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

NHS trust apologises over death of woman, 27, after cancer misdiagnosis

An NHS trust has apologised over the death of a 27-year-old events manager after a locum gynaecologist mistook aggressive cervical cancer for a hormonal or bowel problem.
The family of Porsche McGregor-Sims, who died a day after being admitted to Queen Alexandra hospital in Portsmouth, told her inquest that she had felt she was not listened to and that the misdiagnosis had robbed them of a chance to say goodbye.
The area coroner Rosamund Rhodes-Kemp said the case was one of the most “shocking and traumatic” she had dealt with and she would write to Portsmouth hospitals university NHS trust expressing her concern.
In December 2019, McGregor-Sims’ GP referred her to a consultant after she complained of abdominal pain and vaginal bleeding.
She saw Dr Peter Schlesinger, an agency locum at the Queen Alexandra hospital, at the end of January 2020. He did not physically examine her and believed her symptoms were linked to changing hormones or irritable bowel syndrome (IBS).
After the UK went into lockdown two months later, McGregor-Sims continued to report symptoms but was prescribed antibiotics over the phone and was seen in person only after a GP thought she might have Covid because she had shortness of breath.
McGregor-Sims was finally diagnosed with an aggressive form of cervical cancer and on 13 April was taken to hospital, where she died a day later.
During the inquest, her family accused Schlesinger of having denied them their chance to say goodbye. Her mother, Fiona Hawke, told him: “You robbed us of the opportunity to prepare for her death and say goodbye to her.”
Schlesinger insisted McGregor-Sims’ symptoms – including bleeding after sex – did not lead him to think she had a serious illness.
Dr Claire Burton, a consultant gynaecologist, said Schlesinger should have physically examined McGregor-Sims, and apologised for the care she received at the trust.
Read full story
Source: The Guardian, 24 March 2022
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A&E tents ‘borderline immoral’ and ‘dangerous’, claims royal college

The use of temporary treatment areas for patients arriving via ambulance at over-crowded A&Es is ‘borderline immoral’ and ‘a danger to patient safety and dignity’, the Royal College of Emergency Medicine has warned.
The college said NHS England had told regional bosses to prepare to errect more of the so-called “tents” outside their major emergency departments as part of plans to get a grip on ambulance handover delays, which have reached record highs in the last two weeks.
Senior figures also told HSJ that trusts have been instructed by NHS England to call the overflow facilities “temporary external structures” and not tents – a move also criticised by RCEM president Katherine Henderson.
Dr Henderson told HSJ: “Using tents is just wrong on every level… We’ve been down this route before. It doesn’t work. It’s a huge distraction, and I think what upsets me the most about it is it creates the appearance that people are taking action when it’s not the action that will deal with the problem.”
In an opinion piece for HSJ, Dr Henderson says: “We find ourselves in the completely unacceptable situation where the ‘solution’ to ambulance handover problems is to put up tents or sheds in front of emergency departments – euphemistically being called ‘temporary external structures’.
“Trust leaders and NHS England must not be afraid to stand up and make this case – putting patients in tents is a bad, borderline immoral bodge job to treat the symptom rather than cause, and our patients need to see some real leadership to protect them."
Read full story (paywalled)
Source: HSJ, 25 March 2022
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Acute trust to be prosecuted by CQC

The Care Quality Commission is to prosecute an acute trust after a patient was injured when allegedly exposed to “avoidable harm”.
United Lincolnshire Hospitals Trust is due to appear tomorrow afternoon at Boston Magistrates’ Court.
The alleged incident took place at Lincoln County Hospital, the CQC said. Although the CQC declined to comment further, Lincolnshire Live reported the alleged incident involved 91-year-old Iris Longmate and relates to a failure to provide safe care and treatment on or before 3 March 2019.
The local publication added court papers claimed “at the same time ULHT also failed to give safe care and treatment to patients on Greetwell Ward, who were ‘being exposed to a significant risk of avoidable harm occurring’”. 
Proceedings are being brought under sections 22 and 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These rules require providers to take reasonable steps to minimise risks to people’s health and safety during treatment, and make it a criminal offence if a provider fails to comply and a patient suffers avoidable harm or is exposed to a risk of this happening.
Read full story (paywalled)
Source: HSJ, 24 March 2022
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GPs to face six-month complaint response targets under ombudsman proposals

GP practices are set to face new targets for responding to patient complaints under standards being piloted by the health ombudsman.
All ‘straightforward’ complaints should be dealt with within six months and 95% within three, while 80% of ‘complex’ complaints should be completed within six months and half within three, under the proposals.
The new Parliamentary and Health Service Ombudsman (PHSO) complaint standards are currently being piloted in every sector of the NHS – including one GP practice – and were due to be implemented across the NHS this year. 
However, a PHSO spokesperson told Pulse that due to delays caused by the pandemic, the full rollout is now planned for the beginning of next year, with the ombudsman to implement the standards from April 2023.
The proposed complaints standards said staff should ensure they ‘consistently meet expected timescales for acknowledging a complaint’ and ‘respond to complaints at the earliest opportunity’, providing ‘regular updates throughout’.
They should also give ‘clear timeframes’ for how long investigating the complaint will take and ‘agree timescales with everyone involved’, including the complainant.
An accompanying draft model complaint handling procedure said that complaints will be acknowledged within three working days either verbally or in writing.
Read full story
Source: Pulse, 24 March 2022
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Pregnant women to be offered NHS test to detect pre-eclampsia

Pregnant women with suspected pre-eclampsia will now be offered a test on the NHS to detect the condition.
Pre-eclampsia affects some women, usually during the second half of pregnancy or soon after their baby is born.
It can lead to serious complications if it is not picked up during maternity appointments, with early signs including high blood pressure and protein in the urine.
In some cases, women can develop a severe headache, vision problems such as blurring or flashing, pain just below the ribs, swelling and vomiting.
Tests have been available to help rule out the condition but midwives will now use tests designed to pick up a positive diagnosis.
In new draft guidance, the National Institute for Health and Care Excellence (NICE) said midwives could use one of four blood tests to help diagnose suspected preterm pre-eclampsia.
Jeanette Kusel, the acting director for medtech and digital at NICE, said: “These tests represent a step-change in the management and treatment of pre-eclampsia. New evidence presented to the committee shows that these tests can help successfully diagnose pre-eclampsia, alongside clinical information for decision-making, rather than just rule it out.
“This is extremely valuable to doctors and expectant mothers as now they can have increased confidence in their treatment plans and preparing for a safe birth.”
Read full story
Source: The Guardian, 25 March 2022
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Covid-19: Public inquiry must include effects on children, say experts

The government’s upcoming Covid-19 public inquiry must include the effect of the pandemic on children and young people, a group of leading doctors and scientists have said.
The draft terms of reference for the inquiry were published on 15 March but made no specific mention of children or young people other than a single reference to “restrictions on attendance at places of education."
“There is no doubt that school closures and broader lockdowns harmed children,” said the letter to the Times signed by 50 people including Russell Viner, former president of the Royal College of Paediatrics and Child Health, and Andrew James, president of the Royal College of Psychiatrists. “Educational losses have been most marked in children from deprived families and in vulnerable children.”
They pointed out that mental health problems increased from being experienced by one in nine children and young people before the pandemic to one in six during 2020 and 2021. Childhood obesity rates last year were at least 20% above previous years.
One of the signatories to the letter, education committee chair Robert Halfon, has also written directly to the inquiry chair Heather Hallet.3 “The closure of schools and the restrictions placed on education settings has been nothing short of a national disaster for children and young people, not only in terms of their educational attainment but also with regards to their mental health and wellbeing, their life chances, and their safety,” he wrote.
Read full story
Source: BMJ, 24 March 2022
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Persistent cough may be tuberculosis not Covid, doctor warns

The UK's top public health doctor says anyone with a persistent cough and fever should not dismiss it as Covid - and should consider other infectious illnesses like tuberculosis (TB).
Dr Jenny Harries' warning comes as provisional data shows there were 4,430 cases recorded in England in 2021, despite sharp declines in recent years.
Charities are calling for more funding to tackle the disease around the world. They say the pandemic and conflicts have set back progress worldwide.
In 2020, global deaths because of tuberculosis ranked second to Covid for any infectious disease.
The charity Stop TB Partnership warns the war in Ukraine could have "devastating impacts on health services", including the country's strong national TB treatment programme.
The charity is urging all countries to put facilities in place urgently so refugees can be given the care they need.
In the UK a requirement for Ukrainians to take a TB test before arrival has been waived for those who are coming to the country on the family scheme visa. Refugees arriving on the scheme will get medical care and testing via GPs.
Meanwhile Dr Jenny Harries, chief executive of the UK Health Security Agency, said delayed diagnosis and treatment, particularly during the pandemic, will have increased the number of undetected cases in England.
Read full story
Source: BBC News, 24 March 2022
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Welsh Ambulance: Paramedics say job is soul destroying

"Absolutely soul destroying" is how one paramedic describes his job.
He is not alone.
Over the past few months, BBC Wales has been contacted by employees from the Welsh Ambulance Service who paint a dire picture of a service under immense pressure.
Ambulance waiting times have climbed and climbed throughout the pandemic. The impact that has on patients is well known - but what about those on the other side?
Mark, who did not want to disclose his real name or show his face for fear that he would lose his job, described the stress of his shifts with a radio strapped to his chest, hearing "red calls waiting, red calls waiting".
"That is the potential of somebody's life waiting in the balance - and you can't get there. It's absolutely soul-destroying. We wouldn't treat animals this way, why are we treating humans?", he said.
Mark said the job has always come with pressure and anxiety.
But over the course of the pandemic that has intensified and he has "never known as many people looking for other jobs as they are at the moment".
The stress has become so bad that he is now on antidepressants.
Read full story
Source: BBC News, 25 March 2022
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Government asks NHS to ‘cut core funding’ by £500m

NHS England must find hundreds of millions of pounds in last-minute savings to pay for ongoing covid staff tests, it has been revealed
NHSE chief financial officer Julian Kelly told a meeting of NHS England’s board: “We have been asked to see if we can cut core NHS funding - at the moment that is probably to the tune of £500m.” Mr Kelly said achieving this would likely involve “slowing down” some transformation programmes and ambitions in the Long Term Plan.
He added that rising inflation could add an extra £1bn in financial pressure, telling the board “we’re going to have to look at what that means for our ability to deliver NHS goals in the round.”
It was reported in February that Health Secretary Sajid Javid and Chancellor Rishi Sunak were at loggerheads over whether the Department of Health and Social Care (DHSC) should receive additional funding for covid testing on top of the health service’s spending envelope. The row is said to have led to a delay in plans to scrap all remaining virus-related restrictions.
The DHSC reduced its ask for extra cash down from £5bn to an eventual £1.8bn but even this lower sum was rejected by the Treasury, according to reports. This means continuing staff testing will have to paid for out of the existing NHS budget.
Read full story (paywalled)
Source: HSJ, 24 March 2022
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Whistleblower reveals 'culture of fear' stopped hospital staff exposing baby deaths

A whistleblower who worked at a hospital trust where hundreds of babies died or were left brain-damaged says there was "a climate of fear" among staff who tried to report concerns.
Bernie Bentick was a consultant obstetrician at the Shrewsbury and Telford NHS Trust for almost 30 years.
"In Shrewsbury and Telford there was a climate of fear where staff felt unable to speak up because of risk of victimisation," Mr Bentick said.
"Clearly, when a baby or a mother dies, it's extremely traumatic for everybody concerned.
"Sadly, the mechanisms for trying to prevent recurrence weren't sufficient for a number of factors.
"Resources and the institutionalised bullying and blame culture was a large part of that."
More than 1,800 cases of potentially avoidable harm have been reviewed by the inquiry. Most occurred between 2000 and 2019.
Mr Bentick worked at the Trust until 2020. He said from 2009 onwards, he was raising concerns with managers.
"I believe there were significant issues which promoted risk because of principally understaffing and the culture," he said.
He also accuses hospital bosses of prioritising activity - the number of patients seen and procedures performed - over patient safety.
"I believe that the senior management were mostly concerned with activity rather than safety - and until safety is on a par with clinical activity, I don’t see how the situation is going to be resolved," he said.
Read full story
Source: Sky News, 27 March 2022
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Online retailers stop sales of some blood oxygen monitors after investigation

Amazon, eBay and Wish have stopped stocking some monitors that let people keep track of their blood oxygen levels after an investigation found they were not fit to be sold.
The online marketplaces removed a number of pulse oxygen testing devices known as oximeters from sale after being alerted to flaws identified by the consumer organisation Which?
Pulse oximeters have boomed in popularity as a result of Covid, with millions of people keeping one at home so they can quickly assess if their blood oxygen level has fallen worryingly low – a condition known as “silent hypoxia” – which is a common side-effect of the disease.
Some of the devices were not legally fit to be sold in the UK, did not carry the CE quality Kitemark or wrongly claimed that they had been approved by the NHS.
The Department of Health and Social Care (DHSC) said it would look into the unauthorised use of the health service’s iconic blue and white branding on the devices. It made clear that “the NHS does not approve or endorse any medical devices, including oximeters”.
“The department strictly controls the NHS identity and takes unauthorised use or adaptation of the NHS logo and the letters ‘NHS’ very seriously”, a DHSC spokesperson said.
Which? said that 11 of the cheap pulse oximeters it bought from those websites failed to comply with UK and European Union law when it examined them closely.
“It is very concerning that our investigation found these medical devices for sale without the required safety markings or brazenly claiming to be approved by the NHS, and the biggest online marketplaces were not picking up on these red flags”, said Natalie Hitchens, the consumer group’s head of home products and services.
Read full story
Source: The Guardian, 26 March 2022
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1,500 deaths to be investigated at scandal-hit mental health trust

More than 1,500 patient deaths are to be investigated in the largest-ever independent inquiry into “unacceptable” mental health care.
A probe into the deaths of patients who were cared for by NHS mental health services across Essex has revealed its investigation will cover deaths from 2000 to 2020.
All 1,500 people died while they were a patient on a mental health ward in Essex, or within three months of being discharged from one.
In 2001, following an investigation into 25 deaths, police criticised the trust for “clear and basic” failings but did not pursue a corporate manslaughter prosecution.
And in 2021, the Health and Safety Executive fined the trust £1.5m due to failures linked to the deaths of 11 patients. The regulator said the trust did not manage the risks of ligature points for a period of more than 10 years.
In January 2021, following pressures, former patient safety minister Nadine Dorries commissioned former NHS England mental health director Dr Geraldine Strathdee to chair an independent inquiry.
While it is not known yet how many of the 1,500 deaths were caused by neglect, Dr Strathdee said evidence had so far shown some “unacceptable” and “dispassionate” care.
Melanie Leahy, who has campaigned for change within Essex mental health services since her son died in 2012, has been leading the call for it to become a public inquiry on behalf of the families. Her son, Matthew Leahy, died as an inpatient at the Linden Centre, following multiple failings in his care.
A 2018 parliamentary health service ombudsman report on his death, and that of another young man called Richard Wade, identified “systemic” failings on behalf of the trust. These included the failure to manage his risk level, to look after his physical health and to take action when he reported being raped in the unit.
Read full story
Source: The Independent, 28 March 2022
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Three hundred babies lost to a fixation on natural births

When Debbie Greenaway was told by doctors that she should try to deliver her twin babies naturally, she was nervous. 
But the doctor was adamant, she recalls. “He said: ‘We’ve got the lowest caesarean rates in the country and we are proud of it and we plan to keep it that way'."
For Greenaway, labour was seemingly endless. She was given repeated doses of syntocinon, a drug used to bring on contractions. By the second day, the midwife was worried for one of the babies, whom the couple had named John. “She was getting really concerned that they couldn’t find John’s heartbeat.”
Her husband remembers “the midwife shaking her head”. “She said a number of times that we should be having a caesarean.”
By the time doctors finally decided to perform an emergency C-section, it was too late. Starved of oxygen, baby John had suffered a catastrophic brain injury. When he was delivered at 3am, he had no pulse. Efforts to resuscitate him failed.
Their son’s death was part of what is now recognised as the largest maternity scandal in NHS history. 
The five-year investigation will reveal that the experiences of 1,500 families at Shrewsbury and Telford Hospital Trust between 2000 and 2019 were examined. At least 12 mothers died while giving birth, and some families lost more than one child in separate incidents, the report is expected to show.
The expert midwife Donna Ockenden and a team of more than 90 midwives and doctors will deliver a damning verdict on the Shrewsbury trust, its culture and leadership — and failure to learn from mistakes or listen to families.
At its heart is how a toxic obsession with “normal birth” — fuelled by targets and pressure from the NHS to reduce caesarean rates — became so pervasive that life-or-death decisions on the maternity ward became dangerously distorted for nearly two decades.
Read full story (paywalled)
Source:  The Times, 26 March 2022
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Nurses’ well-being: ‘burnout’ too gentle a term for mental distress

Burnout is not a strong enough term to describe the severe mental distress nurses and other NHS staff are experiencing, says a doctor who has led efforts to improve care for health professionals.
Medical director of the NHS Practitioner Health service Dame Clare Gerada told MPs radical action was needed to improve the mental well-being of NHS staff.
She said nurses and other healthcare staff should be entitled to one hour of paid reflective time per month to be written into NHS employees’ contracts, alongside mentoring, careers advice and leadership training built in throughout people’s careers.
Dr Gerada was among senior clinicians who gave evidence this week to the Health and Social Care Committee, which is looking at issues around recruitment and retention of staff.
She told the committee the term ‘burnout’ simply did not cover the level of stress and mental anguish experienced by NHS workers. ‘Burnout is too gentle a term for the mental distress that is going on amongst our workforce,’ she said.
High suicide rates among nurses and doctors, high levels of bullying and staff being sacked because they have long-COVID are all signs the health service is failing to look after its employees, she said.
‘The symptoms we have got are the symptoms of an organisation that is unable to care for its workforce in the way that it should be caring,’ she said.
Read full story
Source: Nursing Standard, 25 March 2022
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Investigation begins into woman's childbirth death

An investigation has been launched after a woman died during childbirth at a hospital's maternity unit.
It was the third death of a mother in just over three years at Basildon University Hospital in Essex, in addition to a newborn baby's death.
The trust that runs the hospital said it could not comment on the case while it was under investigation.
Basildon University Hospital is part of Mid and South Essex NHS Foundation Trust, which also runs Southend and Broomfield hospitals.
The latest fatality follows the death of 36-year-old Gabriela Pintilie in February 2019. Ms Pintilie died after losing six litres of blood giving birth to her second child at the unit.
In separate incidents, a mother died and another woman had a stillborn baby at the unit in March 2019, while the trust was being inspected by the Care Quality Commission (CQC) following Ms Pintilie's death.
The unit at Basildon had its rating upgraded from "inadequate" to "requires improvement" in December by the CQC.
The hospital also apologised for the death of newborn Frederick Terry after he suffered a brain haemorrhage during a failed forceps delivery in November 2019.
Read full story
Source: BBC News, 27 March 2022
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USA: Former nurse found guilty in accidental injection death of 75-year-old patient

RaDonda Vaught, a former nurse criminally prosecuted for a fatal drug error in 2017, was convicted of gross neglect of an impaired adult and negligent homicide on Friday after a three-day trial in Nashville, Tenn., that gripped nurses across the country.
Vaught faces three to six years in prison for neglect and one to two years for negligent homicide as a defendant with no prior convictions, according to sentencing guidelines provided by the Nashville district attorney's office. Vaught is scheduled to be sentenced 13, and her sentences are likely to run concurrently, said the district attorney's spokesperson, Steve Hayslip.
Vaught was acquitted of reckless homicide. Criminally negligent homicide was a lesser charge included under reckless homicide.
Vaught's trial has been closely watched by nurses and medical professionals across the U.S., many of whom worry it could set a precedent of criminalising medical mistakes. Medical errors are generally handled by professional licensing boards or civil courts, and criminal prosecutions like Vaught's case are exceedingly rare.
Read full story
Source: OPB, 26 March 2022
See also: As a nurse in the US faces prison for a deadly error, her colleagues worry: Could I be next?
 
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