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

NHSE wants ‘witch hunt’ lessons shared widely, says trust’s CEO

NHS England wants lessons learned by a trust overhauling its culture after a high-profile bullying scandal to be shared systemwide because similar problems have been evident at other trusts, the hospital’s boss has said.
West Suffolk Foundation Trust interim chief executive Craig Black said the trust was getting national level “support” to help with a cultural overhaul after a scathing independent review published in December concluded the trust’s hunt for a whistleblower had been “intimidating… flawed, and not fit for purpose”.
Mr Black said he thought NHSE would be “looking to learn from what we are doing” because senior managers viewed concerns raised in the West Suffolk review as having ”resonance with a number of organisations in the NHS at the moment”.
As well as the specific “witch hunt” case, the review raises wider issues about how trusts respond to whistleblowing and other concerns about care and patient safety.
West Suffolk’s executive director of workforce and communications Jeremy Over told the meeting the cultural change required was “organisational development which will take time, significant time”.
The report, West Suffolk Review – organisational development plan, sets out nine broad themes of work, linked to the trust’s core functions, “that capture the priority areas for organisational and cultural development at WSFT in light of the learnings from the report”. 
The document sets out how the trust’s governance, freedom to speak up, HR, staff voice, patient safety and other parts of its corporate infrastructure failed and contributed to a scandal.
Read full story (paywalled)
Source: HSJ, 1 March 2022
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Ukraine’s hospitals ‘desperate’ for medical supplies as oxygen runs out

Hospitals across Ukraine are “desperate” for medical supplies, doctors have warned, as oxygen stores are hit and other vital health supplies run low amid bombardment from Russian forces.
UK-based Ukrainian doctors have issued an urgent appeal for donations of supplies as they travel to eastern Europe in response to reports of shortages of medical equipment and medicines.
The World Health Organisation warned on Sunday evening that oxygen supplies in Ukraine were “dangerously low” as trucks were unable to transport oxygen supplies from plants to hospitals across the country.
Dr Volodymyr Suskyi, an intensive care doctor at Feofaniya Clinical Hospital in Kyiv, told The Independent he had been forced to use an emergency back-up system to supply oxygen to a patient on life support after the area near plant which supplies his hospital was bombed.
Dr Dennis Olugun, a UK-based doctor who is leading the group of medics from the Ukrainian Medical Association of the United Kingdom (UMAUK) to deliver medical supplies, said the situation was “desperate” in some areas. He said some hospitals did not have basic necessities such as rubber gloves.
He told The Independent: “What they need in the hospitals is portable ultrasound machines, portable x-ray machines because they have so many patients they much rather walk around the wards and do whatever diagnostic work rather than transporting patients."
The Association of the British Pharmaceutical Industry and European Federation of Pharmaceutical Industries and Associations have called for medicines, pharmaceutical ingredients and raw materials to be excluded from the scope of sanctions being levied against Russian trade.
Read full story
Source: The Independent, 1 March 2022
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Biden vows to crack down on poorest-performing nursing homes in the US

The White House has announced plans to boost nursing home staffing and oversight, blaming some of the 200,000-plus covid deaths of nursing home residents and staff during the pandemic on inadequate conditions.
Officials said the plan would set minimum staffing levels, reduce the use of shared rooms and crack down on the poorest-performing nursing homes to reduce the risk of residents contracting infectious diseases. The White House also said it planned to scrutinise the role of private equity firms, citing data that their ownership was linked with worse outcomes and higher costs.
Nursing homes have been an epicenter of covid spread during the pandemic, as the virus initially tore through facilities before vaccines were available in 2020, and then continued to sicken and kill residents at an elevated rate last year. Advocates have demanded better policies to ensure the facilities are prepared for emergencies and follow practices to curb the spread of infections.
Under Biden’s plan, officials at the Centers for Medicare and Medicaid Services will propose minimum staffing levels within the next year, which the White House said would improve safety by ensuring residents receive sufficient care and attention. The administration also cited a study that found increased staffing levels were linked with fewer covid cases and deaths.
The nursing home industry has warned that the pandemic has exacerbated long-running staffing shortages, noting that roughly 420,000 employees in nursing homes and long-term care facilities, many of whom complained about low pay, have departed over the last two years.
Read full story (paywalled)
Source: The Washington Post, 28 February 2022
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‘Advice to GPs’ will count towards elective care target

Avoiding GP referrals by providing ‘advice and guidance’ will contribute significantly towards NHS performance on the government’s elective care targets, according to draft NHS plans seen by HSJ.
Under the elective recovery plan, hospital specialists are being asked to offer more advice when GPs are deciding whether to refer a patient for an outpatient appointment, which would avoid some patients being added to waiting lists.
This is aimed at reducing instances where GPs may want to be risk averse and refer a patient when they might be unsure whether a secondary referral is needed.
New documents seen by HSJ, shared in draft by NHSE last week, reveal this avoided activity will be counted in assessing if the service or individual trusts have hit key government targets to increase activity.
NHS England has agreed with government to carry out 10% more ‘clock-stop’ activity in 2022-23 than was taking place pre-covid, but this is “after accounting for the impact of an improved care offer through system transformation, and advice and guidance”.
Read full story (paywalled)
Source: HSJ, 28 February 2022
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Vaccines could mean only one smear test a lifetime

Women who have the HPV vaccine may need only one smear test to prevent cervical cancer in their lifetime, according to a leading scientist.
Women are currently invited for screening every three to five years in the UK. But Prof Peter Sasieni said the vaccine was leading to such dramatic reductions in cancer that the screening programme would need to change soon.
The NHS invites women, and people with a cervix, for regular screening. Swabs of the cervix are used to check for signs of abnormalities using a microscope (the traditional smear test) or more recently to test for the virus itself.
 However, a seismic shift in preventing cervical cancer started in the UK in 2008 with the introduction of the HPV vaccine. It is offered to girls (and boys since 2019) aged between 11 and 13.
Research published in December shows the vaccine is cutting cervical cancer by nearly 90% in those who choose to have the jab.
"This is really exciting," Prof Sasieni, the director of the clinical trials unit at King's College London, told Inside Health on BBC Radio 4.
His modelling suggests between one and three checks a lifetime would be appropriate for people who have been immunised.
"There's a new vaccine which will be used in the UK from the next school year, which protects against even more types of the virus, and I think with that probably one screen would be enough, maybe two, over a lifetime."
However, the Department of Health and Social Care said one in three people do not come for screening when invited, and a spokesperson added: "The NHS Cervical Screening programme remains an important way of protecting the population - including those who have not been vaccinated - from developing cervical cancer."
Read full story
Source: BBC News, 2 March 2022
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Study reveals stark disparities in cancer rates between ethnic groups

Stark disparities in cancer rates between different ethnic groups have been laid bare in new research showing black people are twice as likely to get prostate cancer while white people have double the chance of getting skin and lung cancers.
The analysis of NHS Digital cancer registration data by Cancer Research UK provides the most complete recording ever of cancer rates by ethnicity in England, offering crucial data on how some rates vary. The results are published in the British Journal of Cancer.
White people in England are more than twice as likely to get some types of cancer, including melanoma skin cancer, oesophageal, bladder and lung cancers compared with people from black, Asian or mixed ethnic backgrounds, according to the research.
Black people are almost three times more likely to get myeloma and almost twice as likely to get prostate cancer compared with white people. The study also found that black people are more likely to get stomach and liver cancers, and Asian people are more likely to get liver cancers. 
Genetics are thought to play a part in some of the findings, Cancer Research UK said. For example, white people are more likely to get skin cancer because they tend to burn more easily in the sun.
Preventable risk factors also appear to be involved, the charity added, as white people are more likely than most minority ethnic groups to smoke or be overweight or obese. These are the two largest risk factors in developing cancer and help explain why white people are more likely to get some types of cancer than other ethnic groups.
Read full story
Source: The Guardian, 2 March 2022
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Private healthcare boom adds to fears of two-tier system in UK

Growing numbers of Britons are paying for private medical treatment in a shift that could undermine the NHS and create a “two-tier” health system, a report has warned.
Declining access to and quality of NHS care, both worsened by the Covid-19 pandemic, have begun to “supercharge” the trend, with one in six people prepared to go private instead of waiting.
That is among the findings of a report by the left-leaning IPPR thinktank, which warns that in future getting fast, high-quality care on the NHS could become as difficult as the situation that already exists in regards to state-funded dental treatment, which has become a postcode lottery.
“People are not opting out of the NHS because they have stopped believing in it as the best and fairest model of healthcare,” said Chris Thomas, the IPPR’s principal research fellow and co-author of the report.
“Rather, those who can afford it are being forced to go private by the consequences of austerity and the pandemic on NHS access and quality, and those without the funds are left to ‘put up or shut up’.”
The report says that unless the NHS starts performing better “people who can and are willing to do so will supplement their entitlement to NHS care with private healthcare products”.
“With NHS waiting lists now at record levels, it is not surprising that more patients across the country are looking at private healthcare,” said David Hare, chief executive of the Independent Healthcare Providers Network, a trade body that represents about 100 private providers across the UK.
Read full story
Source: The Guardian, 2 March 2022
Patient Safety Learning

Eating disorders: Worth more than 2 hours of teaching

On average, UK medical students receive less than two hours of teaching on eating disorders throughout their entire medical degree. Even more concerningly, a fifth of medical schools do not include eating disorders at all in their teaching.
Given that 1 in 50 people in the UK suffer from an eating disorder, and around 5% of the population will be affected at some point in their lifetime, this is something that needs to change. 
This week is Eating Disorders Awareness Week and Beat Eating Disorders are campaigning for UK medical schools to introduce comprehensive training on eating disorders to their programmes. 
Eating disorders are highly complex mental illnesses, but they are treatable. Just two hours of training is not enough time to equip medical students with the knowledge to identify the signs and symptoms and provide the necessary support to help sufferers access the most appropriate treatment at the earliest opportunity.
Read more
Source: Beat Eating Disorders
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Parents sue over failures in child hearing service at NHS Lothian

More than a dozen families are seeking compensation following "significant failures" at NHS Lothian's hearing service for children.
The health board apologised to more than 155 families after an independent investigation found serious problems diagnosing and treating hearing loss.
Sophie was born partly deaf and failed repeated hearing tests for years. Her family say no help was offered by the paediatric audiology department at NHS Lothian who kept saying she would be fine. But her parents say she is not.
Sophie is now seven. Her speech and language has not developed fully and is sometimes hard to understand. Her confidence has been affected.
Her mum Sarah said: "They failed Sophie. You kind of trust what they were doing, you thought maybe she doesn't need hearing aids, maybe she will just catch up and now she's almost eight years old and she's still not caught up and you think 'OK, maybe there were mistakes made then'."
An independent investigation by the British Academy of Audiology (BAA), published in December last year, found "significant failures" involving 155 children over nine years at NHS Lothian.
Several profoundly deaf children were diagnosed too late for vital implant surgery. The health board has "apologised sincerely" to those affected.
The BAA looked at more than 1,000 patient records finding "significant failures" in almost 14% of them.
The BAA said it found "no evidence" that national guidelines and protocols on hearing tests for children had been followed or consistently applied "at any point since 2009".
Read full story
Source: BBC News, 2 March 2022
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NHS ‘woefully unprepared’ for care of an ageing England

The NHS is “flying blind” and “woefully unprepared” to cope with England’s rapidly ageing population, senior doctors have warned as stark new figures reveal the country has only one full-time geriatrician to care for every 8,000 older people.
The Royal College of Physicians (RCP) said the drastic shortage of specially trained physicians to look after the rising number of elderly people and a lack of NHS workforce planning meant England was “sleepwalking into an avoidable crisis of care for older people”.
Its analysis of NHS and Office for National Statistics data shows there is just one full-time geriatrician for every 8,031 people over the age of 65 in England. There are also regional disparities, with one geriatrician caring for more than 12,500 over-65s in the east Midlands, while the figure in north-east and central London is one per 3,254.
Estimates suggest that by 2040 there could be as many as 17 million over-65s. But the college warns that many doctors will soon be requiring geriatric care themselves as 48% of consultant geriatricians are due to retire within the next decade.
The RCP said the health service was short of staff across all specialities and the shortage of geriatricians was one example of why the health service needed more workforce planning. It said there was no publicly available data on the number of staff the NHS needed to train now to meet future demand for care.
Dr Jennifer Burns, the president of the British Geriatrics Society, said the crisis would only worsen with the “predictable rise” in the numbers of older people across the country. “It is absolutely vital that these fundamental issues around the recruitment, retention, development and support of the workforce are addressed, and that there is a properly resourced strategy for future needs,” she said.
Read full story
Source: The Guardian, 3 March 2022
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Patient at Broadmoor Hospital died after suffocating, inquest hears

A patient at Broadmoor Hospital has died after suffocating while staff were chatting outside of his room, an inquest has heard.
Aaron Clamp, a patient at the notorious high security mental health hospital Broadmoor, died on 4 January 2021 after asphyxiating whilst in his room.
The Independent understands Mr Clamp’s death may have been the first “non-natural” death since the new Broadmoor Hospital, run by West London Trust, opened in December 2019.
According to evidence heard at the inquest, staff who were meant to be carrying out continuous “eyesight” observations on Mr Clamp, were having a conversation without direct sight into his room.
Mr Clamp’s father told The Independent he was “tormented” by the criminal justice and mental health system which resulted in his “indefinite incarceration.”
“Diagnosed with a mental illness, schizoaffective disorder, the purpose of treatment was rehabilitation.  Psychiatric treatment is conventionally centred on medication to manage symptoms and risk," his father said.
He acknowledged there is a balance to be struck between managing risks and restricting patients, but closer attention of holistic compassionate care should be given.
Read full story
Source: The Independent, 3 March 2022
Patient Safety Learning

More support needed for GPs to treat eating disorders

Two leading medical organisations have told the BBC that GPs are not getting the right support to treat eating disorders.
The Royal College of General Practitioners (RCGP) and the British Medical Association (BMA) say doctors need more time with patients and more specialist units.
Beat Eating Disorders asked nearly 1,700 people about their experience of trying to get a diagnosis from their GP. Over 92% asked thought their GP needed more training with eating disorders. Out of those questioned, 69% also said they felt their GP didn't know how to help them.
The survey has been released to coincide with Eating Disorder Awareness Week.
Jess Griffiths had an eating disorder between the ages of 11 and 21 and, now in full recovery, she works as a consultant to NHS England and with her local eating disorder service in Dorset.
She tells the BBC that when she first went to her GP to try to get help, she wasn't entirely transparent about what she was struggling with.
"I was presenting at a low weight and not having periods, so the GP put me on the pill, but I went there hoping he would ask me the questions [about a potential eating disorder]" she says.
"But it's really hard for people with eating disorders to - in a really pressurised situation with a doctor - say how they really feel."
Dr Richard Van Mellaerts is part of the BMA's GP committee and has told the BBC the results of the survey are "deeply saddening".
"People with eating disorders should never feel that GPs are a barrier to accessing care, so it is vital that medical education and training supports doctors to identify eating disorders and support their treatment," he says.
But he adds that there is "poor provision of specialist care", which has left GPs "frustrated up and down the country".
Read full story
Source: BBC News, 3 March 2022
Read hub blog from Dr Joanna Silver on the challenges the pandemic has brought to patients with eating disorders
Patient Safety Learning

Failure to act on sepsis led to man’s death

A man died after an NHS trust failed to diagnose and treat sepsis quickly enough, a Parliamentary and Health Service Ombudsman investigation has found.
Stephen Durkin died after suffering organ failure from sepsis. Stephen’s wife Michelle made a complaint to the Ombudsman after she was left floored by his sudden death which she believed was avoidable.
Stephen was an otherwise healthy 56-year-old when he attended Wye Valley Trust A&E in July 2017 with chest pain. Hospital staff suspected he had a major blood vessel blockage and admitted him to a ward overnight. The next morning his overall condition had worsened but staff did not monitor him more closely, as national guidance advises, and he continued to deteriorate throughout the day.
The next day Stephen was admitted to intensive care and treated for sepsis but tragically died later that evening. In the space of 48-hours his condition deteriorated rapidly but staff did not act quickly enough and the critical care team attended Stephen ten hours too late.
His wife Michelle arrived at the hospital to visit Stephen, only to find that he was critically ill and unresponsive. She was left devastated by his death and turned to the Ombudsman to look into what had happened with his care.
Ombudsman Rob Behrens said: "Stephen’s tragic death could so easily have been avoided. His case shows why early detection of sepsis, as set out in national guidelines, is crucial."
"Sadly, this is not the first time we have had to highlight this issue. There is clearly more the NHS needs to do. It is vital that NHS trusts ensure their staff are sepsis-aware to reduce the number of avoidable deaths from this life-threatening condition."
Read full story
Source: PHSO, 3 March 2022
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GP surgeries are told to open late and at weekends

GP surgeries must open for routine appointments between 9am and 5pm on Saturdays and during weekday evenings, NHS bosses have said.
From October, patients will be able to book weekend and evening slots with “the full multi-disciplinary team” in a local practice, including for services such as screening, vaccinations and health checks.
The British Medical Association said it was “bitterly disappointed” by the changes, which had been imposed without its agreement. 
A letter tells GPs the appointments must be made available at least two weeks in advance. Same-day online booking should be possible “up until as close to the time slot as possible”. Any unused slots should be available for NHS111 to allocate to callers.
Some may be remote appointments, but networks are told to “ensure a reasonable number” of appointments are face-to-face consultations. 
Rachel Power, chief executive of the Patients Association, said: “There’s a great deal in this letter that patients will welcome, given the struggles they have had since the start of the pandemic to see their GPs face-to-face or even get through to their surgeries.”
Read full story (paywalled)
Source: The Times, 2 March 2022
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RCN launches toolkit to help nursing staff raise concerns

The Royal College of Nursing (RCN) has designed a 'Raising Concerns toolkit', which includes information to help members navigate the process of escalation, from identifying a potential concern through to formally reporting it to senior colleagues.
It’s been designed to help members decide when to escalate a workplace issue and includes a flowchart to support them in deciding what, when and how to report concerns. 
The toolkit outlines the types of concerns that might be raised such as staffing and patient safety, a lack of support or training, as well as cultural or criminal issues. 
It supports nursing staff to understand the importance of remaining factual, staying neutral and keeping records of events. 
RCN Deputy Director of Nursing Eileen Mckenna said: “We know that raising a concern at work isn’t easy, but it safeguards nursing staff and can provide learning opportunities. Our Raising Concerns toolkit can be used by nurses, nursing associates, students and health care support workers in the NHS and independent sector to help them through the process of escalating an issue.
“All workplaces that employ nursing staff should have a culture of safety and focus on system learning, not individual blame in the event of a mistake being made. We will always support members who challenge unsafe practices, processes or conditions at work in the interests of their own safety and that of patients. It’s an important skill that promotes psychological safety, a positive learning environment and wellbeing.”
Read full story
Source: RCN, 2 March 2022
Patient Safety Learning

Staffing crisis deepens in NHS England with 110,000 posts unfilled

The NHS is facing a deepening staffing crisis, with the number of unfilled posts across health services in England rising to 110,192, official figures show.
The shortages include 39,652 nurses and 8,158 doctors, according to the latest quarterly data for health service vacancies published by NHS Digital.
The disclosure prompted warnings that the shortage of frontline personnel would lead to longer delays, hit the campaign to cut the 6.1m treatment backlog and undermine quality of care.
Staff groups said they feared that low pay, burnout from heavy workloads and constant pressure during shifts, compounded by the Covid-19 pandemic, were leading demoralised workers to quit.
“The fact that nursing vacancies remain stubbornly high, at about 40,000 in the NHS in England, is deeply worrying. With every job that remains unfilled, safe patient care becomes even harder to maintain”, said Patricia Marquis, the Royal College of Nursing’s director for England.
Wes Streeting, the shadow health secretary, said: “The Conservatives’ scrapping of the nursing bursary and failure to fix staffing shortages has been disastrous for the NHS, and patients are paying the price. NHS staff do heroic work but there simply aren’t enough of them. Yet the government still has no plan to fill these positions, meaning patients will continue to wait unacceptable lengths of time for treatment.”
Read full story
Source: The Guardian, 3 March 2022
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