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

Man's partner 'begged' for help before his death

A man who died from a mixed medication overdose might still be alive if the help his partner was "begging" for had been provided, a coroner said.
Mental health patient Benjamin Stroud, 42, had been under the care of Essex Partnership University NHS Trust (EPUT) in the weeks before his death in March.
Essex coroner Michelle Brown said in a post-inquest report that, despite "escalating psychosis", his care co-ordinator did not flag the case.
Following an overdose of medication in February, his partner, a nurse, called for psychiatric intervention and despite "begging" for help, Mr Stroud's care co-ordinator did not make a referral to the multi-disciplinary team (MDT).
Mr Stroud died at home on 19 March and was found surrounded by empty insulin pens and pain medication.
In her prevention of future deaths report, the coroner said: "It was clear from [his partner's] account that she had been begging the care co-ordinator for Mr Stroud to have an appointment with the psychiatrist, which did not occur and, from the evidence of EPUT, it was clear that Mr Stroud's care co-ordinator did not make any referral to the MDT, despite his escalating psychosis."
The coroner added that the issue of care co-ordinators failing to document their reasons for not referring cases to the MDT had been raised at other inquests.
"If these practices continue there is a real risk of future deaths occurring," Ms Brown warned.
Paul Scott, chief executive at the trust, said: "We will continue to view all safety-related incidents as an opportunity to learn and make sure lessons are shared across the trust."
Read full story
Source: BBC News, 16 February 2022
Patient Safety Learning

Woman screaming in pain waiting years for hip op

"Seeing how much pain she's in is killing me," the mother of a woman waiting four years for a hip operation has said.
It is only by screaming that Marie Morgan, from Carmarthenshire, can express her level of suffering.
The 30-year-old, who has multiple brain conditions, can speak only a few words and needs round-the-clock care. 
"Her hip is out and is rubbing against bone... there's no socket there," Marie's mother Sandra said. "She can't travel because every time I move her she's screaming in pain.
Marie has cerebral palsy, severe epilepsy and fluid on the brain and the constant agony caused by the wait has meant these conditions, including her seizures, have become "horrendous".
Sandra said: "She used to be so happy, we used to go to the pool, play music... Now she's gone downhill. I don't think she can last much longer to be honest with you."
Marie, from Penygroes, is on a waiting list to have surgery in Morriston Hospital, Swansea.
Her mother said staff have told her she is considered to be high priority, but despite her best efforts, she is still in the dark about when the operation will happen.
"They said because of Covid they weren't operating, now they say it's staff shortages so it's something all the time.
"I feel I'm knocking my head against a wall. It's not fair, she's only 30 and suffering the way she is."
Swansea Bay Health Board said it hoped to tackle the backlog by increasing capacity at one of its hospitals.
Read full story
Source: BBC News, 17 February 2022
Patient Safety Learning

Surgical mesh: Proposed training pathway needs more patient input, say campaigners

A proposed new training pathway for treating complications of pelvic mesh implants needs more input from patients and more consistent supervision of surgical procedures being carried out, campaigners have urged.
The pathway proposed by the Royal College of Obstetricians and Gynaecologists (RCOG) aims to outline the skills required of doctors working in specialist mesh removal centres, which were set up after a recommendation in the Cumberlege review into avoidable harm among patients injured by implanted pelvic mesh.
But a joint blog published on 17 February by Patient Safety Learning and Sling the Mesh raised several concerns about the proposed pathway, including that the consultation for implementing it was too short and not well publicised, offering limited opportunities for patients and groups to comment.
The groups wrote, “While the development of the training pathway did involve a focus group of six women with mesh related issues, we believe that RCOG have missed an opportunity to engage much more widely."
“Patient engagement is key to improving patient safety, even more so when there has been a significant loss of trust for patients in healthcare professionals, such as in the case of surgical mesh. We believe it is vital that RCOG, further to its focus group, should be engaging directly with patient groups to hear their concerns and experiences and to genuinely co-produce this type of guidance.”
Jo Mountfield, vice president of the RCOG, said that the concerns raised by the groups would be considered as part of the review process. She acknowledged that the consultation period could have been longer.
She said, “There will be further opportunity to involve patient groups as part of our application to the General Medical Council for approval of the training pathway, and we will take the comments raised in this blog on board."
Read full story (paywalled)
Source: BMJ, 17 February 2022
Related reading
First Do No Harm APPG public meeting on redress: Speech from Kath Sansom (26 January 2022). Kath Sansom, ‘Mesh removal surgery is a postcode lottery’ – patients harmed by surgical mesh need accessible, consistent treatment (2 December 2021). McFadden et al, The long-term impact of vaginal surgical mesh devices in UK primary care: a cohort study in the CPRD (20 August 2021). Sharon Hartles, Mesh: Denial, half-truths and the harms (23 March 2021). Patient Safety Learning, A year on from the Cumberlege Review: Initial reflections on the Government’s response (23 July 2021).
Patient Safety Learning

The millions of people stuck in pandemic limbo

When the coronavirus pandemic began, Emily Landon thought about her own risk only in rare quiet moments. An infectious-disease doctor at the University of Chicago Medicine, she was cramming months of work into days, preparing her institution for the virus’s arrival in the United States. But Landon had also recently developed rheumatoid arthritis—a disease in which a person’s immune system attacks their own joints—and was taking two drugs that, by suppressing said immune system, made her more vulnerable to pathogens.
Normally, she’d be confident about avoiding infections, even in a hospital setting. This felt different. “We didn’t have enough tests, it was probably around us everywhere, and I’m walking around every day with insufficient antibodies and hamstrung T-cells,” she said.
Two years later, Covid-19 is still all around us, everywhere, and millions of people like Landon are walking around with a compromised immune system. A significant proportion of them don’t respond to Covid vaccines, so despite being vaccinated, many are still unsure whether they’re actually protected—and some know that they aren’t. Much of the United States dropped COVID restrictions long ago; many more cities and states are now following. That means policies that protected Landon and other immunocompromised people, including mask mandates and vaccination requirements, are disappearing, while accommodations that benefited them, such as flexible working options, are being rolled back.
This isn’t a small group. Close to 3% of US adults take immunosuppressive drugs, either to treat cancers or autoimmune disorders or to stop their body from rejecting transplanted organs or stem cells. That makes at least 7 million immunocompromised people.
In the past, immunocompromised people lived with their higher risk of infection, but COVID represents a new threat that, for many, has further jeopardised their ability to be part of the world. From the very start of the pandemic, some commentators have floated the idea “that we can protect the vulnerable and everyone else can go on with their lives.” Seth Trueger, who is on immunosuppressants for an autoimmune complication of cancer, said. “How’s that supposed to work?”
He is an emergency doctor at Northwestern Medicine; he can neither work from home nor protect himself by avoiding public spaces. “How am I supposed to provide for my family or live my life if there’s a pandemic raging?” he said. 
Read full story
Source: The Atlantic, 16 February 2022
Further reading
Read further Covid-19 blogs and stories from staff on the frontline
 
Patient Safety Learning

Men urged to check prostate cancer risk after thousands miss diagnosis in pandemic

Thousands of men are being urged to check their risk of prostate cancer amid warnings that more than 14,000 have missed a diagnosis during the pandemic.
New figures show that the disease accounts for a third of those not treated for cancer during the pandemic, making it the cancer most likely to have been missed and putting lives at risk.
Experts said many men had held off visiting their GP which meant they could now be missing out on vital treatment. NHS figures suggest nearly 50,000 fewer cancer diagnoses across the UK in the Covid crisis, including 34,000 in England.
Experts said prostate cancer made up the largest group of missed cases, followed by breast cancer, of which around 8,000 cases have gone undiagnosed.
Prostate Cancer UK and NHS officials are urging men to use an online tool to assess their risk, with those found to be at high risk urged to then visit their GP.
Read full story (paywalled)
Source: The Telegraph, 17 February 2022
Patient Safety Learning

Government 'destroying lives' by ignoring review recommendations on vaginal mesh and harmful medicines, campaigners warn

Campaigners found to have been harmed by medical products have written to the health secretary warning that government inaction is "causing pain and destroying lives" by ignoring review recommendations.
Some 18 months ago, an independent review recommended financial help for people damaged by some products and drugs that had been prescribed by UK doctors.
The government - which set up the Independent Medicines and Medical Devices Safety Review in the first place - has chosen to ignore several of its recommendations.
Alleged victims of vaginal mesh, and the drugs valproate and Primodos, have written to Health Secretary Sajid Javid and Maria Caulfield to say they feel ignored.
The letter states: "Our members gave evidence to the two-year-long review, sometimes travelling long distances, often with disabilities."
"Families shared intimate details of their medical problems, their daily struggles, their difficulties parenting, sometimes even their sex lives. The panel, led by Baroness Cumberlege, was set up by the government to listen, assess and direct policy towards the best course of action.   "What was the point of this exercise and the hard work of the panel, if their key recommendations are then ignored by the government?" In the letter, campaigners say: "The decision not to offer an agency for redress (Cumberlege recommendation 3) means that the review has lost its teeth."
"Still, no one is facing consequences of medical failures other than the patients. At a time when the public is being asked to put its faith in vaccines, this is a bad look for the government."
Kath Sansom, of the campaign group Sling the Mesh, said: "Women must dutifully accept their health has been irreversibly shattered by a medical product they were told was safe, some now needing a disabled blue badge, and they must put up and shut up."
Read full story
Source: Sky News, 17 February 2022
MeshPrimodosSodiumValproate_LettertoMariaCaulfield_170222.pdf
Patient Safety Learning

Bionic eyes: Obsolete tech leaves patients in the dark

Hundreds of people who had retinal implants to improve their sight face an uncertain future as the technology they rely on is now obsolete.
Second Sight stopped making its Argus II bionic eyes several years ago to focus on a brain implant instead. According to IEEE Spectrum it is now hoping to merge with a biopharmaceutical firm which does not make eye implants.
IEEE Spectrum reports that Second Sight actually discontinued its retinal implants - which effectively take the place of photoreceptors in the eye to create a form of artificial vision - in 2019.
Patients contacted by IEEE Spectrum voiced concern.
One, Ross Doerr, said Second Sight failed to contact any of its patients after its financial difficulties in 2020. "Those of us with this implant are figuratively and literally in the dark," he said.
Another user, Jeroen Perk, had problems when his VPU system broke in November 2020. "I had no vision, no Argus, and no support from Second Sight," he said.
Elizabeth M Renieris, professor of technology ethics at the University of Notre Dame, in the US, described the development as a cautionary tale.
She told the BBC: "This is a prime example of our increasing vulnerability in the face of high-tech, smart and connected devices which are proliferating in the healthcare and biomedical sectors."
"These are not like off-the-shelf products or services that we can actually own or control. Instead we are dependent on software upgrades, proprietary methods and parts, and the commercial drivers and success or failure of for-profit ventures."
Ethical considerations around such technology should in future include "autonomy, dignity, and accountability", she added.
Read full story
Source: BBC News, 17 February 2022
Patient Safety Learning

'My child is in pain - but I'm helpless'

Thomas Hebbron is one of the forgotten victims of the pandemic.
He was diagnosed with leukaemia in February 2019 - a year before Covid hit the UK.
The eight-year-old, from Leeds, has been treated with chemotherapy which has continued throughout the pandemic, but his health has suffered in other ways - and his mother believes the unrelenting focus on the virus is to blame.
Pre-pandemic he was seen in person by doctors every two weeks. But that changed to monthly video calls, and liver and urinary problems went undetected.
His treatment also affected his fine motor skills and has weakened his legs, but he has not seen an occupational therapist since before the pandemic.
"I want to take this pain away from him," says his mother, Gemma. "I don't want to sit and watch him in this pain, but I can't do anything. I just feel completely helpless."
Thomas's story is not unique. An analysis by the Nuffield Trust and Health Foundation has for the first time laid bare how access to core health services in England has been squeezed, threatening to leave behind a generation of young people.
The review has looked at both physical and mental health services and come to the same conclusion - support has been badly disrupted and the plight of children overlooked.
The Nuffield Trust and Health Foundation have been joined by the Royal College of Paediatrics and Child Health (RCPCH) in calling for a dedicated plan for children to help them recover from the pandemic.
Dr Camilla Kingdon, RCPCH president, said the figures "do not take into account the many other 'hidden' waiting lists of children waiting for community therapies and diagnostic assessments, especially for autism".
She added that children are "struggling" and, despite services being stretched, no-one should be deterred from speaking to a health professional.
Read full story
Source: BBC News, 18 February 2022
Patient Safety Learning

NHSE wants ‘urgent’ meetings over ambulance handovers risk

NHS England and the Care Quality Commission have asked systems with large numbers of ambulance handover delays to urgently hold a meeting to try to fix the problem by “balancing the risks” of long 999 waiting times.
The request was made in an email to chief executives, which warned the service was “in a difficult position with all parts of the urgent and emergency care pathway under considerable strain… most acutely in ambulance response times which in turn is linked to challenges in handing patients over to emergency departments”.
The NHSE headed letter was signed by its chief operating officer, nursing director and medical director, but also by the CQC’s chief inspector of hospitals Ted Baker.
It said there was a “strong correlation” between handover delays at hospitals — which take place where A&Es are unable to receive patients from ambulances — and long delays for category two ambulances. This is because ambulances have to wait for long periods outside the hospitals.
The letter said: ”It is vital that we have a whole-system approach to considering risks across the urgent and emergency care pathway to provide the best outcomes for our patients. This may mean consideration of actions to be taken downstream to help improve flow and reduce pressures on emergency departments.”
Read full story (paywalled)
Source: HSJ, 17 February 2022
Patient Safety Learning

Potentially harmful instructions given to pregnant women calling 999

The 'pre-arrival instructions' given by 999 (emergency services) call handlers to pregnant women/people experiencing maternity emergencies is a 'postcode lottery', with potentially harmful advice being given in some cases, the Healthcare Safety Investigation Branch (HSIB) has warned.
A national investigation by the HSIB examined the factors influencing the pre-arrival instructions given to pregnant women/people awaiting an ambulance because of an issue with their pregnancy. The instructions given by 999 call handlers are generated by a clinical decision support system (CDSS), with two CDSSs in use by ambulance services in England: an international system and a UK-based system.
The investigation reference case involved a 30-year-old woman who received advice from a 999 call handler that was in conflict with maternity clinical guidance. Similar concerns were identified in 15 HSIB maternity investigations, which all involved pre-arrival instructions generated by a CDSS that had the potential to cause harm to the woman or pregnant person and/or their baby.
The investigation found no evidence of a regulatory mechanism for 999 call handler pre-arrival instructions, and stakeholders acknowledged a gap in maternity emergency guidance relating to the non-visual, non-clinician-attended environment.
Read full story
Source: Medscape UK, 18 February 2022
Patient Safety Learning

Families to take part in Nottingham maternity inquiry

Seventy families have come forward to be a part of an independent review into maternity services at Nottingham University Hospitals Trust (NUH).
The aim of the review is to "drive rapid improvements to maternity services". It comes after an investigation found 46 babies suffered brain damage and 19 were stillborn between 2010 and 2020.
The Clinical Commissioning Group (CCG) and NHS England are jointly leading the review of maternity incidents, complaints and concerns at Nottingham University Hospitals (NUH).
Cathy Purt, programme director of the review, said during a Nottingham City Council Health Scrutiny Committee meeting on Thursday: "We have had 70 families come forward 19 families have had their first interview with us."
"We have secured via the CCG specialist psychological support for the rest of the families so they will now be able to come forward and have their interviews as well.
"40 staff have come forward so far and more are coming as we go."
The review will cover information dating back to 2006, and is expected to be completed by November 30 2022.
Read full story
Source: BBC News, 18 February 2022
Patient Safety Learning

111 callers eight times more likely to abandon calls in some areas

Callers to NHS 111 services are twice as likely to be judged as needing an ambulance in some regions as others – and up to eight times more likely to abandon their calls.
An HSJ investigation has revealed striking differences in performance between 111 providers. The new integrated urgent care data set, published by NHS England, shows the differences in performance across the country. HSJ analysed data from April to December last year – the first year this data set has been produced.
For example, 15.7% of answered calls to North East Ambulance Service Foundation Trust resulted in an “ambulance disposition” while just 7.7% of calls to London Ambulance Service Trust did so. A total of 14.2% of callers to the privately owned Practice Plus Group were judged to require an ambulance.
41.9% of calls were abandoned before being answered by NEAS and 30.6% of those made to the West Midlands Ambulance Service University FT ended the same way. In contrast just 5.2%of callers from Lincolnshire to services provided by Derbyshire Health United abandoned their calls.
The “standard” for abandoned calls is just 3%, but the average performance across England was 24.1%.
In a statement, the Practice Plus Group said its staff were trained to a high standard on NHS Pathways and it was confident its staff were making appropriate and safe decisions. Over 70 per cent of decisions to instigate a category 3 or 4 ambulance callout were validated in January. As a result ambulances were dispatched in just 20 per cent of those cases, with other patients being directed to alternative pathways.
“We are always looking to enhance the service which is why we are running developmental training for our call handlers in more effective probing to reduce the category 2 ambulance disposition numbers and have introduced GoodSam video technology as part of an NHSE pilot which will support clinicians with eyes on with a patient,” the company added.
Read full story (paywalled)
Source: HSJ, 18 February 2022
Patient Safety Learning

Doctor with Long Covid who suffered violent shakes and hallucinations attacks Boris Johnson's plan to 'live with virus'

A doctor who has suffered violent shakes and hallucinations during her ongoing 15-month battle with long COVID has criticised the government's plan to "live with the virus".
Dr Kelly Fearnley told Sky News she contemplated ending her own life due to the debilitating long-term effects of coronavirus, which she caught while working on a COVID ward in November 2020.
The 35-year-old from Leeds, who was previously fit and healthy, initially had flu-like symptoms before she suffered shortness of breath and painful rashes over her body, as well as swelling around her eye.
More than a year later, she is still unable to return to work due to the effects of long COVID, which have included violent shakes lasting up to 14 hours at a time, hallucinations, night terrors, severe pins and needles in her arms and legs, and a resting heart rate of 140 beats per minute.
With Prime Minister Boris Johnson set to unveil his "living with COVID" plan on Monday, Dr Fearnley branded it a "strategy of denial, driven by the need to cut costs" and she felt "angry and let down".
Read full story
Source: Sky News, 20 February 2022
Sam

Government rejects calls to address nurse burnout and shortage

The government has rejected calls for an overhaul of NHS workforce planning amid concerns of staff shortages and a mounting backlog of patients.
It comes after a House of Commons health and social care committee report in 2021 found burnout among nurses and other healthcare professionals had reached an emergency point.
MPs had called for immediate action to support exhausted staff through a plan to cover staffing needs for the next two decades, led by Health Education England.
But in a government response to the report, the Department of Health and Social Care (DHSC) rejected calls for independent annual reports on workforce shortages and future staffing requirements.
Instead, a new duty in the recently introduced Health and Care Bill will require the health and social care secretary to publish reports on workforce planning in England every five years.
The duty is intended to compliment ‘investment on workforce planning and supply already underway’, the government’s response states.
But UNISON national nursing officer Stuart Tuckwood said a lack of an independent view on what is needed to support the NHS workforce risked the government focusing on cost ‘above all else’.
"The urgent focus for this year must be on preventing further gaps from appearing in the workforce, including nursing teams."
"The failure to grade staff properly for the jobs they do, ensure fair pay for additional hours and deliver flexible work patterns are all reasons cited by nurses, healthcare assistants and other staff for leaving."
Read full story
Source: Nursing Standard, 17 February 2022
Patient Safety Learning

Baby deaths force end to NHS targets for natural births

The NHS has abandoned targets that encouraged hospitals to pursue “normal births”, over fears for the safety of mothers and babies.
Maternity units were told in a letter to stop using caesarean section rates to assess their performance. It comes after repeated scandals in maternity units, blamed in part on a focus on pursuing natural births at the expense of safety.
The letter from Jacqueline Dunkley-Bent, NHS England’s chief midwife, and Dr Matthew Jolly, the national clinical director for maternity, instructed “all maternity services to stop using total caesarean section rates as a means of performance management”.
It added: “We are concerned by the potential for services to pursue targets that may be clinically inappropriate and unsafe in individual cases."
A final report into the deaths of dozens of babies at the Shrewsbury and Telford Hospital NHS Trust will be published next month. It is expected to be highly critical.
The midwife leading the inquiry, Donna Ockenden, has said women “felt pressured to have a normal birth” at the trust, adding: “There was a multi-professional, not midwife-led, focus on normal birth pretty much at any cost.”
Hayley Coates, 29, lost her son Kaylan after staff at Nottingham University Hospitals NHS Trust ignored her pleas for a caesarean section in March 2018. A coroner ruled that neglect contributed to Kaylan’s death. He suffered a fractured skull when he was delivered with forceps and was starved of oxygen.
Coates, a mother of three, said she welcomed the NHS England letter, adding: “I was just ignored when I asked multiple times for a caesarean section. I was told repeatedly: ‘You will have this baby naturally, you don’t want to go to theatre.’ If I had gone to theatre many hours before, my baby wouldn’t have died. They have a duty of care, and the mother’s wishes are supposed to be priority.”
Read full story (paywalled)
Source: The Times, 20 February 2022
Patient Safety Learning

Millions in England face ‘second pandemic’ of mental health issues

Millions of patients in England face dangerously long waits for mental health care unless ministers urgently draw up a recovery plan to tackle a “second pandemic” of depression, anxiety, psychosis and eating disorders, NHS leaders and doctors have warned.
The Covid crisis has sparked a dramatic rise in the numbers of people experiencing mental health problems, with 1.6 million waiting for specialised treatment and another 8 million who cannot get on the waiting list but would benefit from support, the heads of the NHS Confederation and the Royal College of Psychiatrists have told the Guardian.
In some parts of the country, specialist mental health services are so overwhelmed they are “bouncing back” even the most serious cases of patients at risk of suicide, self-harm and starvation to the GPs that referred them, prompting warnings from doctors that some patients will likely die as a result.
“We are moving towards a new phase of needing to ‘live with’ coronavirus but for a worrying number of people, the virus is leaving a growing legacy of poor mental health that services are not equipped to deal with adequately at present,” said Matthew Taylor, the chief executive of the NHS Confederation, which represents the whole of the healthcare system in England.
“With projections showing that 10 million people in England, including 1.5 million children and teenagers, will need new or additional support for their mental health over the next three to five years it is no wonder that health leaders have dubbed this the second pandemic. A national crisis of this scale deserves targeted and sustained attention from the government in the same way we have seen with the elective care backlog.”
One family doctor in Hertfordshire, Dr David Turner, said he was so concerned about the situation that he had chosen to speak out publicly for the first time in his 25-year career. “I and many other GPs feel the issue has become critical and it is only a matter of time before a child dies,” he told the Guardian.
Turner said access to child and adolescent mental health services (CAMHS) was “never great pre-Covid” but was now “appalling”. The double whammy of a spike in demand and underinvestment in CAMHS was putting patients at risk, he added.
Read full story
Source: The Guardian, 21 February 2022
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