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

Stop charging migrant women for NHS maternity care, RCOG urges

The Royal College of Obstetricians and Gynaecologists (RCOG) has called for the immediate suspension of charging for NHS maternity care for migrant women because members say this government policy is harming the health of pregnant women and their babies.  It is the first time the health professionals’ body has issued a position statement on this issue.
The charity Maternity Action and the Royal College of Midwives have long expressed concern about the impact of NHS charging on this group of women. Charging forms a key plank of the Home Office’s hostile environment for migrants.
The government says the charging policy is in place to deter health tourism but medics treating migrant pregnant women say there is little evidence that previously free NHS maternity care for all attracted health tourists.
According to the 2019 MBRRACE-UK confidential inquiry into maternal deaths, three women were found to have died between 2015 and 2017 who may have been reluctant to access maternity care due to fears about charging and impact on their immigration status.
Dr Brenda Kelly, an NHS consultant obstetrician working in Oxford, treats many pregnant migrant women. She is calling for the barriers to them accessing maternity care to be removed urgently.
She described the case of one migrant woman who arrived in A&E shortly before delivering a stillborn baby. The woman had been fearful of coming forward for antenatal care although she was suffering from multiple, pregnancy-related health problems.
“I hope I never have to hear cries like that woman’s cries ever again,” said Kelly. “The way to safeguard these women is to build up trust. If they are landed with a bill of several thousand pounds they will disengage. They are not health tourists, they are desperate. The commitment to maternal health equity means ending charges for maternity care. The time for action is now.”
Read full story
Source: The Guardian, 27 March 2022
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Chief executive of prestigious hospital loses whistleblowing case

The chief executive of one of England’s most prestigious private hospitals has lost her employment tribunal claim that she was dismissed for whistle blowing over patient safety issues.
Aida Yousefi ran the Portland Hospital in central London from January 2017 until her dismissal in December 2019 on two counts of gross misconduct. She was also in charge of The Harley Street Clinic and a specialist cancer centre. 
Ms Yousefi’s argument that she was removed after raising concerns about the patient safety was rejected by central London employment tribunal in a judgment published last week.
The judge instead ruled that while other senior staff had raised patient safety concerns over cost-cutting, there was no evidence that Ms Yousefi had done so.
In their judgment the tribunal panel said: “In oral evidence the claimant further accepted that, as CQC-registered manager, if patient safety concerns were not being dealt with she should have raised it with CQC. She did not do so at any point during her employment.”
Staffing concerns were raised by The Harley Street Centre chief nursing officer Claire Champion and others. However, the tribunal heard evidence that doing so could be frowned upon by senior management at HCA International.
The tribunal was shown an email from then vice president of financial operations at THSC and the Portland Enda O’Meara saying “Frankly – we are starting to piss some very senior people off in appearing that we can’t [make savings]. We can’t always cite patient safety. Because the response will always be other facilities are doing it”. 
Another email from Mr O’Meara said: “Please don’t cite ’patient safety’ unless you truly believe it to be the case. This term is particularly sensitive and nothing winds them up more”.
Read full story (paywalled)
Source: HSJ, 28 March 2022
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£10m long Covid fund completely unspent after six months

Scottish Liberal Democrat leader and health spokesperson Alex Cole-Hamilton MSP today said the SNP/Green Government has “yet again let down long Covid sufferers” as it is revealed that not a single penny of the £10 million announced by ministers last September has been spent.
On 9 September 2021, the Scottish Government announced the £10 million Long Covid Support Fund. 
Now a parliamentary question from Alex Cole-Hamilton and a freedom of information request have confirmed that the money remains entirely unspent. 
Alex Cole-Hamilton commented: “The latest official statistics showed a record are a record 119,000 long Covid sufferers in Scotland. The SNP/Green Government has let down every single one of them by failing to spend any of the £10 million it announced last September.

“Time and again I have pressed Nicola Sturgeon for answers on the absence of long Covid clinics, pressed for automatic referrals and urged the rollout of in-home support for sufferers. Now we’ve learned that none of the money announced more than six months ago has been spent.
“Long Covid sufferers need new hope. Scottish Liberal Democrats are determined to see the rollout of proper care. 
Read full story
Source: Scottish Liberal Democrats, 27 March 2022
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Government must allow at home early medical abortions, MPs warn

The government must stop treating women “like children” and permanently allow at home early medical abortions, MPs and health professionals have said.
Abortion rules changed after Covid hit the UK in March 2020, with the government allowing abortion pills to be sent via post to be taken at home after a phone consultation.
The new system - referred to as “telemedicine” - was due to run out on 25 March but the government declared a six-month extension for at home early medical abortions earlier in the month.
MPs are now set to vote on whether to make telemedicine abortion services permanent on Wednesday.
Clare Murphy, chief executive of the British Pregnancy Advisory Service (BPAS), told The Independent: “We welcome the vote. MPs have the opportunity to prevent the recriminalisation of women who use
Stella Creasy, a Labour MP and campaigner for abortion rights, is one of many MPs calling for telemedicine abortion services to be made permanent.
“Despite the best attempts to scare, telemedicine has been shown to be safe, secure and preferable for many patients for a variety of reasons - it’s time to trust women and ensure they can make the right choices for themselves when it comes to their own medical care”, she said.
Read full story
Source: The Independent, 29 March 2022
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Doctor's bid to be removed from register rejected

A doctor's bid to be voluntarily removed from the medical register on health grounds has been rejected.
It means Dr Heather Steen, who is accused of failings following the death of Claire Roberts in 1996, will still face a fitness to practice tribunal.
The tribunal would have been halted if she had been removed from the register, as she would no longer have been a doctor.
Claire Roberts died at the Royal Belfast Hospital for Sick Children, where Dr Steen worked, in October 1996.
The nine-year-old's death was examined as part of the hyponatraemia inquiry.
Her father Alan said his family welcomed the decision to refuse the paediatrician's application.
He said the tribunal hearing was "in the public interest" and should proceed "to maintain public confidence in the medical profession, the regulatory process and to ensure that professional standards are upheld".
Read full story
Source: BBC News, 28 March 2022
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AI software predicting daily A&E admissions rolled out in 100 NHS hospitals

New artificial intelligence software being rolled-out in NHS hospitals will be able to predict daily A&E admissions weeks in advance.
The software, which launched in 100 hospitals across England on Monday, analyses data, including Covid infections rates, 111 calls and traffic to predict the number of patients that will seek emergency care.
It also takes into consideration public holidays, such as New Year’s Eve, when A&E is more likely to be busy.
The AI software is being rolled after trials showed an “impressive” ability to forecast admissions up to three weeks in advance.
The NHS believes it will help tackle the record waiting list and allow hospitals to more easily manage their patient and bed capacity, prepare for busier days and staff up when needed.
Nine trusts were given the software to use during the pandemic which notified them of expected spikes in cases, staff levels and numbers of beds and equipment necessary.
However, hospitals receiving the new equipment have also been warned uncertainties within the data mean the system should be used as a “starting point to consider an operational response, not as a definite signal for action.”
Read full story
Source: The Independent, 28 March 2022
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Matching drugs to DNA is 'new era of medicine'

We have the technology to start a new era in medicine by precisely matching drugs to people's genetic code, a major report says.
Some drugs are completely ineffective or become deadly because of subtle differences in how our bodies function. The British Pharmacological Society and the Royal College of Physicians say a genetic test can predict how well drugs work in your body.
The tests could be available on the NHS next year.
It would have helped Jane Burns, from Liverpool, who lost two-thirds of her skin when she reacted badly to a new epilepsy drug.
She was put on to carbamazepine when she was 19. Two weeks later, she developed a rash and her parents took her to A&E when she had a raging fever and began hallucinating.
The skin damage started the next morning. Jane told the BBC: "I remember waking up and I was just covered in blisters, it was like something out of a horror film, it was like I'd been on fire."
Jane's experience may sound rare, but Prof Mark Caulfield, the president-elect of the British Pharmacological Society, said "99.5% of us have at least one change in our genome that, if we come across the wrong medicine, it will either not work or it will actually cause harm."
"We need to move away from 'one drug and one dose fits all' to a more personalised approach, where patients are given the right drug at the right dose to improve the effectiveness and safety of medicines," said Prof Sir Munir Pirmohamed, from the University of Liverpool.
Read full story
Source: BBC News, 29 March 2022
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Discharge policy reviewed as NHSE warns ‘capacity may decrease’

Two national reviews are taking place into hospital discharge policy, it has emerged, amid major changes to funding and legislation.
One review, led by the Department of Health and Social Care, is developing discharge policy for once the Health and Care Bill comes into force; and a second is reviewing the “clinical criteria to reside”.
Delayed discharge has been a major problem in the acute and emergency care system this winter, with the number of long-staying patients significantly up on previous years. It has been blamed for long patient waits for ambulances, to get into emergency departments, and to be admitted; and for interrupting elective care recovery. 
An NHSE letter confirmed that the government’s national “discharge taskforce” was developing “best practice in improving discharge processes and addressing barriers to timely discharge”, in preparation for the new system. 
It went on: “This includes improving hospital processes to support discharge; minimising delays in the transfer of care from an acute hospital on to follow-up care services; minimising long lengths of stay in rehabilitation at home or in bedded care and ensuring social care services are available at the right time for people with ongoing care requirements. Further resources and support will be shared as learning from these systems becomes clear.”
Read full story (paywalled)
Source: HSJ, 28 March 2022
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Scotland’s A&Es facing ‘patient safety crisis’ as waiting times hit new high

The Royal College of Emergency Medicine (RCEM) estimated 36 Scots died as a direct result of avoidable delays in the week to 30 March.
It comes as the number of people in hospital with Covid reached another record high, the worst cancer waiting times were reported since records began in 2006, and the Royal College of Nursing issued a warning that patient care is under “serious threat” from record-high staffing shortages.
The RCEM said it would “welcome” a decision to extend the legal requirement to wear face coverings in Scotland to protect the NHS.
“Anything that can continue to reduce the spread and therefore try and relieve as much pressure as possible in the healthcare system would be welcomed,” said RCEM Vice President in Scotland Dr John Thomson.
Dr Thomson, an emergency medicine consultant at Aberdeen Royal Infirmary, said the government must understand the “unconscionable” harm coming to patients.
“We have clear evidence that prolonged weeks in an emergency department lead directly to patient deaths,” he said.
“Good evidence that, irrespective of what the medical problem is that they present with, that long wait alone is associated with death.
“We can measure that quite clearly. One in 72 patients who wait in an emergency department beyond eight hours will die as a direct result.
“In the last week alone we would estimate there were 36 avoidable deaths due to waits beyond eight hours. That's unconscionable.”
A&E’s in Scotland are facing the “biggest patient safety crisis for a generation”, he said.
Read full story
Source: The Scotsman, 29 March 2022
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Ex-trust executive to probe NHS manager’s death

An ambulance trust has appointed a former senior trust executive to lead an independent investigation into the circumstances surrounding the unexplained death of a staff member, HSJ  has learned.
East of England Ambulance Service Trust also shared the terms of reference for the investigation withHSJ, which follows the trust being forced to launch a similar probe in 2020 after three young staff members died in 11 days in December 2019.
The latest investigation is into the death of Nick Lee, 46, from Ovington in west Norfolk, who died on 3 December 2021. Mr Lee was an operations manager for the trust in the west Norfolk area and had worked for the trust for nearly 20 years. The cause of death is yet to be officially established.
Margaret Pratt has been appointed by the trust to lead the investigation. 
A trust statement issued to HSJ said: “The purpose of the investigation is to look at the events leading up to the death, review the circumstances of the death and consider whether there is anything that the trust can learn to contribute to improving the support provided to staff.”
The investigation follows a prolonged period of years in which the trust has been dogged by high-profile and deeply ingrained cultural and bullying problems.
Read full story (paywalled)
Source: HSJ, 29 March 2022
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NHSE pushes ‘private patient opportunities’ in leaked guidance

Official draft guidance has encouraged trusts to grow their ‘private patient opportunities’, despite facing huge backlogs of NHS work.
The NHS England document, leaked to HSJ, includes instructions to local leaders for the new financial year starting in April.
It said: “Trusts should continue to actively explore and develop opportunities to grow their external (non-NHS) income… Private patient services continue to be a significant source of material opportunity in the NHS.”
It adds that NHS England and NHS Improvement will work with trusts to “identify and scale-up NHS export opportunities and support development of private patient opportunities to generate revenue and provide benefits for NHS staff and local patients and services”.
It comes as the NHS faces huge backlogs of elective patients waiting for treatment. NHSE’s own plan to recover from Covid said the waiting list could rise to 14 million, up from the current 6 million.
Sally Gainsbury, senior policy analyst at the Nuffield Trust, said the guidance was “capitalising” on the surge in people paying for private treatment during the pandemic. 
Ms Gainsbury said: “It is a concern that with over 6 million patients on the NHS waiting list, NHS England is actively encouraging NHS trusts to expand their private patient activity."
“Scarce NHS capacity should be focused and prioritised on treating NHS patients and bringing these unacceptable waits down, not capitalising on the growth in the private treatment market on the back of this unprecedented backlog of care.”
Read full story
Source: HSJ, 29 March 2022
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Lifestyle changes saving thousands from diabetes

Thousands of Britons have avoided being diagnosed with type 2 diabetes thanks to an NHS programme aimed at early intervention.
The Diabetes Prevention Programme identifies people at risk of developing the condition and gives them a nine-month plan to change their lifestyles.
Researchers at the University of Manchester found that the programme resulted in 18,000 fewer people in England being diagnosed with type 2 diabetes between 2018 and 2019 — a 7% reduction.
It focuses on eating and exercise habits and enables participants to join peer support groups and receive instruction from health coaches.
The programme also offers a digital service that helps participants monitor their progress using wearable technology and mobile phone apps.
Emma McManus, a research fellow at the university, said that diabetes was a “growing problem” for the country. The NHS spends about 10 per cent of its annual budget on treating it.
“However, if you change your lifestyle, the risk of developing type 2 diabetes reduces,” she said. “Our research has shown that the programme has been successful in reducing the number of new cases of diabetes.”
Emma Elvin, a senior clinical adviser at Diabetes UK, said: “This research adds to the evidence that many type 2 diabetes cases can be delayed or prevented with the right support and further highlights how the NHS diabetes prevention programme can be a real turning point for people at risk of type 2 diabetes.”
Read full story (paywalled)
Source: The Times, 28 March 2022
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Public satisfaction with NHS drops to 25-year low

Public satisfaction with the NHS has dropped to its lowest level for 25 years after a sharp fall during the pandemic, a survey suggests.
The British Social Attitudes poll, seen as the gold standard measure of public opinion, found 36% of the 3,100 asked were satisfied in 2021.
That is a drop from 53% the year before - the largest fall in a single year.
Only once have satisfaction levels been lower since the poll started in 1983. That was in 1997, and shortly after that the Blair government started increasing the budget by record amounts.
The public said it was taking too long to get a GP appointment or hospital care, and there was not enough staff.
Satisfaction with GP care and hospital services were both at their lowest levels since the survey began.
Dan Wellings, senior fellow at the King's Fund, described them as "extraordinary".
He said the NHS initially saw a "halo" effect early on in the pandemic, with satisfaction rates being maintained as the NHS battled through the first wave. But he said it was clear that had now gone.
"People are often struggling to get the care they need. These issues have been exacerbated by the extraordinary events of the past two years, but have been many years in the making following a decade-long funding squeeze, and a workforce crisis that has been left unaddressed for far too long."
Read full story
Source: BBC News, 30 March 2022
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Children’s services rated ‘inadequate’ as trust remains ‘outstanding’

The children’s inpatient unit at an ‘outstanding’ mental health trust has been downgraded to ‘inadequate’ by the Care Quality Commission (CQC), amid a surge in demand for its services.
The CQC previously rated child and adolescent mental health wards at Hertfordshire Partnership University Foundation Trust as “outstanding” in May 2019.
But after an inspection in November and December 2021, these services were downgraded to “inadequate” overall and for the key categories of safety and leadership.
Although inspecting a core service, the CQC said its visit was “not wide-ranging enough” to update overall trust ratings, so HPFT remains “outstanding” overall.
Teenagers aged from 13 to 18 and admitted to Forest House, a 16-bed unit in Radlett providing HPFT’s only inpatient service for children and adolescents, told CQC inspectors they felt “unsafe”, dissatisfied with their care, and had experienced bullying by fellow patients.
Leadership in the service had “significantly deteriorated” since previous inspections, CQC chiefs wrote in a report published today, and this was having a “knock-on effect in all areas of care being provided”.
Staff morale was low and access to clinical psychologists limited, with a reduced ability to provide therapeutic interventions, inspectors added.
Read full story (paywalled)
Source: HSJ, 30 March 2022
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Baby deaths inquiry: Shrewsbury NHS trust condemned for ‘repeated failures’

A damning report into hundreds of baby deaths has condemned the trust at the centre of the biggest maternity scandal in the history of the NHS for blaming mothers while repeatedly ignoring its own catastrophic blunders for decades.
The independent inquiry into maternity practices at Shrewsbury and Telford hospital NHS trust uncovered hundreds of cases in which health officials failed to undertake serious incident investigations, while deaths were dismissed or not investigated appropriately. Instead, grieving families were denied access to reviews of their care and mothers were blamed when their babies died or suffered horrific injuries.
A combination of an obsession with natural births over caesarean sections coupled with a shocking lack of staff, training and oversight of maternity wards resulted in a toxic culture in which mothers and babies died needlessly for 20 years while “repeated failures” were ignored again and again.
Tragically, it meant some babies were stillborn, dying shortly after birth or being left severely brain damaged, while others suffered horrendous skull fractures or avoidable broken bones. Some babies developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries.
The report, led by the maternity expert Donna Ockenden, examined cases involving 1,486 families between 2000 and 2019, and reviewed 1,592 clinical incidents.
“Throughout our final report we have highlighted how failures in care were repeated from one incident to the next,” she said. “For example, ineffective monitoring of foetal growth and a culture of reluctance to perform caesarean sections resulted in many babies dying during birth or shortly after their birth.
“In many cases, mother and babies were left with lifelong conditions as a result of their care and treatment. The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the trust and a culture of not listening to the families involved.
“There was a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths. What is astounding is that for more than two decades these issues have not been challenged internally and the trust was not held to account by external bodies.
“This highlights that systemic change is needed locally, and nationally, to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding. Going forward, there can be no excuses.”
Read full story
Source: The Guardian, 30 March 2022
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Two out of five NHS staff would not recommend their organisation as a place to work

NHS staff are significantly less likely to recommend their organisations as places to work or believe they employ enough people to deliver effective care, the service’s annual staff survey has revealed.
The 2021 survey results, published today, showed regression across a broad range of questions, including in areas such as motivation, morale, workload pressures and staff health.
One of the biggest drop-offs in survey scores related to the question asking whether there were enough staff in their organisation for respondents to do their job properly.
Only 27.2% of those surveyed said staffing was adequate, a fall of 11% points from the previous year (38.4%).
Only 59.4%nof staff said they would recommend their organisation as a place to work. This represented a 7% point decline from the previous year (66.8%). The rating had steadily improved since 2017 when it was at 59.7%.
While a decline was seen across all sectors, the steepest drop was found among ambulance trusts.
Ambulance trusts performing worse compared to other sectors appeared to be a recurring theme across the survey. 
Read full story (paywalled)
Source: 30 March 2022
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