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

Covid: UK government wasn't ready for pandemic, report finds

The UK government was not properly prepared for a pandemic like COVID-19, a new report has found.
The report by the National Audit Office (NAO) said the government lacked detailed plans on shielding, job support schemes and school disruption.
The spending watchdog added that lessons needed to be learned.
In response, the government said the unprecedented pandemic had challenged health systems around the world - not just the UK.
The NAO said preparations for a flu pandemic or highly infectious diseases like Ebola were prioritised over diseases with similar characteristics to Covid.
The watchdog said the UK government did not have specific plans to tackle a disease like COVID-19, which has a lower mortality rate than Ebola but has the ability to spread in communities with asymptomatic infected people.
The report suggests the government had some mitigations in place for a pandemic, like a stockpile of personal protective equipment, but it lacked preparation for "wide-ranging impacts" coronavirus and other pandemic-inducing viruses can have on society and the economy.
A government spokesperson said: "We have always said there are lessons to be learned from the pandemic and have committed to a full public inquiry in spring.
"We prepare for a range of scenarios and while there were extensive arrangements in place, this is an unprecedented pandemic that has challenged health systems around the world."
Labour's shadow Cabinet Office minister Fleur Anderson, said the report showed "Conservative ministers failed to prepare and they failed the public".
Read full story
Source: BBC News, 19 November 2021
Patient Safety Learning

'Dads can get postnatal depression too'

Becoming a father can be the happiest time in a man's life, but for some it can bring unexpected feelings of anxiety, stress and guilt. Until recently, mental health concerns for new dads were little understood and, often, went unaired. But some men who have experienced postnatal depression hope telling their stories will encourage others to open up.
When Stephen's daughter was born five years ago he knew he was meant to feel happy but instead began to think his wife and newborn child might be better off without him.
"You don't get a chance to sit back, take it in, relax and enjoy it," he said. "I'd come home on a weekend after a long week, tired out, and my wife was back at work, working weekends."
"It just affects you, you don't see each other, you don't have the chance to enjoy it, and all the stress and anxiety builds up. I got to such a low point I considered my family were better off without me."
An international study in 2010 suggested that as many as one in 10 men struggle with postnatal depression (PND). More recently, in 2015, a survey by the National Childbirth Trust (NCT) found one in three new fathers had concerns about their mental health.
The NCT has called for more recognition around mental health issues affecting new dads. It has set up Parents in Mind: Partners Project, which offers support to everyone who has an active role raising a child under two.
"Becoming a parent is an emotional rollercoaster," said Catherine Briars, who runs the project in St Helens.
"Fathers sometimes feel uncomfortable opening up about their feelings but we encourage them to do so if they're struggling. It's often the first step to recovering and regaining good mental health."
She said they encourage men to talk to someone they trust or their GP.
Read full story
Source: BBC News, 19 November 2021
Patient Safety Learning

Campaigners say ‘decolonise the curriculum’ to help solve UK maternity inequalities

The increased risk of black and minority ethnic women dying during pregnancy needs to be seen as a whole system problem and not limited to just maternity departments, according to experts on an exclusive panel hosted by The Independent.
Professor Marian Knight, from Oxford University told the virtual event on Wednesday night that the health service needed to change its approach to caring for ethnic minority women in a wider context.
Campaigners Tinuke Awe and Clotilde Rebecca Abe, from the Fivexmore campaign, called for changes to the way midwives were trained and demanded it was time to “decolonise the curriculum” so it recognised the physiological differences between some ethnic minority women and white women.
Dr Mary Ross-Davie, from the Royal College of Midwives, said work was underway to ensure the voices of black women and other minorities were represented in its work and it was examining how it could deliver better training to midwives.
The data on maternity deaths in the UK show black women are four times more likely to die during pregnancy in the UK than white women. For Asian women, they are twice as likely to die.
Read full story and watch video of event
Source: The Independent, 18 November 2021
Patient Safety Learning

NHSE pushing for four-hour target to be scrapped in April

System leaders are pushing for their new bundle of urgent and emergency standards to replace the four-hour target from April, HSJ has learned
Well-placed senior sources said the NHS is seeking to persuade the government that a new package of measures can be introduced from the start of 2022-23.
The new package of targets, which include ambulance response and handover times, as well as arrival to admission times, have some traction among ministers but have not yet got the green light from the top of government.
The new ‘bundle of ten standards’:
Pre-hospital
Response times for ambulances. Reducing avoidable trips (conveyance rates) to emergency departments by 999 ambulances. Proportion of contacts via NHS 111 that receive clinical input. A&E
Percentage of ambulance handovers (from ambulance to A&E) within 15 minutes. Time to initial assessment — percentage within 15 minutes. Average (mean) time in department — for non-admitted patients. Hospital
Average (mean) time in department — for admitted patients. Clinically ready to proceed (time from when decision is made to admit or discharge, and patient is admitted or discharged). Whole system
Patients spending more than 12 hours in A&E. Critical time standards — aimed at ensuring the highest priority patients get care within a set timeframe such as an hour. Read full story (paywalled)
Source: HSJ, 18 November 2021
Patient Safety Learning

Trust fined £2.5m after deaths of two patients

An acute trust has been fined £2.5m after pleading guilty to charges of failing to provide safe care after the deaths of two patients.
The Care Quality Commission brought charges against The Dudley Group Foundation Trust earlier this year over care failings in two separate cases which the regulator said exposed two patients to “significant risk of avoidable harm”.
The trust pleaded guilty to the charges in July and was fined during a sentencing hearing today.
The cases, involving 33-year-old mother of six Natalie Billingham, and 14-year-old Kaysie-Jane Bland [also known as Kaysie-Jayne Robinson], were both in 2018 and  related to care at the trust’s Russells Hall Hospital in Dudley.
Ms Billingham was admitted to Dudley’s Russells Hall Hospital with numbness in her right foot on 28 February 2018 and died on 2 March of organ failure caused by a “time critical” infection.
The court was told she was initially thought to have a deep vein thrombosis after a three-minute triage that failed to identify "disordered" observations. The hospital then had multiple reasons to reconsider the initial diagnosis, but opportunities for review were "missed or ignored".
In the case of Kaysie-Jane, who had cerebral palsy, an "early warning score" was inaccurate, meaning a sepsis screening tool was not triggered.
The CQC said the care both patients received at Russells Hall Hospital was undermined by the Dudley Group’s failure to address known safety failings which the regulator repeatedly raised with the trust in the months before their deaths. The CQC said the trust did not take all reasonable steps to make improvements, despite its intervention. The trust has denied it did not react to the concerns raised. 
Failings included errors in the hospital’s initial assessments and monitoring of both patients, which hindered the timely escalation of concerns.
A lawyer acting on behalf of the Dudley Group NHS Foundation Trust had admitted the trust failed to provide treatment in a safe way, resulting in harm, in February and March 2018.
Read full story (paywalled)
Source: HSJ, 19 November 2021
Patient Safety Learning

Covid: Sajid Javid orders review of medical device racial bias

A review into whether medical devices are equally effective regardless of the patient's ethnicity has been ordered by Health Secretary Sajid Javid.
Research suggests oximeters, which are clipped to a person's finger, can overstate the level of oxygen in the blood of people from ethnic minorities.
Ministers want to know whether bias could have prevented patients receiving appropriate Covid treatment.
Mr Javid said any bias was "totally unacceptable".
But the doctors' union the British Medical Association (BMA) said the review should not simply look at equipment, but also "structural issues" within healthcare that affect ethnic minorities.
Mr Javid announced the review in the Sunday Times, saying he was determined to "close the chasms that the pandemic has exposed".
Asked later on the BBC's Andrew Marr show whether he thought people had died of Covid because of pulse oximeters, Mr Javid said: "I think possibly yes, yes. I don't have the full facts."
He said there was racial bias in some medical instruments, adding: "It's unintentional but it exists."
"And the reason is that a lot of these medical devices, even some of the drugs, some of the procedures, some of the textbooks, most of them are put together in majority white countries and I think this is a systemic issue around this," he said.
Read full story
Source: BBC News, 21 November 2021
Patient Safety Learning

People with long Covid facing months-long wait for treatment at specialist NHS clinics

Only 5,000 people a month are being referred to specialist long Covid clinics each month despite more than a million people having the condition – and a third of those are having to wait at least 15 weeks for their first appointment, NHS figures reveal.
Over the last year the NHS has set up dozens of specialist long Covid clinics in England to assess and diagnose people who visit their GPs with symptoms of the condition.
The Office for National Statistics estimates there are 1.2 million people in the UK – about a million of them in England – with long Covid, meaning they have had symptoms for 12 weeks or more. However, only 4,846 to 5,182 patients a month were referred to the clinics from July to September this year, the first period for which figures are available.
Of those patients who are referred, 33% are having to wait at least 15 weeks to be seen for their first assessment – with another 15% waiting for 10 to 14 weeks, the figures show.
Sarah Woolnough, chief executive of Asthma UK and the British Lung Foundation, said she was extremely concerned by the NHS figures – which tally with anecdotal evidence and her foundation’s own research.
“We’ve heard first-hand from thousands of people whose lives have been turned upside down by long Covid, who have had to quit their jobs and most-loved hobbies as they battle wide-ranging and disabling symptoms like persistent breathlessness,” she said.
“If that wasn’t tough enough, many people are then forced to deal with the debilitating effects of long Covid on their own, because of a lack of support and huge wait times for specialist care,” she added.
“The Government needs to train and recruit more specialist NHS staff, so that people with long Covid can access the specialist care they so desperately need.”
Read full story
Source: iNews, 20 November 2021
Patient Safety Learning

System for assessing who needs to pay for NHS care ‘incentivises racial profiling’

The system for assessing who should be asked to pay for NHS services “incentivises racial profiling”, an investigation has found.
A study by the Institute for Public Policy Research found that overstretched NHS staff sometimes racially profile patients in order to determine who is not “ordinarily resident” in the UK, and therefore must pay for their care.
The report is critical of the more stringent charging regime introduced by NHS England over the past decade as part of a series of measures devised to create a hostile environment for people living in the UK without the correct immigration status. Overseas visitors officers have been appointed by NHS trusts, responsible for identifying chargeable patients, as part of a cost recovery programme launched in 2014.
One of the officers told the IPPR study they had felt forced to discriminate between patients based on their name. “If you’ve got a, I don’t know, Mohammed Khan and a Fred Cooper, you’re obviously going to go for [investigating] the Mohammed Khan … Even for someone who’s, you know, well I’d like to think hopefully open-minded, like myself, you’re just trying to save yourself time because there’s not enough hours in the day,” the officer said.
A hospital employee also reported that discrimination on the basis of ethnicity was used to determine who should be billed for treatment. “It’s a system that is designed to benefit [white] people like me, not people like … the patient on intensive care who is black and British and was unconscious and sent a bill. So why did someone think he was not eligible for care? Given he was unconscious most of the admission, significantly unwell, probably not his accent, more likely his skin colour,” the health worker said.
Under the rules, anyone “not ordinarily resident” in the UK should be charged 150% of the NHS national tariff for most secondary (non-urgent) healthcare, but the report found that processes varied across the country, with a lack of consistent training and widespread confusion over the 130-page rules for the charging system.
Some healthcare staff told IPPR researchers that they disliked the extra burden of having to consider whether to refer a patient for charging, which they felt distracted them from their core medical responsibilities.
Read full story
Source: The Guardian, 23 November 2021
Patient Safety Learning

Calls for major overhaul of the Welsh NHS

More than 20 different health organisations have joined forces to call for a complete overhaul of the National Health Service in Wales.
It comes after the worst ever performance figures for hospital emergency departments and the ambulance service were published, as well as warnings from doctors across the country that patients are dying in ambulances and waiting rooms due to overcrowding.
The group of 22 organisations working across health and social care say Wales needs a single national body with a strategic oversight of the Welsh NHS in order to drive improvements in patient care and hold health boards to account.
They have launched the 'Ending the postcode lottery' campaign which calls for "an end to fragmented health services".
Those involved include the the Royal College of Physicians Wales, the British Heart Foundation, Parkinson's UK and Cancer Research UK. They claim that a single, independent national NHS Wales executive would be better placed to improve patient care and deliver on the aims of a healthier Wales.
The organisations are calling for an independent body with the right powers would have the authority to:
Support system transformation across health board boundaries Play a national leadership role in service improvement Collect and analyse data to improve performance Improve patient outcomes across clinical specialties, public health and inequalities Provide strong governance and accountability to ensure that the NHS in Wales gets the best value from its combined resources. Dr Abrie Theron, chair of Academy of Medical Royal Colleges in Wales, said: "I cannot see how the Welsh NHS is going to implement the changes needed for a Covid recovery without a NHS Executive team facilitating health boards working together as one for the patients of Wales."
Read full story
Source: The National, 22 November 2021
Patient Safety Learning

Calls for support for UK midwives struggling with substance abuse

The Royal College of Midwives is calling for members to be given the same support as doctors when they struggle with drug and alcohol problems.
Research shared with the Guardian – the first of its kind into substance abuse among midwives – has revealed that significant numbers of midwives have problems with drugs or alcohol. It found that 28% said they had problems and 16% said they worked while under the influence of various substances.
Dr Sally Pezaro, the author of the research, found that along with alcohol, midwives used cannabis, cocaine, heroin and sedatives. She said reasons given include work-related stress and anxiety, bullying, traumatic clinical incidents and to maintain overall functioning.
Pezaro, a midwife and fellow of the Royal College of Midwives, said there was no dedicated support programme available for midwives, while doctors struggling with substance abuse can get support from the NHS practitioner health programme. The incidence of substance abuse among midwives, based on the survey of 623 people, appears higher than among doctors – 8%-15% of whom have been found to have substance abuse problems.
Pezaro is calling for more support for midwives. “If midwives seek help they lose their licence to practise. Doctors are treated less harshly by their regulator, the General Medical Council, than we are by ours – the Nursing and Midwifery Council,” she said. Between 2014 and 2016 26% of 1,298 fitness to practise cases that came before the Nursing and Midwifery Council (NMC) involved drugs or alcohol.
A Royal College of Midwives spokesperson said: “It is a brave decision to step forward and say you have a problem and are grappling with substance misuse, which blights the lives of people and their families. For anyone who does this, including healthcare professionals, there should be a compassionate approach.
Read full story
Source: The Guardian, 22 November 2021
Patient Safety Learning

NHS hospital at centre of cover up claims after woman died following repeated paracetamol overdose

The family of a woman who died after being repeatedly overdosed with paracetamol in an NHS hospital have demanded action over her death amid allegations of an NHS cover up.
Laura Higginson, a trainee solicitor and mum of two, died after seeking medical help for sickness and pneumonia. She died two weeks later from multi-organ failure and sepsis.
Whiston Hospital, in Merseyside, has admitted to the overdose but denied it caused her death and rejects any suggestion of wrong doing.
But expert reports, seen by The Independent, including from a liver specialist, questions the trust’s account of what happened, the quality of its post-mortem and concludes the mother-of-two – who only weighed 36kg – suffered liver failure after too much paracetamol in April 2017.
The overdose mistake was recognised by staff on the third day but Laura’s family were never told.
The trust did not record the error as an incident and only started an investigation 14 months later when concerns were raised by Laura’s family. Her husband Antony Higginson says the subsequent investigation report is “littered with inaccuracies.”
He told The Independent: “We just want justice; we don’t care about money. Laura died needlessly and all these institutions charged with ensuring safe care and accountability have point blank failed and have rendered Laura’s life as essentially worthless and that she didn’t matter, when she did matter.”
Read full story
Source: The Independent, 21 November 2021
Patient Safety Learning

Welsh Health Minister rejects frontline staff concerns the NHS is ‘harming patients’

Wales' Health Minister has rejected a suggestion that the NHS is “harming patients” due to the severe levels of pressure on its services. 
Eluned Morgan MS acknowledged that the speed at which patients were receiving treatment was being impacted but said she would “not accept for a moment” that the NHS was harming its patients.
ITV Cymru Wales has spoken to a number of NHS staff and health sector bodies and heard concerns over the sustainability of the health service in its present form.
Ms Morgan said: “I don’t think the NHS is harming patients, no.
“I think our ability to get to patients quickly, that is perhaps compromised by the pressures that we’re under at the moment but no, I would not accept for a moment that the NHS is harming patients. 
“I think the situation is that maybe people have to wait a bit longer for care because of the pressures that have grown as a result of the pandemic and let’s be clear about that, that we’re seeing about 20% more people going to their GPs, we’ve got hugely long waiting lists because, of course, we had to be very careful about who was able to go into hospitals during the height of the pandemic. 
“We’re trying to reign all that back at the same time as dealing with Covid, because that hasn’t finished yet.”
Speaking to ITV Cymru Wales for Wales This Week, looking at the challenges facing the NHS, Dr Pete Williams, a consultant in emergency medicine and paediatric medicine at Ysbyty Gwynedd in Bangor, said he felt the current pressures on services were causing harm to patients. 
He said: “This is not sustainable. We, this department, other departments around the country and the wider NHS, are harming patients because they’re not getting timely care."
Read full story
Source: ITV News, 22 November 2021
 
 
Sam

Trust in staffing crisis as eight ICU nurses quit in just two weeks

Eight highly skilled intensive care (ICU) nurses have resigned from one trust in the past two weeks and more could follow, a leading nurse has warned.
More resignations expected as working conditions remain unsustainable
Belfast Health and Social Care Trust in Northern Ireland has confirmed it is redeploying non-specialist nursing staff to fill the gaps in staffing on ICU wards, with experienced ICU nurses expected to provide supervision.
RCN Northern Ireland director Rita Devlin said the college has heard others at the trust are ‘considering their position’.
"These are highly skilled nurses who are difficult to replace and this is a very worrying situation," she said.
"Nursing staff are doing everything they can to keep services going, but it is not sustainable to work under such pressure for long periods of time without a break."
The resignations come just months after it was revealed that 182 nurses and 50 healthcare assistants had quit their jobs at the trust between January and July.
Read full story
Source: Nursing Standard, 23 November 2021
Patient Safety Learning

Midwives receiving less training in key areas of safety and equality, new report warns

Midwives across England are still not receiving enough essential safety training with the pandemic leaving hospitals delivering less training than three years ago.
A new report from the charity Baby Lifeline, based on an investigation of 124 NHS trusts in England, found 9 in 10 units had training affected by the pandemic with staff shortages named as a major factor in preventing workers from taking time out for learning. This was cited by 72%  of units as a problem.
The average spend on maternity training was significantly lower in 2020-21 at £34,290 compared to £59,873 in 2017-18, with NHS trusts delivering less training to staff than they did in 2017-18.
Despite concerns over the poor quality of safety investigations in the NHS, fewer than a third of NHS units trained staff in how to carry out investigations.
Judy Ledger, chief executive and founder of Baby Lifeline, said: “Today’s report highlights how gaps and variation in the delivery of maternity training across the NHS continues to impact on the safety and care women and babies receive. Time and again evidence shows that training investment can save lives, and the pandemic has widened existing, detrimental gaps that years of chronic under-funding and staff shortages have created.
Read full story
Source: The Independent, 23 November 2021
Patient Safety Learning

Change to sepsis advice after mums' herpes deaths

Advice on how new mothers with sepsis should be treated is to change after two women died of a herpes infection.
The Royal College of Obstetricians and Gynaecologists says viral sources of infections should be considered and appropriate treatment offered. This comes after the BBC revealed one surgeon might have infected the mothers while performing Caesareans on them.
The East Kent Hospitals Trust said it had not been possible to identify the source of either infection.
Kimberley Sampson, 29, and Samantha Mulcahy, 32, died of an infection caused by the herpes virus 44 days apart in 2018, shortly after giving birth by Caesarean section.
Their families were told there was no link between the deaths but BBC News revealed on Monday that both operations had been carried out by the same surgeon.
Documents we uncovered showed that the trust had been told two weeks after the second death that "it does look like surgical contamination".
Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, which set standards in maternity care, said routine investigation and management of maternal sepsis "should always consider viral sources of infection, and appropriate changes should be instituted to support earlier diagnosis and treatment".
Medics treating Ms Sampson and Mrs Mulcahy assumed they were suffering from a bacterial infection and didn't prescribe the anti-viral medication that may had saved their lives.
The Royal College said the two deaths should be "fully investigated" as "surgical infection appears to be a significant possibility".
But BBC News has learned that the East Kent Hospitals Trust, which treated both women, never told the coroner's office that the same surgeon had carried out both operations or that an investigation they had ordered had suggested the virus strains the two women had died from appeared to be "epidemiologically linked".
Read full story
Source: BBC News, 23 November 2021
Patient Safety Learning

Patient Safety Learning joins the National Voices coalition

Press release: 23 November 2021
We are pleased to announce that Patient Safety Learning is now a member of National Voices, the leading coalition of health and social care charities in England. Members of National Voices work together to strengthen the voice of patients, service users, carers, their families and the voluntary organisations that work for them.
Commenting on today’s announcement, Patient Safety Learning’s Chief Executive Helen Hughes said:
“We are delighted to have joined National Voices. To reduce avoidable harm in health and social care we all need to work in partnership to identify patient safety concerns, highlight where changes are needed and share good practice, to help deliver the systemic change required to create a patient-safe future. We look forward to working closely with partners in National Voices going forward to help improve patient safety.”
Notes to editors:
Patient Safety Learning is a charity and independent voice for improving patient safety. We harness the knowledge, insights, enthusiasm and commitment of health and social care organisations, professionals and patients for system-wide change and the reduction of avoidable harm. National Voices is the leading coalition of health and social care charities in England. We have more than 180 members covering a diverse range of health conditions and communities, connecting us with the experiences of millions of people. We work together to strengthen the voice of patients, service users, carers, their families and the voluntary organisations that work for them.
Patient Safety Learning
Registered address: Patient Safety Learning, China Works SB203, 100 Black Prince Road Vauxhall, London, SE1 7SJ

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