Skip to content
the hub has moved to a new software platform. You will need to login using your email address. Find out more here.

News

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

A women left in ‘hell’ for nine years after poor postnatal care

It has been nine years living “like a prisoner” in “excruciating” pain and Kate is still facing a wait for surgery to tackle the horrifying mistakes in her postnatal care.
Despite a difficult birth at Leeds General Hospital, Kate described the atmosphere at the trust’s labour ward as “lovely”.
However, her experience quickly deteriorated into “hell” after she was told she had third-degree tears and was admitted to a postnatal ward, describing the care she received as “awful”.
A few days following her discharge, which occurred before she’d had a bowel movement, Kate said she was left “screaming in pain” at home, “bleeding a lot from the back passage” and “incontinent”.
Despite reporting these symptoms to the maternity department, Kate was told it was a “normal” experience.
“I felt like nobody was listening to me,” Kate said.
After six months, living in “intense pain”, with “flooding diarrhoea” and not able to leave the house, she was told by the NHS her symptoms were down to postnatal depression.
She was referred to a colorectal surgeon, who found her anal sphincter was “fully open almost as if it wasn’t ever stitched”.
Following an operation in 2015 to fix the issue, Kate developed sepsis, nearly losing her life and meaning it took 18 weeks for her wound to heal.
However, her ordeal did not stop there. She had developed nerve damage, chronic pelvic pain, incontinence, coxalgia and a prolapse as a result of her problems being neglected for so long.
By 2022, nine years later, she is now waiting for a colostomy bag operation – the only option to address her pain.
Kate told The Independent: “Everywhere I go I have to plan the full day. I need to know where the toilets are. I don’t go out of the house. I’ve felt like a prisoner in my own home for nine years.
“It makes me so emotional thinking about everything they have put me through. It hasn’t just affected my life, it’s also affected my partner and family. I have lost so much time that I’ll never get back. I couldn’t enjoy life and do the things that all mothers do with their babies.
“There was no care, no sympathy, nothing. Nobody cared for me apart from my surgeon at Sheffield. I’ve forgotten what it feels like to feel normal. I can’t remember life without pain."
Read full story
Source: The Independent, 13 March 2022
Patient Safety Learning

Number of women being seen for urgent NHS breast cancer referrals hits record new low

Less than half of women are being seen following an urgent breast cancer referral, as NHS performance drops to a new low.
‘Alarming’ new NHS figures have shown just 47% of women in England referred “urgently” for breast cancer symptoms were seen by a specialist within two weeks.
For women without symptoms but referred urgently to see a specialist, just 49% were seen within two weeks. In both cases this is the first time since records began that less than 50% cent of women were seen.
Within some trusts less than 10% of women referred with symptoms were seen within two weeks, with less than two per cent of women referred to United Lincolnshire Hospitals Trust being seen within this time frame in January.
Wes Streeting, Labour shadow health secretary said: “I know from experience the importance of an early cancer diagnosis and quick treatment. It is appalling that most suspected breast cancer patients are left waiting so long before being seen, with the insecurity of not knowing."
Baroness Delyth Morgan, chief executive at Breast Cancer Now, said: “It’s alarming that in January, for the first time, less than half of women 47.5 per cent in England who were urgently referred with potential breast cancer symptoms, were seen by a specialist within two weeks."
“...the government must consider what immediate steps it can take to reverse this rapid decline. Agonising delays must be replaced with prompt diagnoses for all women – and the sooner breast cancer is diagnosed the greater the chance of treatment being successful.”
Read full story
Source: The Independent, 11 March 2022
Patient Safety Learning

GMC admits it needs to do more to reduce racial inequalities

The General Medical Council (GMC) has achieved marginal improvements against its targets to reduce racial inequalities, it said in an annual update on the programme.
However, BAME doctor representatives as well as the GMC itself said the progress was not sufficient against the targets which the regulator had set itself last year.
These included stopping disproportionate complaints from employers about ethnic minority doctors by 2026, and getting rid of disadvantage and discrimination in medical education and training by 2031.
According to the update, the gap between employer referral rates for ethnic minority doctors and international medical graduates, compared to white doctors, has marginally reduced.
The report also acknowledged the judgment by an employment tribunal in June last year, which found that the GMC had discriminated against a doctor based on his race.
Reading Employment Tribunal upheld a complaint that Dr Omer Karim, who previously worked as a consultant urologist in Slough, had been discriminated against during an investigation by the GMC, after the body dismissed charges against a white doctor accused of the same conduct. 
The GMC has appealed the verdict but is still waiting for the appeal to be heard.
Read full story
Source: Pulse, 10 March 2022
Patient Safety Learning

‘Inadequate’ children’s mental health hospital ‘put safety of patients at risk’ CQC report finds

Serious safety concerns have been raised about a children’s mental health hospital where staff lacked respect for patients, as the provider faces a police investigation into another one of its units.
The Huntercombe Hospital in Stafford has been rated as “inadequate” by watchdog the Care Quality Commission (CQC) after inspectors found the safety of children within the hospital was at risk.
The concerns about this hospital come as The Independent revealed police have launched an investigation into another mental health unit run by the provider in Maidenhead.
Following an inspection in October inspectors sent an urgent warning notice to the provider, after it found there were not enough staff to keep patients safe.
The hospital was described as relaying on agency workers who did not have knowledge of the patients.
The CQC inspectors found children’s wards were dirty with poor hygiene measures in the hospital and patients at risk of infection.
According to the report staff were found “sitting with their eyes closed for prolonged periods of time”, and that staff observations of at risk patients were “undermined by a blind spot where people could self-harm unseen.”
Craig Howarth, CQC head of inspection for mental health and community health services, said: “Further to these issues, we saw that staff sometimes showed a lack of respect to patients and one ward was poorly furnished and maintained and there wasn’t always enough emphasis on some people’s individual requirements.”
Read full story
Source: The Independent, 11 March 2022
Patient Safety Learning

Ireland: Legislation to cover non-disclosure issues that arose in cervical check controversy

More than 200 women were affected by failures in Ireland’s CervicalCheck screening system. It emerged in 2018 that 221 women and families were not told about misreported smear tests.
The Minister for Health said that non-disclosure issues which arose in the cervical check screening controversy will be legislated for to prevent it from happening again.
Stephen Donnelly said new legislation will address the negligence issues and ensure that the failure to inform the women of the clinical audit of their screening will “never happen again”.
Mr Donnelly was discussing a number of amendments at the committee stage of Ireland's Patient Safety Bill.
The new legislation will require the mandatory open disclosure of serious patient safety incidents, and sets out a list of incidents which must be reported to the health watchdog, Health Information and Quality Authority (HIQA).
Mr Donnelly said that he will introduce an amendment at the report stage of the Bill that will provide for non-disclosure and will deal with issues around delayed diagnosis and delayed screening.
Mr Donnelly said: “I’ve had lengthy discussions with the department on this and it doesn’t fit neatly with this Bill because the serious patient safety issues which result in death or serious harm, they are very clear and binary.
“Legislating around delayed diagnosis and delayed screening, it is really complex and doesn’t fit neatly in this Bill, however my view is that the non-disclosure that happened in cervical check, even though it doesn’t neatly fit here, should still be legislated for."
Read full story
Source: The Independent, 11 March 2022
Patient Safety Learning

Chronic UTI infections: NHS finally recognises debilitating condition exists in online advice for patients

The NHS has publicly recognised that chronic urinary tract infections (UTIs) exist and has updated its advice for patients following pressure from campaign groups.
For many patients who develop a UTI, their experience is extremely painful but short-lived. But for thousands of others, a one-off acute attack turns into a chronic infection that dominates their lives and lasts for months or even years.
NHS Digital updated its website to last week to provide information around chronic bladder infections where previously there was none.
Campaigners say this is a “huge step forward” but there is still a long way to go in improving testing and treatments for the condition. 
Chronic UTI sufferer Leah Herridge has been pushing for the change alongside Chronic Urinary Tract Infection Campaign (CUTIC) and Bladder Health UK.
The NHS website’s Cystitis page has been updated to include mentions of chronic UTI and to acknowledge that current tests may not pick up these infections. 
Previously, the NHS made no mention of chronic UTIs, meaning GPs and even consultants would often default to misdiagnosing patients with interstitial cystitis.
Specialists say the infections, which often begin as an acute bout of cystitis, can occur when bacteria become embedded within the bladder wall and become difficult to treat with short courses of antibiotics.
“People tend to think chronic means really bad. What it means is everlasting,” said Carolyn Andrew, from CUTIC.
In August 2021, Ms Herridge sent a letter to NHS Digital demanding the web page be updated. The campaign was backed by CUTIC and Bladder Health UK as well as 100 other chronic UTI sufferers who also wrote letters.
“NHS Digital has actually been really, really fantastic at working with us and I do feel like they have really co-produced, certainly the interstitial cystitis page with the leading professionals in the area, the charities and myself,” said Ms Herridge.
Read full story
Source: iNews, 14 March 2022
Patient Safety Learning

‘The real thing’: Delta-Omicron hybrid identified for first time

A newly-discovered Covid variant that combines mutations from both Omicron and Delta is “the real thing,” scientists have said.
Earlier in the year, concern was raised after a lab in Cyprus claimed to have found evidence of a Delta-Omicron recombination event – when the two variants co-infect a patient and exchange genetic material to produce a new viral offspring – but experts said the findings were false.
Now, however, virologists from L’Institut Pasteur in Paris have sequenced the genome of a genuine “Deltacron” variant, which has been detected in several regions of France and appears to have been circulating since early January.
“This one is legit,” said Aris Katzourakis, a professor of evolution and genomics at the University of Oxford. “[It is] one to keep an eye on.”
“The French cluster appears to be a validated occurrence where a recombination event has given rise to a virus fit enough to circulate,” said Dr Stephen Griffin, a virologist at the University of Leeds.
In deriving its spike from Omicron, the Deltacron variant could similarly target the upper respiratory pathway, rather than the lungs, Dr Griffin said. “At the same time, there are some parts of Omicron thought to lessen severity that are missing from the recombinant,” he said.
Dr Griffin said: "This is another clear demonstration that we remain in a dynamic situation with respect to Sars-2, and that the maintenance of genetic surveillance and testing is both relevant and prudent."
Read full story
Source: The Independent, 11 March 2022
Patient Safety Learning

England mental health referrals at 4.3 million high

The number of referrals for specialist NHS mental health care reached a record high in England by the end of 2021, an analysis suggests.
The Royal College of Psychiatrists says the pandemic has led to unprecedented demand and backlogs and services are struggling to keep up.
There were 4.3 million referrals, for conditions such as anxiety and depression, in 2021, NHS Digital says. Just under a quarter - 1.025 million - were for children or adolescents.
The college said the NHS had delivered 1.8 million mental health consultations in December 2021, but an estimated 1.4 million people were still waiting for treatment.
And hundreds of adults were being sent far from home for treatment because of a lack of beds in their area.
President Dr Adrian James said: "As the pressure on services continues to ratchet up, the silence from government continues to be of grave concern for the college, the wider mental health workforce and, most importantly, our patients.
"The warning of the long tail of mental ill health caused by the pandemic has not been heeded.
"Many thousands of people will be left waiting far too long for the treatment they need unless the government wakes up to the crisis that is engulfing the country.
"Staff are working flat out to give their patients the support they need but the lack of resources and lack of staff mean it's becoming an impossible situation to manage...
"...We need a fully funded plan for mental-health services, backed by a long-term workforce plan, as the country comes to terms with the biggest hit to its mental health in generations."
Read full story
Source: BBC News, 15 March 2022
Patient Safety Learning

Keeping electives on same site as A&E is ‘optimal’, says CEO

The chief executive of three NHS trusts says ringfencing elective care within an acute hospital site is potentially more ‘productive’ than sending it to a separate ‘cold’ site.
Glen Burley, who leads a “provider group” in the West Midlands, says his trusts have been grappling with the challenge of how to maximise elective activity without it being disrupted by emergency pressures.
The conventional view – as outlined in the NHS long-term plan – is that performing more elective care on a separate site from emergency can help ensure theatre lists are not disrupted.
But George Eliot Trust, which has been led by Mr Burley since 2018 and only has a single district general hospital, has created a “ringfenced” elective hub within the site.
In an interview with HSJ, Mr Burley said: “So I actually think the most productive model in the NHS is if you can pull that off.
“If you can actually protect your elective capacity and offer it on the same site [as] urgent care, so the clinicians are not having to move between sites, you’ve got optimal productivity.
“The challenge right across the NHS has been avoiding that spillage, of emergency care into your elective capacity.
“As you get busier and you escalate… the order in which you encroach into areas that you should not encroach into, is really key in that. We are saying we are going to protect our elective beds in a way that we haven’t done before."
Read full story (paywalled)
Source: HSJ, 14 March 2022
Patient Safety Learning

791 medical graduates could miss out on NHS junior doctor training

The highest ever number of medical students have been told there are no places for them this year, despite the health service’s crippling shortage of medics.
The risk that young would-be doctors may not be allocated to start their training at a hospital in the UK has sparked concern among the medical students affected, as well as medical organisations.
Pressure is growing for action to close the gap between the number of training places available across the NHS and the number of graduates seeking one, so medical talent is not wasted and hospitals hire as many fresh recruits as they can to help tackle the widespread lack of medics.
Doctors are worried that the mismatch between demand for and supply of training places will lead to the NHS missing out on medics it sorely needs and that some of those denied a place will either go to work abroad instead or give up medicine altogether. The most recent official figures showed that the NHS in England is short of almost 8,200 doctors.
Dr Dustyn Saint, a GP in Norfolk, tweeted the health secretary, Sajid Javid, about the situation, saying: “Sajid Javid sort this out! You know how much general practice needs these people in a few years, standing by and doing nothing is inexcusable.”
Another doctor said: “It’s bonkers that 800 would-be doctors could be denied training places at a time when the NHS in England is short of 8,200 doctors.”
The British Medical Association has voiced concern about the large number of unallocated medics. “Now we have a situation where a record number are left with unnecessary uncertainty about where they are headed this August,” said Khadija Meghrawi, the co-chair of its medical students committee. “In a time where student mental health is declining, this additional source of uncertainty and stress is particularly unfair.”
Read full story
Source: The Guardian, 15 March 2022
Patient Safety Learning

Private hospital rated ‘inadequate’ again amid safety concerns

A privately run mental health hospital put in special measures last year has been rated “inadequate” again following a fresh Care Quality Commission inspection.
Inspectors raised serious concerns about unsafe ward environments and staff not managing patient risks at the Priory Hospital Arnold, which has beds commissioned by Nottinghamshire Healthcare Foundation Trust.
Inspectors said that while the leadership team was experienced, the registered manager had been in post since April last year and the improvements they had made “had not been fully embedded”.
The registered manager had changed after the service was placed in special measures.
Ligature risks were found in patients’ bathrooms despite the provider making “some progress” and undertaking “substantial work” to remove them, the CQC said.
And in one instance, a patient had tried to harm themselves with a plastic bag which was a restricted item on the ward. 
CQC head of hospital inspection for mental health and community services Craig Howarth said staff “had not followed the patient’s risk assessment” and had not searched the patient on their return from a visit off the ward.
He added: “It was also concerning that despite rotas showing enough staff were available across the hospital, staff gave examples of when a lack of staffing had impacted on patient care and safety.
“Despite the measures in place, the risks to patients were not reduced and there was evidence of incidents of harm to patients.”
Read full story (paywalled)
Source: HSJ, 15 March 2022
Patient Safety Learning

Ukraine: GPs get updated guidance on treating refugees and returning citizens

GPs have received updated guidance on providing healthcare to people coming from Ukraine.
In a bulletin to general practices on 10 March notifying them of the update from the Office for Health Improvement and Disparities, NHS England said that the health service was starting to see refugees and citizens returning from Ukraine and reminded practices that proof of identity is not required for registration at a practice.
The guidance advises practices to explain to people coming from Ukraine how the NHS works and their entitlements to healthcare, to ensure that they are up to date with the UK immunisation schedule, and to ask about any travel plans they may have to visit friends and relatives in their country of origin.
GPs are also advised to:
Screen all new entrants, including children, for tuberculosis Ascertain any risk factors for hepatitis B infection that may indicate the need for screening (owing to its low prevalence in the UK) Consider screening for hepatitis C, because of a considerably higher prevalence in Ukraine than in the UK Ensure that travellers are offered typhoid immunisation and advice on preventing enteric fever Consider nutritional and metabolic concerns (anaemia, vitamin D, vitamin A, iodine) Work with a professional interpreter where language barriers are present Consider the effects of culture, religion, and gender on health Assess for mental health conditions, and Refer pregnant women to antenatal care. Read full story
Source: BMJ, 14 March 2022
Patient Safety Learning

Archie Batten: Inquest hears baby's mother was turned away from maternity unit

The parents of a baby boy who lived for just 27 minutes have told an inquest they were "completely dismissed" throughout labour.
Archie Batten died on 1 September 2019 at the Queen Elizabeth the Queen Mother Hospital (QEQM) in Margate, Kent.
His inquest began on Monday at Maidstone Coroner's Court. The East Kent Hospitals University NHS Foundation Trust has already admitted liability and apologised for Archie's death.
The coroner heard Archie's mother Rachel Higgs was frustrated at being turned away from the maternity unit in the morning, when she had gone to complain of vomiting and extreme pain.
She was told she was not far enough into labour to be admitted. 
She returned home to Broadstairs with her partner Andrew Batten, but continued to feel unwell so phoned the hospital. She was told the unit was now closed.
Instead, two community midwives were sent to their home, where they attempted to deliver the baby but could not find a heartbeat.
Andrew Batten told the inquest the midwives looked "terrified," and that there was "an air of panic", with the midwives whispering in the hallway instead of telling him and Ms Higgs what was happening.
Under examination from the family's barrister Richard Baker, Victoria Jackson, the midwife who had originally seen Ms Higgs, admitted the high number of patients she was having to deal with had affected her ability to spend time with her.
Read full story
Source: BBC News, 14 March 2022
Patient Safety Learning

USA: Drop boxes are making it easier to get rid of old medication

What do you do with bottles of expired or no-longer-needed medications? That’s a problem, according to Elizabeth Skoy, an associate professor at North Dakota State University’s School of Pharmacy in the USA.
“In recent years, there’s been a spotlight on medication disposal, because of the opioid epidemic,” she said. “It’s important to get rid of any medication when you are done with it to prevent misuse or having it fall into the hands of others.” Plus, having old medications in the home increases the chances of accidental poisoning of children or pets.
But while many of us might be aware that we shouldn’t toss pill bottles in the trash or flush medication down the toilet, we’re less knowledgeable about safe alternatives. And there haven’t been many options beyond the USA's Drug Enforcement Administration’s semiannual National Prescription Drug Take Back Day.
In the past decade, however, pharmacies, hospitals and law enforcement agencies have been stepping up to help clean out medicine cabinets year-round. One of the most accessible solutions is medication collection bins, which are being added to convenient locations such as retail stores, health clinics, police stations and other easily accessed sites.
“We decided in 2016 we wanted to be part of the solution,” said Kurt Henke, ambulatory pharmacy manager for Colorado’s Denver Health hospital system, which has collection bins in each of its eight pharmacies. Drugstore chain CVS began putting units in police departments in 2014 and adding them to its more than 9,000 retail locations in 2017; so far it has deployed more than 4,000 of the bins. States are taking the initiative, as well. In North Dakota the state’s Board of Pharmacy provides MedSafe, a take-back box, to any pharmacy that wants one; at this point, about 120 are participating.
The DEA maintains a searchable database of controlled-substance collection sites. Simply type in your Zip code or city to find the nearest one.
Read full story (paywalled)
Source: The Washington Post, 15 March 2022
 
Patient Safety Learning

Covid-19: Countries in the Americas are warned not to lower their guard

Covid-19 is on the retreat across the American continents but it is too early for the region to let its guard down, warned the Pan American Health Organisation, the World Health Organization’s regional office for the Americas, on 9 March.
Reported cases of Covid-19 fell by 26% in the past week and deaths by nearly 19%, as the omicron wave of infections tailed off. But ongoing transmission and future variants could expose the region’s public health priorities once more, said PAHO’s director, Carissa Etienne.
A total of 2.6 million people have died from Covid-19 in the Americas, the highest number of any region of the world and almost half of the global total, despite being home to only 13% of its population. “This is a tragedy of enormous proportions, and its effects will be felt for years to come,” said Etienne on the second anniversary of the pandemic.
Patchy vaccination coverage has left countries vulnerable to current and future variants of SARS-CoV-2. Around 248 million people in Latin America and the Caribbean are yet to receive a single dose of a covid vaccine, with vaccination rates particularly low in hard-to-reach rural areas.
In the first two months of 2022 the Americas accounted for 63% of the world’s new cases. Despite a general fall in incidence across the region, new cases rose by 2.2% in the Caribbean, while Bolivia and Puerto Rico reported an increase in deaths in the past week.
Michael Touchton, head of the University of Miami’s Covid-19 policy observatory for Latin America, said, “Latin America is perhaps the most vulnerable region in the world to the emergence of a new variant. Vaccine delays have a greater impact in Latin America due to concentrated urban populations, chronic disease burden, and low capacity health systems. Taken together, Latin America is likelier to fare worse than other similarly low and middle income regions.”
Read full story
Source: BMJ, 14 March 2022
Patient Safety Learning

Lateral flow tests could cost care home visitors £73 a month

Lateral flow tests could cost care home visitors £73 a month, a leading UK charity has said, as it renewed calls to keep the devices free in such settings.
The government has previously announced that free testing for the general public will end from 1 April, and that this will include care home visitors.
However, charities have warned the shift away from free tests could place a heavy financial burden on those visiting care homes, where testing is still advised.
James White, the head of public affairs and campaigns at the Alzheimer’s Society, said the proposed charge on lateral flow tests for visitors to care homes was a cruel tax on care.
“Over the past two years, we’ve consistently heard many tragic stories from families struggling to visit their loved ones in care homes. For many people with dementia, this isolation has led to a significant deterioration in their condition and mental health,” he said.
“With infection rates rising once again, the government must provide free lateral flow tests for all visitors to care homes so that families are not put in an agonising position where they are forced to ration visits, leaving people with dementia once again isolated and alone.”
Caroline Abrahams, Age UK’s charity director, said: “No one should have to pay out of their own pocket for tests in circumstances where the expert advice is clear that testing remains an important safeguard against Covid,” she said.
“If care home visitors are going to continue to be asked to keep testing to protect their loved ones, it would be completely unacceptable to expect them to pay.”
Read full story
Source: The Guardian, 15 March 2022
Further reading
Visiting restrictions and the impact on patients and their families: a relative's perspective
Patient Safety Learning
Registered address: Patient Safety Learning, China Works SB203, 100 Black Prince Road Vauxhall, London, SE1 7SJ

Account

Navigation

Search

Search

Configure browser push notifications
Chrome (Android)
  1. Tap the lock icon next to the address bar.
  2. Tap Permissions → Notifications.
  3. Adjust your preference.
Chrome (Desktop)
  1. Click the padlock icon in the address bar.
  2. Select Site settings.
  3. Find Notifications and adjust your preference.