group of individual consultants who did not work well as a team. There is a culture of distrust, a lack of departmental cohesion and allegations of bullying in the department. All of which reinforce a clear divide between the interventional and non-interventional consultant cardiologists."
“There have been a number of allegations of belittling, intimidation and undermining…The review team heard accounts of a culture where datix has been used as a tool for possible personal reprisal along with ignoring/downplaying incidents that have been raised.”
The review concludes: “This behaviour is impacting on patient care and therefore, all medical staff should be reminded of good medical practice as the [General Medical Council] code of conduct of how doctors must work collaboratively with colleagues.”
Read full story (paywalled)
Source: HSJ, 16 November 2021
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Bereaved left in limbo by report delays, says mum

The mother of a man who took his own life said bereaved families would be left "in limbo" by a mental health trust's serious incident report delays.
Local health officials have raised concerns over the "timeliness" of Cambridgeshire and Peterborough NHS Foundation Trust's (CPFT) reports.
Maria Nowshadi, whose son James died in 2020, said they should be done quickly "so there's answers for families".
Ms Nowshadi said: "These investigations should happen in a timely, quick manner so there's answers for families, but also in case there's any learning to be had... to make sure there's no further deaths that happen in the same way, because of any errors within the system."
She said when the original date the report was due to be completed passed, she "reached the stage where I was looking at the mailbox every day". She said she told a patient liaison officer: "This is actually starting to affect my mental health.
The chief nurse at Cambridgeshire and Peterborough's Clinical Commissioning Group (CCG), Carol Anderson, said there were "concerns... [around] serious incident processes and reporting" at CPFT.
A CCG spokeswoman added they had agreed an extension with CPFT "for the completion of serious incident reports due to additional pressures due to the pandemic and staff redeployment".
"Our overall concern is the timeliness of serious incident reporting, so that we can ensure that learning is put in place as soon as possible," she added.
Read full story
Source: BBC News, 17 November 2021
Patient Safety Learning

Widow demands answers over Covid official's death

The widow of a top Scottish government official, who died after contracting Covid, believes the full details of his illness were concealed to protect the reputation of a troubled hospital.
Andrew Slorance, Scottish government's head of response and communication unit, in charge of its handling of the Covid pandemic, went into Glasgow's Queen Elizabeth University Hospital for cancer treatment a year ago.
His wife Louise believes he caught Covid there as well as another life-threatening infection. 
Andrew went in to the £850m flagship Queen Elizabeth University Hospital (QUEH) at the end of October 2020 for a stem cell transplant and chemotherapy as part of treatment for Mantle Cell Lymphoma (MCL). 
He died nearly six weeks into his stay, with the cause of his death listed as Covid pneumonia. But after requesting a copy of his medical notes, Mrs Slorance discovered her husband had also been treated for an infection caused by a fungus called aspergillus, which had not been discussed with either of them during his hospital stay.
The infection is common in the environment but can be extremely dangerous for people with weak immune systems.
Mrs Slorance questions whether it may have played a part in her husband's death, and if so, why she was not told?
She told the BBC: "I think somebody and probably a number of people have made an active decision not to inform his family of that infection, either during his admission or post-death."
Mrs Slorance believes that officials wanted to protect the hospital, which is already the subject of a public inquiry, and its reputation, "no matter what the cost".
Mrs Slorance says a full investigation should take place into incidences of aspergillus at the hospital campus.
In response, NHS Greater Glasgow and Clyde said: "We are sorry that the family are unhappy with aspects of Mr Slorance's treatment, details of which were discussed with the family at the time.
"While we cannot comment on individual patients, we do not recognise the claims being made. We are confident that the appropriate care was provided. There has been a clinical review of this case and we would like to reassure the family that we have been open and honest and there has been no attempt to conceal any information from them."
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Source: BBC News, 18 November 2021
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'It's not just physical': suicidal thoughts common in those living with spinal cord injury

Suicidal thoughts are three times as common in those living with a spinal cord injury in the UK, according to new research
And yet, it’s estimated that only one third of people living with a spinal cord injury (SCI) are getting access to mental health support, and of those, 68% do not feel that support services available are able to meet their needs.
These alarming statistics are taken from a new report, ‘It’s not just physical’ which was presented to parliament yesterday (17 November).  The report shines a light on the mental health problems faced by people with spinal cord injuries in the UK today.
It's calling on the NHS, government and other health policy makers to provide better mental health support services for people with spinal cord injuries – and their unpaid carers – as a matter of urgency.  Nik Hartley, Spinal Injuries Association CEO said:
“We are at risk of failing thousands of people in the UK living with a spinal cord injury. Our new report highlights that psychological damage caused by a SCI is, at best, considered as an afterthought, and at worst, completely ignored by the medical profession. We need urgent action and for services to be sufficiently specialised to support the thousands of people living with this type of injury before it is too late.”
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Source: Spinal Injuries Association, 17 November 2021
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'Some progress' made at failing Shropshire hospital trust

An inspection at a failing hospital trust has identified "some progress" but its services are still inadequate.
The Care Quality Commission (CQC) inspected the Shrewsbury and Telford Hospital NHS Trust (SaTH) in August. The Trust has been in special measures since 2018 and its maternity services are subject of a review following a high rate of baby and maternal deaths.
The CQC said SaTH still had "significant work to do" to improve its patient care and safety standards.
Inspectors highlighted particular concerns around risk management at the Trust which it said was "inconsistent" and and urgent and emergency care where patients "did not always receive timely assessment".
The CQC also reported a shortage of staff working in end-of-life care and midwifery, however maternity staff were said to have "an exceptionally dedicated and caring approach".
"I recognise the enormous pressure NHS services are under across the country and that usual expectations cannot always be maintained, but it is important they do all they can to mitigate risks to patient safety while facing these pressures," chief inspector of hospitals, Ted Baker, said.
"While the trust continues to have significant work to do to provide care that meets standards people have a right to expect, it is providing more effective care overall.
"However, its risk management remains inconsistent and we are not assured it is doing all it can to ensure people's safety."
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Source: BBC News, 18 November 2021
 
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A&E overcrowding in UK ‘killing thousands a year’, say doctors

Thousands of patients a year are dying because of overcrowding in A&E units in Britain, and more fatalities will follow this winter, emergency care doctors claim.
An estimated 4,519 people in England died in 2020-21 as a direct result of people receiving less than ideal care while delayed in A&E waiting to start treatment in the hospital.
“To say this figure is shocking is an understatement. Quite simply, crowding kills,” said Dr Adrian Boyle, a vice-president of the Royal College of Emergency Medicine (RCEM).
There have also been 709 deaths in Wales and 303 in Scotland so far this year for the same reason, according to a report by the college. Another 566 excess deaths caused by overcrowding occurred in Northern Ireland in 2020-21. The 4,519 in England “may be an underestimate”, it adds.
The four figures taken together mean the college has identified at least 6,097 deaths across the four home nations that it believes occurred because overcrowding hampered the person’s treatment.
“There’s a lot of human misery behind these figures. It’s uncomfortable and unbearable that people are being put through this. It’s impossible not to feel upset and angry about this,” Boyle said.
Read full story
Source: The Guardian, 18 November 2021
Patient Safety Learning

Long-acting HIV jabs to replace daily pills in ‘great step forward’

The NHS has been given the green light to offer people living with HIV the first "long-acting injectable" to keep the virus at bay.
Charities have hailed the "incredible news" which offers an alternative to adults living with HIV who have to take daily antiretroviral drugs.
Many people living with HIV can keep the virus at very low levels by taking antiretroviral tablets each day. These drugs keep the number of virus particles in the blood - also known as the viral load - so low that it cannot be detected or transmitted between people.
But now an estimated 13,000 people will be eligible for the injectable treatment in England which means they no longer need daily treatment but will have two injections every two months. This means they can reduce the days they receive treatment from 365 to 6 per year.
Meindert Boysen, deputy chief executive NICE, said: "Despite scientific advances HIV is still incurable, but the virus can be controlled by modern treatment. However, for some people, having to take daily multi-tablet regimens can be difficult because of drug-related side effects, toxicity, and other psychosocial issues such as stigma or changes in lifestyle."
"We're pleased therefore to be able to recommend cabotegravir with rilpivirine as a valuable treatment option for people who already have good levels of adherence to daily tablets, but who might prefer an injectable regimen with less frequent dosing."
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Source: 18 November 2021
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Oral drug for spinal muscular atrophy to be available on NHS in England

The NHS is to introduce a revolutionary new treatment to tackle the leading genetic cause of death among babies and young children.
About 1,500 patients in England with certain types of spinal muscular atrophy (SMA) are expected to benefit from risdiplam, after a recommendation from the health watchdog. The drug, also called Evrysdi and made by Roche, is a syrup that can be taken at home and is the first non-injectable treatment for the condition.
SMA is a progressive neuromuscular condition affecting the nerves in the spinal cord controlling movement and can cause paralysis, muscle weakness and progressive loss of mobility.
The NHS England chief executive, Amanda Pritchard, said: “In the last three years the NHS has revolutionised care for people with SMA, by securing access to a trio of innovative treatments – Spinraza, Zolgensma and now risdiplam – where three years ago clinicians had no effective medicines at all.
“Spinal muscular atrophy is a cruel disease and the leading genetic cause of death among babies and young children, which is why NHS England has been determined to make these treatments available to people as soon as possible to help transform the lives of patients and their families.”
Meindert Boysen, the deputy chief executive of NICE, said the watchdog was pleased to recommend a “convenient oral treatment for people with SMA that can be administered at home”.
He said: “This will not only be less burdensome, and therefore have a positive impact on the lives of both people with SMA and their caregivers, but it will also reduce the treatment administration requirements for the NHS.
“In practical terms, the availability of an oral drug should lead to greater adherence to treatment, along with giving access to a treatment to those who aren’t able to have other currently recommended options.”
Read full story
Source: The Guardian, 19 November 2021
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