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

Girl, 13, likely to have survived if moved to intensive care, coroner rules

A 13-year-old girl who died after contracting sepsis in an NHS hospital probably would have survived if doctors had identified the warning signs and transferred her to intensive care earlier, a coroner has ruled.
Martha Mills was the first ever child to die at King’s College hospital (KCH) with a pancreatic injury of the type she sustained in a fall from her bike on an off-road family trail in Wales while on holiday last year. She was transferred to the south London hospital because it is one of three national centres for the care of children with pancreatic trauma.
An inquest at St Pancras coroner’s court, north London, heard that several opportunities were missed to refer Martha to intensive care, which probably would have saved her life.
In an emotional witness statement, Martha’s mother, Merope, said that after their daughter contracted an infection on 21 August last year, she and her husband, Paul Laity, raised concerns about Martha’s deteriorating health a number of times but doctors sought to reassure them rather than escalate her care.
Mills said in her statement that she explicitly raised her fears about Martha going into septic shock over the bank holiday weekend.
On 29 August, Martha had high fever, low blood pressure, a racing heart and a rash, which was misdiagnosed by a junior doctor despite Mills voicing her concern that it was caused by sepsis. It was only the next day that Martha was admitted to paediatric intensive care.
“I felt that my anxieties about all of Martha’s symptoms, and especially what they might mean when put together and considered in the round, weren’t given proper acknowledgement,” Mills told the court.
Prof William Bernal, who produced a serious incident report on Martha’s death for KCH, said there were at least five occasions when she should have had a critical care review.
He wrote that Martha’s chances of survival “would have been greatly increased” if she had been admitted to critical care earlier.
The inquest heard that KCH was making changes in the wake of Martha’s death, including improving diagnostics and taking account of parents’ views.
Read full story
Source: The Guardian, 3 March 2022
Patient Safety Learning

Cervical cancer: Scottish hospital is first in UK to pilot artificial intelligence in screening programme

A Scottish hospital has become the first in the UK and one of the first in the world to pilot using artificial intelligence (AI) in its cervical cancer screening programme.
University Hospital Monklands has increased capacity by around 25% and improved analysis turn-around times with the measure, which experts said could “revolutionise” the screening process.
The system, from medical technology company Hologic, creates digital images of cervical smear slides from samples that have tested positive for Human Papilloma Virus (HPV).
These are then reviewed using an advanced algorithm, which quickly assesses the cells in the sample and highlights the most relevant to medical experts, saving them time in identifying and analysing abnormalities.
“Preliminary results from the pilot are promising, as the team at University Hospital Monklands has increased capacity by around 25 per cent in the slide assessment and improved analysis turn-around times, as well as allowing screeners to dedicate more time to training on the latest technologies and dealing with difficult-to-diagnose cases,” says Allan Wilson, consultant biomedical scientist at NHS Lanarkshire who is leading the pilot.
"Through AI and digital diagnostics, we have the potential to improve outcomes for women not only in Scotland, but around the world.”
Samantha Dixon, chief executive of Jo’s Cervical Cancer Trust, welcomed the pilot.
“Catching cervical cell changes means they can be treated to prevent them from developing into cervical cancer,” she said.
Read full story
Source: The Scotsman, 4 March 2022
Patient Safety Learning

'Overworked staff' impacting patient safety at Torbay Hospital

The Care Quality Commission (CQC) has raised concerns about Torbay Hospital being understaffed and the impact that has had on patient safety.
It carried out an unannounced focused inspection of medical care services at Torbay Hospital in December, after receiving information of concern about the service. 
Cath Campbell, CQC’s head of hospital inspection, said: “When we inspected medical care services at Torbay Hospital, we were mindful of the pressures that the COVID-19 pandemic had had on the trust, and aware that staff were working extremely hard during this time. However, we were concerned to find some of the wards didn’t have enough staff to meet the needs of patients, especially those on a dedicated COVID-19 ward, and the trust wasn’t able to provide us with evidence that there were enough staff on the ward to monitor patients to keep them safe.!
“In addition, staff didn’t always complete risk assessments for each patient to remove or minimise risks to people’s safety. Staff also did not always identify patients at risk of deterioration and act quickly to keep them safe."
The Torbay and South Devon NHS Foundation Trust says it has taken the CQC’s findings very seriously and made immediate improvements, which the CQC have recognised. 
Read full story
Source: Torbay Weekly, 4 March 2022
Patient Safety Learning

Delayed NHS patients will be able to choose private ops online

Patients whose operations have been delayed will be able to shop online for hospitals with the shortest waiting times in the public and private sector, under plans being announced by the health secretary this week reports The Times.
Sajid Javid will unveil a three-point plan to transform the NHS as part of efforts to tackle a record backlog of more than six million people.
Under the proposals, patients referred for hospital care will be able to go online to look up the waiting time at their local hospital, and compare it with times at any hospital in the country, including those in the private sector. The website will allow patients to book their treatment at any unit in the country and there are plans to make the service available on the NHS app.
The proposals will be set out in a speech on Tuesday. Javid said: “The NHS constitution says already that you as a patient have the right to ask for an alternative provider for your treatment."
However, is this just a distraction? writes Roy Lilley in his latest newsletter. Shopping on-line for treatment depends on getting a website organised that can collect real-time data from all Trusts, for every specialty, that can take into account staffing, rota-gaps and clinical priorities.
Software might be able to cope but has the potential to throw the NHS into chaos. People arriving from ‘out of area’ will need video-out-patient consultations, some way of doing blood, imaging and other tests. And post-op? The same again for out-patients and physio, OT, aids, adaptations, pharmacy and social care support... ... to say nothing of the stress on patients and their families.
None of this is impossible but the NHS is nowhere near geared up for it.
Sources:
The Times, 6 March 2022 (paywalled)
Roy Lilley's newsletter, 7 March 2022
Patient Safety Learning

NHS accused of racism as black nurses report being put in Covid areas

The NHS has been accused of “shocking and systemic” racism during the pandemic as black healthcare workers say they were given poor PPE and pushed into the Covid frontline first.
Hundreds of black and brown healthcare staff across the UK have spoken to academics at Sheffield Hallam University about their experiences of racism during the pandemic.
The accounts raised issues of racism within the health service which led to black and brown nurses and midwives being put at greater risk than their white colleagues, due to poorer PPE, training, workload and shift patterns.
Rosalie Sanni-Ajose, a senior theatre practitioner, who worked across multiple London NHS hospitals through an agency called Yourworld told The Independent: “During the pandemic, we found that most of us (black agency nurses) have been placed in ITU to look after Covid patients are on a Continuous positive airway pressure (CPAP) machine or the ventilator."
“Then when I work in A&E, they divided areas into sections - green area, red area, and the normal areas. So some of the ethnic minority staff were then put in the red areas all the time. Further some of us, we have comorbidities like asthma, or diabetes, or have an exemption that has been clearly stated they not allowed to work there.”
Through its research, which involved 350 black and brown nurses, midwives and healthcare staff across the UK, Sheffield Hallam University found 77% of respondents said they’d been treated unfairly when they challenged racism.
Just over 50% of the respondents said they’d experienced unfair treatment in the pandemic in relation to Covid deployment, PPE or risk assessment.
One third have left their job as a result of racism, while more than half have experienced poor mental health due to the racism they experienced.
The academic team, lead by Professor Anandi Ramamurthy said the healthcare professionals’ reports reveal “a story of systematic neglect and harassment which predates the pandemic.”
Read full story
Source: The Independent, 5 March 2022
Patient Safety Learning

Covid pandemic sparks steep rise in number of people in UK with long-term illness

More than a third of working-age people in the UK now suffer from a long-term illness, with new figures showing a dramatic rise since the pandemic began. Post-Covid conditions, including Long Covid, breathing difficulties and mental-health problems, are among the causes, according to disability charities and health campaigners.
An Observer analysis of the Office for National Statistics’ (ONS) labour market status of disabled people figures shows that nearly 14.2 million people in the UK aged 16 to 64 said they had a health condition lasting for at least 12 months in 2021 – a rise of 1.2 million during the two years of the pandemic.
Levels of long-term ill-health had been rising more slowly before the emergence of Covid, at an annual average of about 275,000 cases a year between 2014 and 2018, but the rapid increase over the last two years highlights the health problems facing the UK, says the disability charity Scope.
About 800,000 more people suffered from mental-health problems in 2020-21 than did so in 2018-19, Scope said, and the number of people with chest and breathing problems had grown by about 570,000 over the same period.
James Taylor, Scope’s director of strategy, said: “These figures show the ongoing shock waves of the past two years continue to affect lives today. We’re concerned things will continue to get worse as time goes on."
Long Covid is another factor. The latest ONS long Covid report estimates that 1.5 million have had Covid symptoms for more than four weeks, and 685,000 people had symptoms that had lasted more than a year.
Further analysis by Long Covid Kids shows that people with pre-existing conditions are more likely to suffer long Covid than those without. Those whose activity is limited are, on average, more than three times as likely to suffer long Covid as those with no pre-existing conditions.
Dr Susannah Thompson was infected in April 2020 while working as a GP in her local hospital’s urgent care centre in north-west England. She made a “slow, gradual recovery” over the next months and was involved in setting up the GP-led vaccination programme until she had a “massive relapse” in January 2021.
“It feels like we’re ignoring Long Covid,” Thompson said. “People in the middle of their lives are getting robbed of their livelihoods, at risk of losing their homes. I can’t fathom why we don’t try to prevent it. But we’re not.”
Read full story
Source: The Guardian, 5 March 2022
Patient Safety Learning

Midwife-supported home births scrapped in Guernsey

Midwife-supported homebirths will not be re-introduced in Guernsey after their suspension due to coronavirus. The committee for health and social care explained it is difficult for a small team to accommodate the births.
It said that if the service was reinstated, it may impact deliveries on Loveridge Ward in Princess Elizabeth Hospital.
A spokesperson said they were "very sorry" to parents who wanted to give birth at home.
The committee said homebirths rely on a demanding on-call commitment from community midwives on top of their contracted hours.
To facilitate a birth at home, two of the five midwives are required to be on-call for 24 hours a day, for up to five weeks at a time.
Deputy Tina Bury, vice president of the committee for health and social care, said: "The midwifery team is small and it was simply not sustainable or safe in the long-term to provide the kind of on-call cover needed to support homebirths.
Read full story
Source: BBC News, 5 March 2022
Patient Safety Learning

Release of vulnerable people from immigration detention is often medically unsafe and chaotic, says charity

Vulnerable people released from immigration detention in the UK are too often left without crucial continuity of care, leading to quickly deteriorating health, concludes a report.
The report comes from Medical Justice, a charity that sends independent volunteer clinicians into immigration removal centres across the UK to offer medical advice and assessments to immigration detainees.
The charity said that between 1 October 2020 and 30 September 2021 a total of 21 362 people were detained in UK immigration centres and 17 283 were released into the community, having been granted bail or leave to enter the UK or remain. Of these, 2239 were considered to be “adults at risk.”
One woman whose delay in treatment “could potentially have life or limb threatening consequences”, struggled to re-arrange an orthopaedic oncology appointment that she missed because she had been detained.  One released Medical Justice client described how he ended up a number of times in Accident & Emergency, having been unable to secure a recommended cardiology appointment.
The report found that release from detention is often unplanned, chaotic and medically unsafe.
 
Medical Justice sees repeated cases of vulnerable people released into the community without adequate care plans, with little or no information and support about entitlement and how to access a GP, and rarely with referrals to community support services such as local mental health teams. This has included people who had very recently attempted suicide in detention.
Read full story
Source: BMJ, 4 March 2022
Patient Safety Learning

USA: Antibody drug to protect the vulnerable from Covid goes unused

Sasha Mallett, Sue Taylor and Kimberly Cooley all have immune deficiencies that make them especially vulnerable to Covid-19, and all have tried to get the same thing: a new treatment that can prevent the disease in people who either cannot produce antibodies after receiving a coronavirus vaccine or cannot get vaccinated at all.
Ms. Cooley, a liver transplant recipient in Duck Hill, Mississippi, got the antibody drug, called Evusheld, from her transplant team at the University of Mississippi Medical Center with no trouble. But Ms. Taylor, of Cincinnati, was denied the treatment by two hospitals near her home. And Dr. Mallett, a physician in Portland, Ore., had to drive five hours to a hospital willing to give her a dose.
As much of the USA unmasks amid plummeting caseloads and fresh hope that the pandemic is fading, the Biden administration has insisted it will continue protecting the more than seven million Americans with weakened immune systems who remain vulnerable to Covid. Evusheld, which was developed by AstraZeneca with financial support from the federal government, is essential to its strategy.
But there is so much confusion about the drug among healthcare providers that roughly 80% of the available doses are sitting unused in warehouses and on pharmacy and hospital shelves.
Interviews with doctors, patients and government officials suggest the reasons the drug is going unused are varied. Some patients and doctors do not know Evusheld exists. Some do not know where to get it. Government guidelines on who should be prioritised for the drug are scant. In some hospitals and medical centres, supplies are being reserved for patients at the highest risk, such as recent transplant recipients and cancer patients, while doses in other areas of the country are being given out through a lottery or on a first-come, first-served basis.
Hesitance is also an issue. Some doctors and other providers do not know how to use Evusheld and are thus loath to prescribe it.
Read full story (paywalled)
Source: New York Times, 6 March 2022
Patient Safety Learning

‘Serious failings’ contributed to death of patient at Broadmoor hospital

Serious failings by healthcare staff at Broadmoor Hospital were likely to have contributed to the death of a patient from self-asphyxiation, a jury has found.
Following a two-week inquest at Reading Coroner’s Court, a jury found staff failed to recognise and reduce the risks that acutely unwell patient Aaron Clamp presented to himself in the minutes leading to his death.
Mr Clamp died on 4 January 2021 after choking in his room at the NHS-run high secure mental health hospital Broadmoor.
In the weeks prior to his death, Mr Clamp’s mental health had deteriorated. He was transferred into a “psychiatric intensive care” ward at Broadmoor Hospital and placed in long-term segregation.
A summary of the jury’s findings shared with The Independent has found there was “a serious failure in the timely manner to recognise and reduce the level of risk, and a serious failure to recognise and execute the steps to remove the item of fabric” that Mr Clamp choked on.
“This omission probably contributed to the death,” the jury said.
It was also found there was “insufficient” recording by the trust of previous incidents of self-asphyxiation by Mr Clamp when he died.
Jurors said the plan for staff to carry out constant eyesight observations was appropriate, but not all aspects of the plan were adequately followed by staff members.

Read full story
Source: The Independent, 7 March 2022
Patient Safety Learning

Nearly quarter of all deaths in 2020 considered avoidable, says ONS

Nearly a quarter of all deaths in Great Britain were considered avoidable in 2020, according to new analysis.
The Office for National Statistics said 153,008 deaths out of 672,015 – or 22.8% – were avoidable, the highest rate since 2010.
Of the avoidable deaths in 2020, 68.6% were attributed to conditions considered preventable, while 31.4% were attributed to treatable conditions, the ONS said. Coronavirus has been assigned as a preventable cause in the avoidable mortality definition.
Wales had the highest avoidable mortality for deaths due to Covid-19, with 36.1 deaths per 100,000 people. Scotland had the lowest rate with, 28.5 deaths per 100,000 people, and England had 34.9 deaths per 100,000 people.
Avoidable mortality rates increased for alcohol-related and drug-related deaths in 2020 in all countries, the ONS analysis showed.
Across England, Scotland and Wales, the increase in ASMRs for alcohol-related and drug-related conditions in 2020 was driven by alcoholic liver disease, and poisoning by, and exposure to, other and unspecified drugs, medicaments and biological substances, the ONS said.
Read full story
Source: The Independent, 7 March 2022
 
Patient Safety Learning

Hospital patient sent 'whistleblower' letters

A patient who spent months in hospital because of a medical error received anonymous letters alleging safety concerns at the unit that treated her.
Marilyn Smith was diagnosed with tetanus after she was discharged following treatment for a leg injury at Hinchingbrooke Hospital in Huntingdon, Cambridgeshire.
 She said she was not asked about her tetanus immunisation status and was discharged from Hinchingbrooke without a booster shot.
A few days later she woke up with trismus, commonly known as lockjaw, and was unable to open her mouth - a symptom of tetanus, which only a handful of people contract in the UK each year. 
She subsequently spent more than 120 days in hospital in Hinchingbrooke, and then Peterborough, when her condition worsened and she was moved to critical care, placed in an induced coma and needed intubation. She said she now struggled to walk.
She received the first anonymous letter, claiming to be from "a group of current and previous A&E staff at Hinchingbrooke", in the post in January after she had been home from hospital for two weeks.
"I wasn't a letter to me, but a letter about me," Ms Smith said.
It described alleged shortcomings in her care.
Two subsequent letters made similar claims and on the same day the third arrived at her house, on 24 February, the BBC also received one giving Ms Smith's name and address and describing the alleged failures in her initial care.
This letter stated "the trust has been ignoring concerns about patient safety" and contained further allegations that related to an individual.
She has since instructed a lawyer to look at her case because, she said, she did not want anybody else to suffer like she had.
Read full story
Source: BBC News, 8 March 2022
Patient Safety Learning

UTI testing '50 years out of date'

A painful infection that mainly affects women is too often dismissed as "women's problems".
One in every two women suffer a urinary tract infection (UTI) and they are the second most common infection globally.
Among those affected is Hannah Hanratty, 36, who suffered months of agony despite multiple negative tests. During her pregnancy, Mrs Hanratty felt the "razor-blade burning pain" when passing urine. It soon developed into a constant pain. Two weeks after giving birth she needed antibiotics following a routine procedure and said the pain immediately went. "It was a UTI all along that just hadn't been picked up by the tests," she said.
Now Dr Emma Hayhurst, a senior lecturer in Molecular Biology at the University of South Wales, has developed a device to improve testing and said the current system is "50 years out of date".
At the moment a UTI patient may be asked to provide a urine sample which is sent for analysis, with tests back in two to three days.
"That's not good enough, we need to make it quicker," said Dr Hayhurst, explaining that the device she's working on would reduce that.
"Within 30 minutes the clinician will be able to say what bacteria is causing the UTI and indeed whether there is a UTI in the first place."
Dr Hayhurst has received a £50,000 Women in Innovation Award to further her work, but also in recognition of her position as a female role model in the field of science, technology, engineering and medicine - or STEM subjects, as they're also known.
"We should be listening to the women who are telling us this is a problem in their lives, but we know many feel like they are being dismissed," she said.
Wales' Health Minister Eluned Morgan is due to publish a quality statement on women's health in the summer, and has announced funding for each health board to have a specialist endometriosis nurse.
"I feel I have particular responsibility, as the first woman health minister in a long time, to make sure we look at the issue of women's health in a lot more detail," she said.
"There are clearly some gaps, certainly when it comes to research, but also in terms of where people are concentrating their efforts and investment.
"Quite often, women are not heard in the same way as men are heard and we've really got to make sure we are rebalancing that unconscious bias."
Read full story
Source: 7 March 2022
Patient Safety Learning

Brain changes seen after 'mild' covid

Catching Covid may cause changes to the brain, a study suggests.
Scientists found significant differences in MRI (magnetic resonance imaging) scans before and after infection.
Even after a mild infection, the overall size of the brain had shrunk slightly, with less grey matter in the parts related to smell and memory.
The researchers do not know whether the changes are permanent but stressed the brain could heal.
Lead author Prof Gwenaelle Douaud, from the Wellcome Centre for Integrative Neuroimaging, at the University of Oxford, said: "We were looking at essentially mild infection, so to see that we could really see some differences in their brain and how much their brain had changed compared with those who had not been infected was quite a surprise."
But the researchers do not know whether the changes are reversible or truly matter for health and wellbeing.
"We need to bear in mind that the brain is really plastic - by that we mean it can heal itself - so there is a really good chance that, over time, the harmful effects of infection will ease," Prof Douaud said.
The most significant loss of grey matter was in the olfactory areas - but it is unclear whether the virus directly attacks this region or cells simply die off through lack of use after people with Covid lose their sense of smell.
UK Biobank chief scientist Prof Naomi Allen said: "It opens up all sorts of questions that other researchers can follow up about the effect of coronavirus infection on cognitive function, on brain fog and on other areas of the brain - and to really focus research on how best to mitigate that."
Read full story
Source: BBC News, 8 March 2022
Patient Safety Learning

No new funding to tackle NHS work shortages, says Sajid Javid

Sajid Javid has announced a plan to tackle NHS workforce shortages will be published by the end of the year - but the health service will not receive any additional funding to back it, he said.
In a speech setting out widespread reforms, the health secretary on Tuesday said the NHS is the area where the government spends the most money, adding that spending increases have meant areas such as education have lost out.
Mr Javid said the UK has now come to a “crossroads” where it must choose between “endlessly putting in more and more money, or reforming how we do healthcare”.
He confirmed the government will publish a long-awaited plan for the NHS workforce by the end of the year, but in response to questions from The Independent over funding, he said it would not go above the £36 billion already promised. Mr Javid said costs for the new staffing plan would come from existing budgets.
Healthcare leaders have repeatedly called for a long-term “fully funded” plan to address staff shortages across the NHS, alongside a funding commitment for health education regulator Health Education England.
As part of the government’s latest plan to reform NHS services, the health secretary said patients who have been waiting the longest would travel to less busy hospitals or private facilities for care - with the NHS footing the bill for travel and accommodation.
He also urged people to harness the “power of families” to make a difference for their loved ones’ health, recalling when his father quit smoking at the request of his mother.
Read full story
Source: The Independent, 8 March 2022
Patient Safety Learning

Shropshire baby deaths: Ockenden report delayed for second time

The publication of a report into failures of maternity care at an NHS trust has been delayed again.
Senior midwife Donna Ockenden has been investigating hundreds of cases in which mothers and babies may have been harmed at Shrewsbury and Telford Hospital NHS Trust (SaTh).
Her report had been due to be published on 22 March after being postponed from December.
In a letter to families, Ms Ockenden said that date "can no longer happen". She added it was down to "parliamentary processes" which have to happen before the final report can be published.
A written statement to Parliament on Tuesday by patient safety minister Maria Caulfield said the NHS had been working to get indemnity cover.
She said it would be to cover any potential legal action following the publication of the report and had been agreed in principle by the Treasury.
Ms Ockenden's team has been examining 1,862 cases and it is thought to be the largest ever review of maternity care in the NHS. Her interim report published in December 2020 found some mothers were blamed for their babies' deaths.
In her letter about the delay, Ms Ockenden said she and her team were "also very disappointed in the delay" and would be working to agree a new publication date.
Read full story
Source: BBC News, 9 March 2022
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