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

Nurse who mistreated patient with dementia asks to be removed from register

A nurse who admitted she was unfit to practise after dragging a patient with dementia to her room and forcefully attempting to administer a sedative has been suspended for a year by the nursing regulator.
Carol Picton was working in the stroke unit at the Western General Hospital in Edinburgh in November 2017 when colleagues raised concerns about her treatment of a vulnerable older woman.
Witnesses who gave evidence to an NMC fitness to practice (FtP) panel said they heard the patient screaming in distress after being roughly dragged by her arm back to her room by Ms Picton.
The nurse then attempted to forcefully administer the anti-psychotic drug Haloperidol without checking the correct dosage, the hearing was told. She tried to give the drug orally using a 2ml injection syringe rather than an oral syringe.
Ms Picton denied forceful mistreatment and panel found no evidence she had shown insight into her misconduct
When the patient spat out the drug Ms Picton gave her more without knowing how much she had ingested, risking an overdose, the panel heard. Ms Picton, who was referred to the NMC by her employer following an internal investigation, was also said to have tilted the patient’s bed to prevent her getting out and leaving her room.
The panel, which found five charges proven, concluded that Ms Picton’s actions were ‘deplorable’ and amounted to harassment and abuse.
Read full story
Source: Nursing Standard, 21 March 2022
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‘You lose your human rights’: Mental Health Act usage up by 12%

“When you’re sectioned under the Mental Health Act, you not only lose your voice, but you lose your human rights too”, Kelly a 47-year-old from Surrey tells The Independent.
After experiencing a mental health crisis in 2019, Kelly was subject to a “traumatic” detention under the Mental Health Act, during which she says she was “criminalised” for being unwell.
Kelly’s story comes as a new analysis of NHS data has revealed the number of people detained under the Mental Health Act increased by 12% in December 2021 compared to the 12 months prior.
Major charity Mind, which carried out the analysis, has called for promised reforms to the Mental Health Act to be implemented after recommendations following a major review published in 2019.
According to the analysis, the number of people subject to detention under the mental health act increased from, 10,760 in December 2020 to 12,013 December 2021.
Speaking with The Independent Kelly, who has had several experiences of being detained under the Mental Health Act, described her most recent experience in 2019 as “very traumatic.”
She said: “I had a very public breakdown near where I live. I had neighbours on the phone to the ambulance, and I had, you know, warrants for a psychiatrist or social worker and to enter my property. To have people invade your privacy like that, and to have a warrant to enter property, it’s almost like they’re criminalising you because you’re unwell.
Read full story
Source: The Independent, 21 March 2022
Patient Safety Learning

USA: Black adult hospitalisations reached a pandemic high during the omicron wave, CDC study finds

During the peak of the omicron variant wave of the coronavirus this winter, Black adults in the United States were hospitalised at rates higher than at any moment in the pandemic, according to a report published last week by the Centers for Disease Control and Prevention.
Black adults were four times as likely to be hospitalised compared with White adults during the height of the omicron variant surge, which started in mid-December and continued through January, the report said. In January, the CDC found, hospitalisation rates for Black patients reached the highest level for any racial or ethnic group since the dawn of the pandemic.
As the highly transmissible omicron variant usurped the delta variant’s dominance, people who were unvaccinated were 12 times more likely to be hospitalised than those who were vaccinated and boosted against the coronavirus, according to the report.
And fewer Black adults had been immunised compared with White adults, said the report, which analysed hospitalization rates in 99 counties in 14 states. 
Teresa Y. Smith saw evidence of the phenomenon outlined in the CDC’s report as she treated patients as an emergency physician at SUNY Downstate in Brooklyn.
She has felt the crush of the pandemic’s unequal impact since the pre-vaccine waves but has contended with the consequences of health disparities for much longer. Her hospital sits in a heavily Black and Latino borough, where — as in so many communities of color across the country — social, political, economic and environmental factors erode health and shorten lives.
In December, she watched as the number of cases and admissions resulting from the omicron variant “just exploded in a short, short amount of time,” saying then, “there is no subtlety to it.” And while the vaccinated patients she treated were less likely to be “lethally sick,” many still needed to be admitted to the hospital.
Read full story
Source: The Washington Post, 18 March 2022
 
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Updated PPE guidance puts NHS staff at risk of infection, say medics

NHS staff face unacceptable health risks as a result of “retrograde” changes to the government’s guidance on preventing spread of Covid-19, doctors’ leaders have warned.
The BMA said on 16 March it was concerned over updated guidance issued by the UK Health Security Agency covering use of personal protective equipment. It said the guidance failed to properly acknowledge that SARS-CoV-2 infection can spread in the air during the routine care of patients as they cough or sneeze and not just when specific processes known as aerosol generating procedures (AGPs) are being undertaken.
“This is a retrograde step as it once again means that healthcare workers will not be routinely provided the right level of protective masks and equipment they need to be safe at work when looking after covid patients,” said Chaand Nagpaul, the BMA’s chair of council.
The BMA said it was crucial that any staff looking after patients with confirmed or suspected Covid-19, or in other situations where a local risk assessment required it, had access to respiratory protective equipment such as filtering face piece (FFP3) masks.
Nagpaul said, “All healthcare workers who are caring for Covid-19 patients are putting themselves at risk, each and every day, and the very least the government should do is to provide surety that staff will be given the best protection possible.”
Respirators such as FFP3 masks are designed to protect the wearer from ingress of contaminated air and are fitted to ensure no gaps. They offer higher protection than surgical masks, which block the outward escape of droplets from the wearer.
The BMA’s concern follows a supposed clarification of the main messages regarding airborne transmission in the latest infection and prevention and control guidance issued on 15 March 2022.
The guidance said that respiratory protective equipment (FFP3 masks) are recommended when caring for patients with a suspected or confirmed infection spread “predominantly” by the airborne route (during the infectious period).
The word “predominantly” has been added to the previous guidance update, which was issued on 17 January 2022, and is the crux of doctors’ concern, one leading scientist said.
Read full story
Source: BMJ, 18 March 2022
Patient Safety Learning

No evidence Covid vaccines lead to young deaths

There is no evidence that Covid vaccines have led to an increase in deaths in young people, the Office for National Statistics (ONS) has said.
Six months after the mass rollout of Covid vaccines, medical regulators started to report slightly higher rates of two heart conditions after receiving the Pfizer and Moderna jabs.
Myocarditis is an inflammation of the heart muscle itself, while pericarditis is inflammation of the fluid-filled sac the heart sits in. Both side effects are very rare but appear to be more common after a second dose of either Covid jab, particularly in younger men.
The ONS looked at outcomes shortly after vaccination, when the risk of any side effect is highest.
The chance of a young person dying in that time was no different to later periods the researchers looked at.
Julie Stanborough, deputy director at the ONS said: "We have found no evidence of an increased risk of cardiac death in young people following Covid-19 vaccination."
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Source: BBC News, 22 March 2022
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£3bn group of hospitals moves to centralise electives

North west London’s acute trusts are exploring whether to set up a new elective orthopaedic centre in the region as they seek to capitalise on the concept of “fast-track” surgical hubs.
Last week, a report to Imperial College Healthcare Trust’s board said a more “strategic, larger-scale” approach was being sought to improve capacity for more high-volume, low-complexity work across the sector.
This covers the four acute trusts in the area, which now share a single chair, and have a total turnover of more than £3bn: Imperial, Chelsea and Westminster, London North West, and Hillingdon.
The board report said leaders were exploring how best to establish the centre for the region while “maximising” planned surgery capacity overall, with the South West London Elective Orthopaedic Centre run by Epsom and St Helier University Hospitals Trust highlighted as a “well-established example”.
Central Middlesex Hospital, which is operated by London North West University Healthcare Trust, has been identified as a preferred location for the centre, the report said. A project management team is also being set up to explore the options available before proposals are developed for broader consideration.
It comes after 14 “fast-track” hubs were set up across hospitals in north west London to maximise theatre capacity, which predominantly focused on high-volume, low-complexity work surrounding specialties such as gynaecology, urology, orthopaedics and ear, nose and throat.
The report to ICHT’s board warned that, without some “further intervention,” the number of patients awaiting orthopaedic surgery in north west London could increase to just under a fifth by 2030 from a current position of 12,000 people seeking inpatient or outpatient care.
However, it added that a “large amount of work” was still required to explore the case for an elective orthopaedic centre, including establishing the best location and identifying capital and revenue funding and workforce requirements.
Read full story (paywalled)
Source: HSJ, 22 March 2022
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Long Covid could create a generation affected by disability, expert warns

Long Covid could create a generation affected by disability, with people forced out of their homes and work, and some even driven to suicide, a leading expert has warned.
In an exclusive interview with the Guardian, Prof Danny Altmann – an immunologist at Imperial College London – said that the UK’s current approach to Covid fails to take the impact of infections sufficiently seriously, adding that more needs to be done to aid diagnosis and treatment of Long Covid.
“It’s kind of an anathema to me that we’ve kind of thrown in the towel on control of Omicron wave infections and have said ‘it’s endemic, and we don’t care any more, because it’s very benign’,” he said. “It just isn’t. And there are new people joining the long Covid support groups all the time with their disabilities. It’s really not OK, and it’s heartbreaking.”
According to data from the Office for National Statistics, by the end of January this year about 1.5 million people – or 2.4% of the population – in the UK said they were experiencing ongoing symptoms more than four weeks after their first suspected Covid infection, with 45% reporting that infection was a year or more ago.
The findings chime with a recent UK study that found only around one in three patients who had ongoing Covid symptoms after being hospitalised with the disease reported feeling fully recovered a year later.
Asked whether Long Covid could lead to a generation affected by disability, Altmann agreed. “Totally,” he said.
Read full story
Source: The Guardian, 23 March 2022
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Thousands more women getting tested for autism after ‘being missed for decades’

Tens of thousands more women tested themselves for autism last year with numbers seeking tests now far outstripping men, new data shows.
Statistics seen by The Independent show around 150,000 women took an online test verified by health professionals to see if they have autism last year, up from about 49,000 in 2020.
Health professionals said the increase was a consequence of women not being diagnosed with the neurodevelopmental disorder as children and teens due to autism wrongly being viewed as a male disorder.
Experts told The Independent autistic women and girls are routinely overlooked and neglected by health services due to them being more likely to conceal or internalise symptoms.
Data from Clinical Partners, one of the UK’s leading mental health care providers which works closely with the NHS, shows women made up 56 per cent of those using their autism tests last year. This is substantially higher than the 46 per cent of women testing themselves for autism in 2020.
Hannah Hayward, neurodevelopmental specialist at Clinical Partners, who provided the exclusive data, explained: “Diagnosis is crucial – without which, women and men can be susceptible to symptoms of mental health conditions including anxiety and depression and it is common for them to be misdiagnosed with or develop other conditions such as anxiety, anorexia, depression or Borderline Personality Disorder,” 
Read full story
Source: The Independent, 23 March 2022
 
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'My husband cried on the phone, begging for help'

A man who experiences regular mental health crises says an NHS scheme designed to offer support during emergency episodes has become broken.
The trust running the service says a crisis team offers immediate support in an emergency, and a 24-hour helpline.
But when Mark Doody, who has bipolar disorder, cried "down the phone, begging the team for help", he was told to call an ambulance, his wife said.
The trust said a 999 call could sometimes be the appropriate action.
Trish Doody cited a "dreadful" deterioration in mental healthcare where the couple lived in Redditch, Worcestershire.
She said while her husband was able to get support if an emergency happened "between 9am and 5pm", assistance became difficult outside of those hours.
Mr Doody said his condition meant he experienced a mental health crisis every three months. He has also made suicide attempts.
Mental healthcare provision in the county had gone downhill over the last 20 years, Mrs Doody said, with her husband adding: "The system is just broken really."
Healthwatch Worcestershire, which helps hold the NHS to account locally, said it was "exploring" whether there was a problem with the crisis helpline, and was also aware of delays for those seeking one-to-one counselling, which it said the trust was tackling.
Read full story
Source: BBC News, 22 March 2022
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Lack of transcripts 'prejudices employment hearings'

Judges’ notes are regarded as the official record and are made available to employment appeal tribunals, but they are seen as private documents and are not available to the parties.
If the judgment that follows a hearing omits substantial elements of oral evidence that support the claimant’s case, the prospects of a successful appeal are hampered without a court record.
'This imbalance irretrievably denies parties the right to prepare adequately an appeal and it is manifestly unfair,' the letter states. Reference to the full record 'is the only way to determine whether the decision made was fair and proper'.
Signatories include Sir Adam Ridley, a former senior civil servant at 10 Downing Street and the pioneering cardiologist Jane Somerville of Imperial College, London.
A spokesperson for the judiciary said: 'The letter has been received and is being reviewed.'
Barrister Sophie Walker, founder of the company Just Transcription, told the Gazette: 'Providing litigants and their legal teams recordings and automated transcripts of the hearing would be a major leap forward for open justice and access to justice.' 
Read full story
Source: The Law Society Gazette, 22 March 2022
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As a nurse in the US faces prison for a deadly error, her colleagues worry: Could I be next?

Four years ago, inside the most prestigious hospital in Tennessee, nurse RaDonda Vaught withdrew a vial from an electronic medication cabinet, administered the drug to a patient, and somehow overlooked signs of a terrible and deadly mistake.
The patient was supposed to get Versed, a sedative intended to calm her before being scanned in a large, MRI-like machine. But Vaught accidentally grabbed vecuronium, a powerful paralyser, which stopped the patient’s breathing and left her brain-dead before the error was discovered.
Vaught, 38, admitted her mistake at a Tennessee Board of Nursing hearing last year, saying she became “complacent” in her job and “distracted” by a trainee while operating the computerized medication cabinet. She did not shirk responsibility for the error, but she said the blame was not hers alone.
“I know the reason this patient is no longer here is because of me,” Vaught said, starting to cry. “There won’t ever be a day that goes by that I don’t think about what I did.”
If Vaught’s story followed the path of most medical errors, it would have been over hours later, when the Board of Nursing revoked her RN license and almost certainly ended her nursing career. But Vaught’s case is different: This week she goes on trial in Nashville on criminal charges of reckless homicide and felony abuse of an impaired adult for the killing of Charlene Murphey, a 75-year-old patient who died at Vanderbilt University Medical Center on the 27 December 2017.
Prosecutors do not allege in their court filings that Vaught intended to hurt Murphey or was impaired by any substance when she made the mistake, so her prosecution is a rare example of a health care worker facing years in prison for a medical error. Fatal errors are generally handled by licensing boards and civil courts. And experts say prosecutions like Vaught’s loom large for a profession terrified of the criminalization of such mistakes — especially because her case hinges on an automated system for dispensing drugs that many nurses use every day.
Read full story
Source: Kaiser Health News, 22 March 2022
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England’s CNO says 50,000 more NHS nurses ‘no longer enough’

The chief nursing officer for England has spoken about the ongoing shortages of nurses across the country and how the government’s previous pledge for 50,000 more nurses is now “not enough”.
At one of her first in-person speeches since the start of the pandemic, Ruth May also revealed that she thought the removal of the student nurse bursary in England was “fundamentally the wrong decision”.
Ms May was speaking at an event organised by the League of St Bartholomew’s Nurses in honour of pioneering nurse Pam Hibbs, who died following a Covid-19 infection last year.
During her keynote address, Ms May said workforce remained a “big focus” for her team due to the “shortage” of nursing staff nationally.
She said work to address the gaps was centred on the three areas of international recruitment, domestic training, and retention.
She said numbers of nurses being recruited from overseas annually had risen from around 5,000 to 6,000 before the pandemic, to an expected 20,000 in this financial year.
“I’m very, very glad that the NHS has had a diverse workforce from its very inception. We have welcomed colleagues from across all countries of the world, and we will continue to do that,” Ms May said.
Read full story (paywalled)
Source: The Nursing Times, 22 March 2022
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Covid crisis ‘not over’ as hospitalisations to rise for two weeks, warns Chris Whitty

Covid hospitalisations will continue to rise for at least two weeks, England’s government’s chief medical officer warned on Wednesday as Britain’s daily cases breached 100,000 for the second time this month.
Professor Sir Chris Whitty said the country’s Covid crisis “is not over” and that new variants of the disease could arise at any time.
He pointed to the latest data showing that the number of people with Covid in hospitals has been rising, and said this would likely continue for at least two weeks.
The current rise in cases is “currently being driven by Omicron rather than new variants”, he told an audience at a Local Government Association conference, but added: “We need to keep a very close eye on this, because at any point new variants could emerge anywhere in the world, including the UK, obviously, as what happened with the Alpha variant.”
Another 194 Covid deaths were reported on Wednesday, up 27% on last week.
Prof Whitty said that death rates were fortunately still low but that hospitalisations meant there was still pressure on the NHS.
Asked about the end of free testing for the public on 1 April, Sir Chris said it was a “trade-off between disparities, because the effects of free testing are probably going to be differential across society, and [there are] very substantial sums that are going into it, which otherwise would be going into other public health issues."
However, he said that testing for staff within health and social care was “slightly different” as the risks are greater, and those who are in hospital or care homes are more vulnerable.
His comments come on the second anniversary of the day the UK announced a national lockdown.
Read full story
Source: The Independent, 23 March 2022
 
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Chancellor ‘doubles NHS efficiency target’

The government has doubled the annual efficiency expectation on the NHS, he has said, as systems and trusts grapple with large gaps in their financial plans for 2022-23.
The Treasury told the media over the weekend the Chancellor was doubling the NHS’s annual savings target to 2.2% from 1.1%. Reports said this would deliver an annual saving of £4.75bn. 
It is unclear whether the move represents a change to the underlying efficiency expectation in NHS planning — which would require all systems and trusts to revise their plans for 2022-23 — or is simply a re-statement or recognition that the effective efficiency requirement was already well above the 1.1 per cent envisaged under the pre-covid NHS long-term plan.
Rishi Sunak told the Mail on Sunday the move was linked to the “health and social care levy” which will see a rise in National Insurance next month. He also said he would chair a new cabinet committee to reduce waste in the public sector.
Speaking ahead of his Spring Statement on Wednesday, he said: “Your readers should be reassured that unlike any other tax that they pay, every penny of this levy goes specifically to the thing that they care most about… So we are setting up a new Cabinet committee, that I am chairing, to focus on efficiency, value for money, waste and reform. Working with the health secretary we are doubling the efficiency target for the NHS. Every pound from this levy is going to go incredibly far.”
In NHS England’s annual report, published last month, its chief executive Amanda Pritchard said: ”The certainty we have recently received on both capital and revenue budgets for the years ahead provide a welcome basis on which the NHS nationally and locally can now plan. We should however be under no illusions that the challenges ahead – for financial balance and operational performance – are anything other than unprecedented.”
Read full story (paywalled)
Source: HSJ, 20 March 2022
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Burnout: set up watchdog to protect NHS staff, says wellbeing champion

A regulator that sets standards on staff wellbeing and holds the NHS to account should be established to help protect doctors from burnout, a champion of physicians’ wellbeing has said.
The proposal was one of several put forward by Clare Gerada, president of the Royal College of General Practitioners, who recently stepped down as medical director of the confidential mental health support service NHS Practitioner Health.
She was speaking on 22 March to MPs on the House of Commons health and social care committee about how the Covid-19 pandemic had increased the number of doctors struggling with mental health problems, particularly in general practice.
Read full story (paywalled)
Source: BMJ, 24 March 2022
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Trust loses whistleblowing case over ‘pioneering’ procedure

A senior medic has won a whistleblowing case after judges ruled she was dismissed after raising concerns about a new procedure her department was using.
An employment tribunal found consultant nephrologist Jasna Macanovic was fired from Portsmouth Hospitals University Trust in March 2018 after telling bosses a dialysis technique called “buttonholing”, which had been “championed” there, was potentially dangerous.
The trust’s case was that the way she had gone about raising concerns had made for an untenable working environment in the Wessex Kidney Centre.
The process saw a Care Quality Commission complaint, an independent investigation and multiple referrals to the General Medical Council.
Employment Judge Fowell said: “The plain fact is that after over twenty years of excellent service in the NHS, Dr Macanovic was dismissed from her post shortly after raising a series of protected disclosures about this one issue. It is no answer to a claim of whistleblowing to say that feelings ran so high that working relationships broke down completely, and so the whistleblower had to be dismissed.”
Dr Macanovic resigned from the regional renal transplant team in July 2016 when she discovered two incidents had occurred that “had not been reported by either surgeon” and felt that one of the surgeons had misled the medical director over the issue, the tribunal heard.
In an email sent after the resignation meeting, Dr Macanovic said the practice was considered inappropriate by the vast majority of experts in the field and that no other renal unit in England was using it. 
The case exposes some worrying governance, both within the trust and between it and the Care Quality Commission, with which the issues were raised in 2016.
When the CQC asked the trust for more information the unit’s clinical director responded that in his view that the deaths and infections were not due to the buttonholing.
The CQC made no further enquiries and wrote back saying “they were satisfied that there were no safety concerns and that appropriate governance had been followed”.
Read full story
Source: HSJ, 24 March 2022
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