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

Mother calls for stillbirth inquest law change

"You hear his heartbeat and the next thing you know, you've got nothing."
A woman whose son was stillborn has said she wants to change the law to enable an inquest to investigate the circumstances surrounding his death.
Katie Wood's son Oscar was stillborn on 29 March 2015, but under law in England and Wales, inquests for stillborn babies cannot take place.
A consultation was put out by the UK government in March 2019, but the findings have yet to be published. The UK government said it would set out its response in due course, but this delay was criticised by the House of Commons justice committee in September.
Katie and her family said they have never received satisfactory answers about why Oscar died.
Her pregnancy, while challenging, had not given any serious cause for concern.
An investigation by the Aneurin Bevan health board found a number of failings in Katie's care.
A post-mortem examination suggested a condition known as shoulder dystocia, where the baby's shoulder becomes stuck during birth, may have contributed, but this is rarely fatal.
The health board said it conducted a serious incident investigation into Oscar's death and added: "Whilst we seek to find answers during any investigation, in some cases, a full understanding around the cause of death may not always be achieved and we accept the unavoidable distress this may pose for families."
Clinical negligence and medical law specialist, Mari Rosser, says allowing coroners to look into the reasons for a baby's death is long overdue.
"Currently parents who suffer a still birth can have the circumstances investigated, but the circumstances are investigated by the health board and of course that's less independent," she said.
Read full story
Source: BBC News, 9 December 2021
Sam

NHS staffing ‘crisis’ as nursing vacancies rise by almost 20% in three months

Vacancies for nurses and midwives in Scotland have increased by almost 20% in just three months, new figures show.
Official figures revealed that at the end of September the whole time equivalent (WTE) of 5,761.2 posts were unfilled across the NHS – a rise of 18.9% from the WTE total of 4,845.4 that was recorded at the end of June.
The rise in vacancies comes at the same time as health service staffing reached a record high, with the NHS employing the equivalent of 154,307.8 full-time workers as of September 30 – 5.2% higher than a year ago.
However, opposition leaders warned the health service, which is coming under ongoing pressure as a result of the coronavirus pandemic, is facing a “staffing crisis” this winter.
Scottish Labour health spokeswoman and deputy leader Jackie Baillie said: “Across our NHS services are on the brink of collapse, and things will only get worse as the cold weather bites.
“This staffing crisis at the heart of this catastrophe has unfolded entirely on Nicola Sturgeon’s watch and will jeopardise the ability of services to remobilise and cope with demand.
“Looking at the state of services in Scotland, we can all only hope we don’t get sick this winter.”
Read full story
Source: The Independent, 8 December 2021
Sam

Police drop manslaughter investigation into trust

A trust will not face a second prosecution over the death of a baby seven days after a chaotic birth at one of its hospitals, unless new evidence emerges.
Kent police had been looking into incidents at the maternity services department of East Kent Hospitals University Foundation Trust. These incidents include the death of Harry Richford, who was born at Queen Elizabeth, the Queen Mother, Hospital in November 2017. A coroner found a string of failures in his care amounted to neglect.
The trust pleaded guilty to failing to meet fundamental standards of care and was fined £733,000 in a case brought by the Care Quality Commission earlier this year.
But detective chief superintendent Paul Fotheringham, head of major crime at Kent Police, said: “After careful consideration and following consultation with the Crown Prosecution Service, we took the decision that a criminal investigation would not be undertaken at this time as there is no realistic prospect of conviction against any individual or organisation based on the evidence currently available."
In a statement, Harry’s family said: “We are disappointed that Kent Police, in collaboration with the CPS special crime unit in London, have not been able to take forward a charge of corporate manslaughter for Harry at this time. They have assured us that they will keep an open mind on this matter, and any other appropriate charges as and when new evidence is brought before them.
“We believe that the Kirkup inquiry and investigation may allow them to revisit a raft of charges on behalf of harmed babies in east Kent in due course. Only when senior leaders are properly held to account, will there be lasting change.”
Read full story (paywalled)
Source: HSJ, 9 December 2021
Sam

Scathing review slams West Suffolk’s ‘intimidating’ hunt for whistleblower

West Suffolk Foundation Trust’s investigation to find a whistleblower was “intimidating…flawed and not fit for purpose”, according to a damning review which is highly critical of the organisation’s leadership.
The long-awaited review, published today, was triggered by ministers back in January 2020 following allegations that trust directors had ordered staff to give fingerprints and handwriting samples during a “witch hunt” for a whistleblower.
The review, led by Christine Outram, has corroborated many of the allegations.
It concluded trust leaders’ investigation to uncover the identity of the author of an anonymous letter sent to a patient’s family was “intimidating, flawed and not fit for purpose… impractical and unwise.”
It said: “The decision to use fingerprinting and handwriting analysis in an NHS hospital, in the context of an anonymous letter and where no crime has been committed, was highly unusual and without doubt extremely ill-judged.”
Read full story (paywalled)
Source: HSJ, 9 December 2021
Patient Safety Learning

How hiring district nurses may reduce pressure in the NHS

Is hiring more district nurses the smartest way to tackle the NHS care crisis as overstretched staff claim they are quitting hospitals due to intolerable pressure?
District nurses are the unsung backbone of the NHS – going in to people’s homes to perform everything from wound dressings to support at the end of life. Yet what was once a thriving district nurse workforce has, over the past decade, been decimated. 
An ever-increasing caseload, limited resources and far more complex and challenging health needs have left them burnt out and fed up. As a result, they’re leaving in droves – at a time when we need them more than ever.
The number of people dying at home is up by one third since before the pandemic, and those who do make it into hospital for care are discharged faster than ever to free up beds, long before they’ve made a full recovery.
Ministers have tabled some ambitious ideas to address the vital need for at-home care, including a wave of new community health hubs, or more video appointments. But none are a quick fix, nor are they proven to solve the problem. Recruiting more district nurses could help alleviate these pressures, say experts, as well as tackling what threatens to be a spiralling crisis in community care. But this might be harder than it sounds.
Read full story
Source: Mail Online, 13 November 2021
Patient Safety Learning

Long Covid among staff adding to healthcare pressures, say NHS leaders

NHS bosses have warned the high prevalence of long Covid among staff is adding to rising healthcare pressures, amid growing concern that the new omicron variant could further drive infections and absences in the workforce.
Some 40,000 (3.26%) of healthcare workers in the UK are estimated to have long Covid, according to the Office for National Statistics. This figure has risen by 5,000 since July.
Many will be unable to work, though others are continuing to work despite their debilitating symptoms, experts say.
“Trust leaders have told us they are concerned about the prevalence of long Covid amongst health and care staff,” said Chris Hopson, chief executive of NHS Providers.
“Staff who are unwell need time to recover with support. But this may worsen unavoidable absences and sickness levels in the NHS at a time when pressures on the health service are mounting.”
Read full story
Source: The Independent, 9 December 2021
Sam

Hospital trust must 'immediately improve' services

A hospital trust has been told to "immediately improve" its maternity and surgical services.
The Care Quality Commission (CQC) made unannounced inspections in September and October at four of the hospitals run by University Hospitals Sussex NHS Foundation Trust.
Inspectors raised concerns about staff shortages, skills training and risk management.
At the trust's four maternity services, inspectors found departments "did not have enough staff to keep women and babies safe" and staff were "not up to date" with training.
Infection prevention measures in surgical services at the Royal Sussex County Hospital were "not consistently applied" and managers were not running services well, inspectors noted.
The report also said morale was low and often staff "did not have time to report incidents".
The trust said it has taken "urgent action" to make improvements.
Read full story
Source: BBC News, 10 December 2021
Sam

Blood supplies could soon become ‘critical,’ NHS warns

NHS stocks of blood may become “critical” this winter, a regulator has warned, as Covid and higher than average winter rates of cold and flu risk donation levels.
The NHS Blood and Transplant authority declared a major incident at the end of October after its supply of blood supplies dropped to critical levels, nationally.
The regulator’s supply was at risk of dropping to below two days’ supply across the country, when it aims to have at least five days at all times.
This is the second time the regulator, which is responsible for blood donation supplies to the NHS, has declared a critical incident in the last 12 months.
The last time the regulator declared an incident over low stocks was due to bad weather and snow in 2018 during the “beast from the east” storm and in Cornwall in 2019, which resulted in decreased donation levels.
Read full story
Source: The Independent, 12 December 2021
Patient Safety Learning

Mothers and babies at risk as vital health services in England stay shut

Mothers and babies are being put at risk as vital health checks and support services remain shut months after lockdown was lifted, health professionals and charities have warned.
Face-to-face services for new families stopped when lockdown began in March last year and have not come back in many parts of the country. Now experts fear the spread of the Omicron variant and the reintroduction of some restrictions means the reopening will be delayed further.
Missing services include drop-in baby-weighing clinics, tongue-tie clinics, face-to-face breastfeeding support and council-run baby classes and playgroups.
Experts have accused the government of failing to prioritise the needs of a generation of babies and their parents, with cost-cutting and a shortage of midwives and health visitors blamed for the closures.
Health visitor drop-in clinics are “no longer running” in nearly a third of areas, and around 28% of newborn checks are being carried out via phone or video call, according to the No One Wants to See My Baby report by charities the Parent-Infant Foundation, Home-Start UK and Best Beginnings.
The Institute of Health Visiting said different interpretations of government guidance meant some areas had brought back full services while others had not, creating a “postcode lottery of support for families”.
It questioned official advice that routine checks could continue to be done via video and telephone calls, warning there was no evidence these were “safe or effective”.
Executive director Alison Morton said: “Alongside the concerns of parents, there is a growing body of evidence that childhood conditions and disabilities are being missed, and vulnerable babies and young children are being harmed, as they are invisible to services when these assessments are not completed face to face.”
Read full story
Source: The Guardian, 12 December 2021
Patient Safety Learning

Doctor with Long Covid found to have multiple blood clots in his brain

A doctor who became very unwell with COVID-19 at the start of the pandemic was later found to have multiple blood clots in his brain which could easily have killed him.
Dr Ian Frayling started suffering with a "bone-cracking" fever, muscle pain and a "cough like no other" in March 2020, weeks before the national lockdown was announced by the UK and Welsh governments.
His condition then took a turn for the worse when he started experiencing problems with his breathing and encountering such extreme brain fog that entire days would pass him by.
The 62-year-old said his "frightening" range of symptoms, which also included irritable bowel syndrome, disruptive sleep and difficulty with coordination, persisted for many months and left him a fatigued shell of his former self.
After sharing his story with WalesOnline 12 months ago, Dr Frayling was invited to meet the Senedd's health committee in March 2021 to give evidence of his battle with Long Covid. It led to a respiratory consultant reaching out to him and offering him a full clinical assessment at the University Hospital Llandough.
Not only did she find problems with his heart and blood pressure, which were to be expected, but a referral for CT scans in May 2021 revealed that he was living with several blood clots in his brain which were very likely to be attributed to the after-effects of coronavirus. It meant suffering a catastrophic stroke was highly likely.
After being given the deeply distressing news, Dr Frayling said his mind began turning to other people with Long Covid who may be experiencing similar neurological symptoms but are waiting many months to be referred to see a specialist doctor by their GP.
"The consultant used her clinical skills and expertise [to properly assess me and give me a CT scan]. I'm one of the lucky ones. A GP can't directly send people off for these kind of tests, so there could be thousands of people with Long Covid, just like me, who aren't getting the help they need and are just being fobbed off."
Read full story
Source: Wales Online, 28 November 2021
Patient Safety Learning

COVID-19: Build on success of vaccination programme in reaching ethnic minority groups, report recommends

Lessons learnt in relation to increasing uptake of the COVID-19 vaccine among ethnic minority groups should now be applied to the booster programme, a government progress report recommends.
This includes continuing to use respected local voices to build trust and to help tackle misinformation, the report from the government’s Race Disparity Unit says. Such approaches should also be carried over to the winter flu and childhood immunisation programmes and be applied to the work to tackle longer standing health disparities.
In June 2020 the minister for equalities was asked to look at why COVID-19 was having a disproportionate impact on ethnic minority groups and to consider how the government response to this could be improved. This latest report is the final one of four.
Taken together the reports identified that the main factors behind the higher risk of COVIDd-19 infection for ethnic minority groups include occupation, living in multigenerational households, and living in densely populated urban areas with poor air quality and high levels of deprivations.
Read full story
Source: BMJ, 3 December 2021
Sam

Surgery 'may have played role in woman's death'

An inquest into whether a pioneering surgery technique played any role in a Gloucestershire woman's death has opened.
Jacqui Kingston, from Marshfield, died on 16 March 2020 after having mesh fitted for a prolapsed bowel at Southmead Hospital in Bristol.
On Monday an inquest opened at Avon Coroner's Court examining whether the surgery performed by colorectal surgeon Tony Dixon contributed to her death. It is due to run until Thursday.
Pathologist Edward Sheffield told the hearing that the use of the mesh for a prolapsed bowel - which was fitted in 2016 - may have contributed to her death.
The inquest heard that Mrs Kingston was a fragile patient with many underlying health conditions who developed complications.
Mr Dixon was dismissed by the North Bristol NHS Trust in 2019 after dozens of his patients were told they should have been offered alternative treatment first.
Read full story
Source: BBC News, 13 December 2021
Patient Safety Learning

Hundreds face six-hour booster jab queue as rollout to all adults begins

Hundreds of Britons faced many hours-long queues to receive their coronavirus booster jab in a day of chaos that saw lateral flow tests run out on the government website and the NHS site struggle with the surge in booster bookings.
It comes as Boris Johnson opened the booster jab programme to all adults in a bid to offer the third dose to all over-18s by the end of December, bringing his original target forward by one month.
St Thomas’ Vaccination Centre in Westminister confirmed a wait time of six hours for a booster jab, The Independent was told, with queues snaking around the building.
The hospital trust warned the public of a “high demand” for walk-in appointments causing extended waiting times.
Operations manager Ria Burke, 25, who had been waiting in the queue for 20 minutes, said: “It’s the first day my age group is allowed to get jabbed and I live locally.
“I’d like to not endanger my family at Christmas. This is my third jab. I watched the prime minister’s announcement last night and it was a good sign post but I think like a lot of other people I was just waiting for the portal to open.”
At Essentials Pharmacy in Covent Garden, Grace Whiley, 26, had been waiting in the queue for an hour and a half. She said: “It was a last-minute decision, I work round the corner and my age group can’t book til Wednesday. I just want to get it done. I’m pregnant so I want to be as protected as possible.”
Read full story
Source: The Independent, 13 December 2021
Patient Safety Learning

NHS trusts criticised over system that films mental health patients in their bedrooms

NHS trusts are facing calls to suspend the use of a monitoring system that continuously records video of mental health patients in their bedrooms amid concerns that it breaches their human rights.
Mental health charities said the Oxevision system, used by 23 NHS trusts in some psychiatric wards to monitor patients’ vital signs, could breach their right to privacy and exacerbate their distress.
The call comes after Camden and Islington NHS foundation trust (C&I) suspended its use of Oxevision after a formal complaint by a female patient who said the system amounted to “covert surveillance”.
The Oxevision system allows staff to monitor a patient’s pulse and breathing rate via an optical sensor, which consists of a camera and an infrared illuminator to allow night-time observation.

It includes a live video feed of the patient, which is recorded and kept for 24-72 hours, depending on the NHS trust, before being deleted. Oxehealth, which created the system, said it was not like CCTV because staff could only view the video feed for about 10-15 seconds during a vital signs check or in response to a safety incident.
The system, which is also installed at Exeter police station custody suite and an Oxfordshire care home, can alert staff if someone else has unexpectedly entered a patient’s room or if they are in a blindspot, such as the bathroom, for too long.
Alexa Knight, associate director of policy and practice at Rethink Mental Illness, said: “While we appreciate that the motivation for putting surveillance cameras in people’s bedrooms stems from the need to protect them, to do so without clear consent is unjustifiable and this pilot should be suspended immediately.”
Read full story
Source: The Guardian, 13 December 2021
Patient Safety Learning

COVID-19: Coroners call for changes after highlighting avoidable deaths during pandemic

Coroners in England are demanding changes in a series of reports highlighting how the struggling healthcare system’s responses to the pressures of the COVID-19 pandemic contributed to patients’ deaths.
Coroners are obliged to write a report recommending action in any cases where they believe that this is necessary to prevent future deaths. Reports now emerging suggest that factors in deaths during the pandemic include the move by GPs to telephone consultations, the requirement for vulnerable patients to attend hospital appointments alone, and the lack of safeguards for patients in care homes.
The replacement of in-person appointments by telephone consultations reduced GPs’ ability to pinpoint patients’ needs, the coroners said, and the absence of family members from consultations with vulnerable patients meant that clinicians were often unable to get a full picture of their needs.
An example is in the Yorkshire and Humber region which saw an increased incidence of children with severe nutritional anaemia in 2020, resulting in two deaths. Maya Zab, who died aged 11 months, was one of the two. Language barriers had caused missed opportunities for primary carers to see Maya, but this was compounded by the pandemic, said Ian Pears, coroner. The “stay at home” message resulted in fewer one-to-one consultations and meant that healthcare professionals were unable to spot signs of her condition, while the limitation of social contact meant that other professionals and friends were unable to report concerns.
Read full story
Source: BMJ, 8 December 2021
Patient Safety Learning

NHS told to raise its game on IPC or face omicron-driven surge in hospital infections

The NHS must apply Covid infection prevention and control measures more robustly if it is to avoid a steep rise in infections within healthcare settings, a senior doctor at NHS England has said.
The warning came from NHS England national clinical director for antimicrobial resistance and infection prevention and control Mark Wilcox during a webinar for NHS leaders.
He said that the effectiveness of the vaccination programme had led “understandably” to the NHS being more relaxed when it came to Covid IPC.
However, he warned that “the effectiveness of the vaccines has diminished substantially with respect to two doses” because of the omicron variant, and that “if we carry on with the level of IPC that we have been lulled into then we will see very significant problems with nosocomial infection”.
Read full story (paywalled)
Source: HSJ, 14 December 2021
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