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

NHSE orders health check blitz to stop mortality gap growing

NHS England is urging health systems to ramp up physical health checks for people with severe mental illnesses to address a widening life expectancy gap caused by covid, according to a letter seen by HSJ.
In a letter circulated to integrated care system leads, chairs, mental health and community trust executives on Wednesday, national commissioners warn the impact of the pandemic may widen current gaps in life expectancy for people with SMI and learning disabilities even further, without “decisive and proactive action”.
The letter, circulated by national mental health director Claire Murdoch, learning disability and autism director Tom Cahill and inequalities director Bola Owolabi, quotes NHS data suggesting people with SMI are five-and-a-half times more likely to die prematurely and those with learning disabilities three times more likely to die from an avoidable cause of death.
It says: ”The health inequalities faced by people living with SMI and people with a learning disability are stark… The impacts of the pandemic will widen this gap further unless we take decisive and proactive action to address inequalities… These checks are a key lever to address the reduced life expectancy for both groups.”
It calls on primary care teams, already delivering thousands of covid vaccinations as part of the booster programme, to prioritise annual physical health checks alongside the rollout, “even as we continue with a level 4 national incident” caused by the omicron variant.
Read full story (paywalled)
Source: HSJ, 14 January 2022
Patient Safety Learning

Multiple sclerosis could be caused by the common ‘kissing disease’ virus, scientists say

The debilitating disease multiple sclerosis could be caused by the common virus behind "kissing disease", scientists claim.
A new study from Harvard University suggests the chronic disease could be from an infection of Epstein-Barr, a herpes virus that causes infectious mononucleosis.
Mono or glandular fever, as it’s otherwise known, is colloquially known as "the kissing disease" for being highly contagious through saliva.
While causing fatigue, fever, rash, and swollen glands, researchers propose that the Epstein-Barr virus could also establish a latent, lifelong infection that may be a leading cause of multiple sclerosis.
Affecting 2.8 million people, there is no known cure for the chronic inflammatory disease of the central nervous system.
“The hypothesis that EBV causes MS has been investigated by our group and others for several years, but this is the first study providing compelling evidence of causality,” the study’s senior author Alberto Ascherio, a professor of epidemiology and nutrition at Harvard Chan School, said in a press release.
“This is a big step because it suggests that most MS cases could be prevented by stopping EBV infection, and that targeting EBV could lead to the discovery of a cure for MS.”
Read full story
Source: The Independent, 13 January 2022
Patient Safety Learning

NHSE tells staff: Consider legal action against patients who refuse to leave beds

NHS England has encouraged trusts to consider taking legal action against patients who refuse to leave hospital beds when step-down care is made available.
NHSE guidance sent to trusts late last year, seen by HSJ, advised clinicians that where people “with mental capacity” refuse to vacate a bed because they do not accept NHS-funded short-term care offers, the “local discharge choice policy” should be followed, which could involve legal action.
The guidance said the process “may include seeking an order for possession of the hospital bed” under civil law, and that “appropriate formal notification of the process must be given to the person and their representatives/carers”.
These legal powers were open to trusts prior to covid, but the memo from NHSE comes amid increasing pressure on trusts to improve discharge rates, as waits for emergency and elective care continue to soar.
Helen Hughes, chief executive of Patient Safety Learning, said: “Given the current pressures posed by covid, it is understandable that the NHS is seeking to ensure that the hospital discharge process is as swift and effective as possible.
“However, hospital discharges are complex processes and can potentially result in avoidable harm if patients are discharged before they are clinically ready. It only takes one element of this complex process failing to put a patient’s safety at risk.
“We would be particularly concerned if patients and their carers were put under pressure to accept potentially unsafe discharge options due to the threat of possible legal action by an NHS trust.”
Read full story (paywalled)
Source: HSJ, 14 January 2022
Sam

No payments for unvaccinated staff, trusts told as NHS prepares for dismissals

NHS organisations have been told to prepare for redeploying or dismissing thousands of unvaccinated staff without an exit payment, and to raise the alarm about services which may be rendered unsafe.
NHS England today issued guidance on ‘phase two’ of the government’s “vaccination as a condition of deployment”, which requires all patient-facing staff to have had two covid vaccinations by 1 April. 
Tens of thousands of staff are believed to still be unvaccinated, and the cut off for having a first dose is 3 February.
The guidance said efforts should be made to adjust roles or redeploy staff, but added: “From 4 February 2022, staff who remain unvaccinated (excluding those who are exempt) should be invited to a formal meeting chaired by an appropriate manager, in which they are notified that a potential outcome of the meeting may be dismissal.”
It continued: “Whilst organisations are encouraged to explore deployment, the general principles which apply in a redundancy exercise are not applicable here, and it is important that managers are aware of this.”
Employers will “not be concerned with finding ‘suitable alternative employment’ and there will be no redundancy entitlements, including payments, whether statutory or contractual, triggered by this process”.
Trusts also do not have to “collectively consult” with staff being dismissed — as they would with a restructure — although this is “ultimately a decision for each organisation to take”.
Read full story (paywalled)
Source: HSJ, 14 January 2022
Sam

Red levels of staffing are the norm’: NHS workers on coping with Covid

The number of Covid patients in hospitals in England and Scotland has continued to rise this week, as NHS England reached a deal with private hospitals to free up beds amid the outbreak of Omicron cases.
Meanwhile, Covid staff absences in England rose to their highest level since the introduction of the vaccine. The number of NHS workers in England off sick because of Covid was up by 41% in the week to 2 January, according to the latest figures.
Five health workers describe some of the challenges they are facing, including understaffing, waiting times and bed-blocking.
Read full story
Source: The Guardian, 14 January 2022
Sam

Sleep deprived doctors concerned about patient safety

Over a third of doctors say they feel sleep deprived on at least a weekly basis and over a quarter have been in a position where tiredness has impacted their ability to treat patients, a new survey by the Medical Defence Union (MDU) has found.
The UK's leading medical defence organisation carried out the survey among its doctor members. Of 532 respondents one in four doctors (26%) said tiredness had affected their ability to safely care for patients, including almost 40 near misses and seven cases in which a patient actually sustained harm. In addition, six in ten respondents said their sleep patterns had worsened slightly or significantly during the pandemic.
Dr Matthew Lee, MDU chief executive, said:
"Doctors and their healthcare colleagues are running on empty. Our members have come through a period of immense pressure caused by the pandemic and it is affecting all aspects of their life, including sleep patterns. Previous studies have shown that fatigue can increase the risk of medical error and affect doctors' health and wellbeing. In our survey, side effects doctors reported due to sleep deprivation included poor concentration (64%), decision making difficulties (40%), mood swings, (37%) and mental health problems (30%).
"Taking regular breaks is vital in the interests of doctors and their patients yet in our survey, three in ten doctors got no breaks at all during the working day despite many working long shifts. In addition, 21% didn't have anywhere to go such as a staff room, or quiet area, to take a break.
"Pressures on frontline healthcare workers are likely to get worse for doctors in the coming weeks. At a time of considerable staff absence in the NHS it is more important than ever that those staff who are fit to work are properly supported so they can care for patients safely."
Read full story
Source: MDU, 17 January 2022
Patient Safety Learning

Family of Cornwall girl, 6, misled over cause of death, coroner finds

A six-year-old girl thought to have died from sepsis was in fact suffering from a blood condition triggered by E coli infection, an inquest has found.
Coco Rose Bradford was taken to the Royal Cornwall hospital in the summer of 2017 suffering from stomach problems and later transferred to the Bristol Royal hospital for children, where she died.
The following year an independent review flagged up failings in her care in Cornwall and the Royal Cornwall hospitals trust apologised for how it had treated her.
Her family were left with the belief she had died of sepsis and could have been saved if she had been given antibiotics. But on Friday, coroner Andrew Cox, sitting in Truro, found that Coco died from multiple organ failure caused by haemolytic uraemic syndrome (HUS). The inquest heard there is no proven treatment for HUS.
Cox said Coco’s family had been misled over the sepsis diagnosis, which he said was deeply regrettable, adding: “As a matter of fact, I find Coco had overwhelming HUS, not overwhelming sepsis.”
During the inquest, the court heard Coco’s family felt staff at the Cornish hospital were “dismissive, rude and arrogant” and did not take her condition seriously.
Cox found that although staff had recognised the risk of HUS from the moment Coco was admitted, this was not clearly set out in a robust management plan. The coroner also said a lack of communication had made Coco “something of a hostage to fortune”.
Read full story
Source: The Guardian, 14 January 2022
Patient Safety Learning

Dozens of deaths and stillbirths at maternity units cost hospital trust £103m in damages over decade

More than £100 million has been paid out in damages by one hospital trust over 10 years after its maternity units were accused of being responsible for dozens of deaths and stillbirths, Channel 4 News has revealed.
From April 2010 to March 2021, £103,097,198 was paid out by the Mid & South Essex NHS Foundation Trust involving 176 obstetrics claims, according to NHS Resolution figures obtained by a freedom of information request.
Of those claims made against the trust, 36 related to mothers and children dying, 27 referred to stillbirths and 55 concerned babies born with brain damage or cerebral palsy.
Gabriela Pintilie died in Basildon University Hospital, which is run by the trust, in 2019 after losing six litres of blood giving birth, and a coroner said there were “serious failings” in her care.
Basildon University Hospital’s maternity unit was twice rated inadequate in 2020, following two separate inspections, with a report saying the service “did not always have enough staff to keep women safe”.
The report also criticised “longstanding poor staff culture” which had “created an ineffective team”.
In August 2020, the Care Quality Commission (CQC) issued a warning notice to the hospital as inspectors found six serious incidents occurred between March and April that year in which babies were born in a poor condition starved of oxygen and at risk of brain damage.
Read full story
Source: Channel 4 News, 14 January 2022
Patient Safety Learning

Vulnerable woman starved to death in NHS hospital following ‘unacceptable’ failures

“Unacceptable” failures by a mental health hospital to manage the physical healthcare of a woman detained under the mental health act contributed to her starving to death, The Independent has learned.
A second inquest into the death of a 45-year-old woman, Jennifer Lewis, has found that the mental health hospital to which she was admitted “failed to manage her declining physical health” as she suffered from the effects of malnutrition.
Ms Lewis had a long-term diagnosis of schizophrenia. Her family described how she had lived a full life, completed a degree, and given lectures about living with mental illness. However, after undergoing bariatric surgery, against the wishes of her family, her mental state declined and she was admitted to the Bracton Centre, run by Oxleas, in 2014.
In an interview with The independent, her sister, Angela, described how, in the year before her death, Ms Lewis lost her hair, suffered from diarrhoea, and developed sores on her legs as she effectively “starved to death” from malnutrition.
Ms Lewis’s sister told The Independent that in the year leading up to her death, when the family warned doctors she was “starving to death”, their concerns were dismissed and they were told that the hospital “will not let it come to that”.
Mental health charity Rethink has called for improvements to physical healthcare for patients with severe mental illness, whose physical needs they say are “all too often ignored”, while experts at think tank the Centre for Mental Health have warned that patients with mental illness are dying too young as the system “still separates mental and physical health”.
Read full story
Source: The Independent, January 2022
Patient Safety Learning

Increasing management spend does not improve hospital performance, research concludes

There is no significant relationship between the number of managers or the amount spent on management and the quality of NHS hospital services, research has concluded.
Researchers at the London School of Economics studied the performance of all 129 non-specialist acute trusts between 2012-13 and 2018-19.
They measured hospital performance on five indicators covering financial position, elective and emergency waiting times, level of admissions and mortality. This was then compared to the number of managers each trust employed and the amount spent on management staff.
The researchers also attempted to measure the quality of management based on answers given to relevant questions in the annual NHS staff survey.
Reviewing the evidence they analysed, the LSE team state: “We find no evidence of an association between our measures of quantity of managerial input and quality of management… Furthermore, we find no associations between our measures of quantity of management input and five measures of hospital performance.”
They add: “This holds, irrespective of how we define managerial input, whether by number of managers or expenditure on management. These results are generally robust to how we account for variation between hospitals and within hospitals over time.”
This leads the researchers to conclude: “Hospitals hiring more managers do not see an improvement in the quality of management leading to better performance, and increasing the numbers of managers does not appear to improve hospital performance through any other direct or indirect mechanism.”
Read full story (paywalled)
Source: HSJ, 17 January 2022
Patient Safety Learning

Mum tells of heartbreak at baby loss in Covid coma

A woman has spoken of her "devastation" after losing a baby delivered while she was in an induced coma with Covid.
Rachel, from Wolverhampton was admitted to hospital over the summer in the 19th week of pregnancy. She said uncertainty about whether pregnant women should have the Covid vaccine had put her off getting it.
Her condition deteriorated and she said she was so ill she did not realise at first son Jaxon was stillborn.
"I was heavily sedated a lot of the time and from what I'm told by my family, my chances weren't looking very good," the 38-year-old said. "They were trying to get the baby to survive to 28 weeks but unfortunately, at 24 weeks, my son was born stillborn."
Rachel, who said she had planned to have the vaccine after giving birth, is now urging others to get the jab, particularly women from minority backgrounds, for whom uptake is lower.
Read full story
Source: BBC News, 15 January 2022
Patient Safety Learning

One in four NHS doctors tired to the point of impairment, survey finds

One in four doctors in the NHS are so tired that their ability to treat patients has become impaired, according to the first survey to reveal the impact of sleep deprivation on medics during the coronavirus pandemic.
Growing workloads, longer hours and widespread staff shortages are causing extreme tiredness among medics, leading to memory problems and difficulty concentrating, according to the report by the Medical Defence Union (MDU), which provides legal support to about 200,000 doctors, nurses, dentists and other healthcare workers.
The survey of more than 500 doctors across the UK, carried out within the past month and seen by the Guardian, uncovered almost 40 near misses as a direct result of exhaustion. In at least seven cases, patients actually sustained harm.
Despite encouraging signs the Omicron wave may be fading, doctors admitted the constant pressure of the past 22 months spent fighting coronavirus on the frontline was taking a toll on their technical skills and even their ability to make what should be straightforward medical decisions. Medics admitted for the first time sleep deprivation was causing real harm to patients in the NHS.
Almost six in 10 doctors (59%) reported their sleep patterns had worsened during the pandemic. More than a quarter (26%) of medics admitted being so tired that their ability to treat patients was “impaired”. Of these, one in six (18%) said a patient was harmed or a near miss occurred as a result.
Read full story
Source: The Guardian, 17 January 2022
Read MDU press release
Sam

Yorkshire heart attack patient urged to take lift to York hospital

An ambulance trust has apologised after a man having a heart attack said he was advised to get a lift to hospital or face a long wait.
Graham Reagan said he was on the verge of collapsing when he finally got to York hospital after a lift from his son.
Mr Reagan said he was concerned about the impact on patients with potentially life-threatening conditions.
Speaking to BBC Yorkshire and Lincolnshire's Politics North programme, Mr Reagan described his experience as "scary".
"I'd had indigestion, or so I thought, for a couple of days, and then on 17 December I went to bed early feeling rough," he said.
In the early hours, Mr Reagan said the pains in his chest grew worse and he asked his wife to call for an ambulance. "I couldn't take it any more," he said.
Mr Reagan, from Malton in North Yorkshire, said his wife was asked "can you get to hospital" as the nearest ambulance was about 20 to 30 miles away.
"My wife doesn't drive, but fortunately my son was with us and he drove me to York hospital."
On arrival Mr Reagan said they found the entrance to A&E had also been re-routed.
"So, we then had to walk out of the hospital grounds and back in - by which time I'm collapsing," he added.
He said staff at the hospital were "absolutely brilliant" and arranged for him to be transferred to Hull for treatment after a heart attack was confirmed. However, he said he was faced with a further 35-minute delay while he waited for an ambulance to take him.
Mr Reagan said he wanted to share his experience to raise awareness.
Read full story
Source: BBC News, 16 January 2022
Patient Safety Learning

Specialist mental health unit failures exposed by patients

There are serious concerns over the standards of specialist care being provided to patients with the most complex mental health needs, a BBC investigation has found.
Patients sent by the NHS to stay in mental health rehabilitation units say they have been placed in unsafe environments, often far from home, with untrained staff.
Experts say not enough is being done to regulate the sector, which costs the NHS half a billion pounds a year.
Lissa had spent years struggling with her mental health, having experienced traumatic life events. She was diagnosed with mixed personality disorder, depression and high-functioning Asperger's. So when the NHS sent her to a unit in Coventry run by Cygnet Health Care for a specialist talking therapy, she agreed.
The hospital, however, was in special measures. There had been two deaths in the previous 20 months. In both cases there was found to be a failure to follow the patient's care plan and carry out observations correctly. Lissa says staff failed to treat her with dignity and respect.
The system in England is regulated by the Care Quality Commission, (CQC). Some rehabilitation wards haven't been inspected for four or more years.
John Chacksfield, who was a CQC inspector until late 2020, says greater scrutiny is needed.
"Sometimes the private sector provides really excellent service, but there are certain units that really do need regular inspections just to make sure staff are being trained enough, or are having enough clinical supervision. It does worry me," he says.
Read full story
Source: BBC News, 18 January 2022
Sam

Swedish expert praises leading work in patient safety in Scotland

Swedish expert has praised Scotland for leading work in improving patient safety, with a decade-long programme which is now expanding into social care.
Dr Pelle Gustafson (below), chief medical officer, of Swedish patient insurer Löf, said he was “particularly impressed” by the work in Scotland over the past 10 years during a meeting of the House of Commons Health and Social Care Committee.
The Scottish Patient Safety Programme (SPSP), which has been in existence for around 13 years, was set up to make patient safety a priority in NHS Scotland, drawing on lessons from the airline industry such as introducing checklists.
Gustafson was asked by Tory MP Dr Luke Evans which country he would hold at the “very top of the pillar” for preventative work during an evidence session on NHS litigation reform last week.
He responded: “If you take all preventive work as regards patient safety, I would say that I am personally very impressed by Scotland.
“In Scotland, you have a long-standing tradition of working. You have development in the right direction.
“You have a system that is fairly equal all over the place and you also have improvement activities going on. I am very impressed by Scotland.”
He added: “I am particularly impressed by the Scottish work over the last 10 years. There are a lot of things that we, in the Nordic countries, can learn from Scotland too.”
Read full story
Source: The National, 16 January 2022
 
 
 
 
Sam

Coroner concerned with Barts NHS trust after woman 'unlawfully killed'

Barts Health NHS Trust has been told to take action to prevent future deaths after an elderly woman was unlawfully killed at one of its hospitals.
East London acting senior coroner Graeme Irvine sent a report to the trust in which he raised concerns over the death of 78-year-old Surekha Shivalkar in 2018.
The report follows an inquest into Mrs Shivalkar's death, which reached a narrative conclusion incorporating a finding of unlawful killing.
A Barts spokesperson said the trust had made a number of changes after carrying out an investigation.
Mrs Shivalkar underwent hip replacement revision surgery at Newham Hospital on September 28, 2018 in a procedure estimated to last between four and five hours, the coroner wrote. 
She had a number of serious conditions, including ischaemic heart disease, osteoporosis and chronic obstructive pulmonary disorder. But Mr Irvine said an inaccurate risk of death of less than 5% was given, as no formal risk assessment tool was used. 
The surgery took longer than seven and a half hours, during which time Mr Irvine said Mrs Shivalkar sustained a "prolonged and dangerous" period of hypotension, or low blood pressure.
He said the anaesthetist failed to communicate this to the surgical team and agreed to prolong surgery at the six hour point.
Mr Irvine said: "Poor communication between the orthopaedic surgical team and the anaesthetist during surgery led to a collective failure to identify a critically ill patient."
Read full story
Source: Newham Recorder, 17 January 2022
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