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

Women and babies remain at risk of unsafe NHS care, experts warn

A shortage of more than 2,000 midwives means women and babies will remain at risk of unsafe care in the NHS despite an inquiry into the biggest maternity scandal in its history, health leaders have warned.
A landmark review of Shrewsbury and Telford hospital NHS trust, led by the maternity expert Donna Ockenden, will publish its final findings on Wednesday with significant implications for maternity care across the UK.
The inquiry, which has examined more than 1,800 cases over two decades, is expected to conclude that hundreds of babies died or were seriously disabled because of mistakes at the NHS trust, and call for changes.
But NHS and midwifery officials said they fear a growing shortage of NHS maternity staff means trusts may be unable to meet new standards set out in the report.
“I am deeply worried when senior staff are saying they cannot meet the recommendations in the Ockenden review which are vital to ensuring women and babies get the safest possible maternity care,” said Gill Walton, chief executive of the Royal College of Midwives (RCM).
The number of midwives has fallen to 26,901, according to NHS England figures published last month, from 27,272 a year ago. The RCM says the fall in numbers adds to an existing shortage of more than 2,000 staff.
Experts said the shortage was caused by the NHS struggling to attract new midwives while losing existing staff, who felt overworked and fed up at being spread too thinly across maternity wards.
Read full story
Source: The Guardian, 29 March 2022
Patient Safety Learning

All patients with type 1 diabetes in England should be offered continuous glucose monitoring, says NICE

Everyone with type 1 diabetes in England should be offered some form of continuous glucose monitoring (CGM) technology to support their care, the National Institute for Health and Care Excellence (NICE) has recommended.
Updated draft guidelines published on 31 March recommend that all adults with type 1 diabetes should be offered a choice of either real time or intermittent (flash) CGM through a sensor attached to the skin as part of their ongoing NHS care.
NICE also recommends that all young people aged 4 years and over with type 1 diabetes should be offered real time CGM and that some people with type 2 diabetes who use insulin intensive therapy (4 or more injections a day) should have access to Flash.
Read full story (paywalled)
Source: BMJ, 31 March 2022
Read NICE guidelines here.
Patient Safety Learning

The NHS’s multimillion-pound blunders laid bare in new report

The reasons behind the most catastrophic blunders in emergency departments have been laid bare in a NHS Resolution report highlighting some of the biggest pay outs for NHS A&E errors.
NHS Resolution conducted a deep dive into compensation claims concerning emergency departments in England, including 16 cases which saw more than £1 million handed out after life-changing or deadly errors.
The average “high-value claim” was £2,069,029, with many of them related to spinal cord injuries which, left undetected, can have a life-long impact on patients.
The report detailed the case of a woman who suffered permanent neurological damage and now has bladder, bowel and sexual dysfunction symptoms, as well as loss of mobility, after a spinal condition was misdiagnosed as sciatica.
The report also looked at 86 deaths which resulted in average pay outs of more than £45,000.
After reviewing 220 claims between 2014 and 2018, the authors highlighted a number of “common themes”, including:
diagnostic errors, including missing signs a patient was deteriorating a failure to recognise the significance of repeat attendance at A&E delays in care problems with communication, including problems with different hospital departments talking to each other. Read full story
Source: In Your Area News, 29 March 2022
Patient Safety Learning

‘Ideologically driven’ NHSE maternity model causing national tension

A policy ‘at the heart’ of NHS England’s efforts to improve maternity care is under question after being sharply criticised by an independent inquiry, and is the subject of major tensions within NHSE and midwifery, HSJ understands.
The Ockenden report into major care failings at Shrewsbury and Telford Hospital Trust included 15 “immediate actions” for all maternity services in England, which government has accepted and said it would begin implementation.
However, one of these relates to the “continuity of carer” model, which NHS England has championed since 2017, when it was described as “at the heart of” its national plans for improving maternity care and outcomes.
The model intends to give women “dedicated support” from the same midwifery team throughout their pregnancy, with claimed benefits including improved outcomes, with a particular focus on some minority groups.
However, Ms Ockenden indicated its implementation in recent years had stretched staffing, and therefore harmed quality and safety overall, and also appeared to question whether the model was evidenced.
Some midwifery leaders are advocates for the model, but others have described how it can result in awful working patterns, with concerns it is causing some staff to leave the profession.
Royal College of Midwives director for professional midwifery Mary Ross-Davie told HSJ: “With the right resources and the right number of midwives, CoC can have a positive impact on maternity care – but in too many trusts and boards this is simply not the situation. We are really pleased, therefore, to see that the review team has echoed the RCM’s recommendations around the suspension of continuity of carer where too few staff puts safe deployment at risk.”
She said the model was “something to which many maternity services aspire, particularly for women who need enhanced monitoring throughout their pregnancy to deliver better outcomes for them and their baby”.
Helen Hughes, chief executive of Patient Safety Learning charity, said that although it had heard positive feedback that the model can improve outcomes, there must also be a “robust assessment of the safety impact of implementing such changes and the sources and staffing in place to deliver this”.
“Otherwise the core intentions and benefits will be lost,” Ms Hughes said.
Read full story (paywalled)
Source: HSJ, 31 March 2022
Further reading
Midwifery Continuity of Carer: What does good look like? Midwifery Continuity of Carer: Frontline insights The benefits of Continuity of Carer: a midwife’s personal reflection
Patient Safety Learning

Shrewsbury maternity scandal: Sajid Javid’s statement to the Commons

Sajid Javid has issued an apology for the maternity service failings reported at Shrewsbury and Telford Hospital NHS Trust.
The health secretary spoke in the Commons on Wednesday after an independent inquiry into the UK’s biggest maternity scandal found that 201 babies and nine mothers could have - or would have - survived if the NHS trust had provided better care.
Speaking in the Commons, the health secretary said Donna Ockenden - a maternity expert who led the report - told him about “basic oversights” at “every level of patient care” at the trust.
He said the report “has given a voice at last to those families who were ignored and so grievously wronged”.
Javid said the report painted a tragic and harrowing picture of repeated failures in care over two decades which led to unimaginable trauma for so many people.
Rather than moments of joy and happiness for these families their experience of maternity care was one of tragedy and distress and the effects of these failures were felt across families, communities and generations.
The cases in this report are stark and deeply upsetting.
Mr Javid offered reassurances that the individuals who are responsible for the “serious and repeated failures” will be held to account.
Read full story and Sajid Javid's statement
Source: The Independent, 30 March 2022
Patient Safety Learning

Every ICS expected to break even in ‘harsh’ new regime

Every health and care system — including those carrying huge deficits going into the pandemic — will be told to deliver financial balance in 2022-23, according to draft guidance seen by HSJ.
For the last two years, local NHS organisations have effectively seen all their spending covered by the government under temporary Covid measures.
But a more typical financial regime is now due to begin in April, with systems expected to deliver services from within funding envelopes set at the start of the year, and to be held to account on this.
Some integrated care systems went into the pandemic with deficits of more than £100m, and will likely struggle to reach a balanced position.
But draft guidance circulated to local leaders in recent months by NHS England says: “NHS England and NHS Improvement intend to use additional powers in the legislation to set a financial objective for each integrated care board [the local commissioning body] and its partner trusts to deliver a financially balanced system, namely a duty on break even.”
However, it is unclear what the consequences will be for an ICS that fails to meet what is described as a “new joint legal duty”.
Read full story (paywalled)
Source: HSJ, 31 March 2022
Patient Safety Learning

Less than half of staff at maternity scandal trust feel able to speak out

Less than half of staff at scandal-hit Shrewsbury and Telford Hospital NHS Trust feel they can speak up about concerns, according to a staff survey, as a damning report warned serious problems persist in maternity care.
Shrewsbury and Telford Hospital Trust is one of the worst-performing trusts on the latest national survey of staff for the NHS.
It comes after Donna Ockenden, who chaired a review into maternity failures at the trust, said her “biggest concern” was that staff had been told not to share concerns with her inquiry.
Ms Ockenden told The Independent her biggest concern was “that ordinary staff on the ground are telling me they were advised not to cooperate with the Ockenden review”.
The NHS staff survey, published on Wednesday, showed just 49% of staff at the trust reported they would feel safe enough speaking up about concerns in 2021 – down from 53% in 2020.
Meanwhile, just 34% of staff said they feel their concerns would be addressed if there were to speak up.
The trust is one of the worst three hospital trusts in the country when it comes to rising care concerns, the figures show. Only United Lincolnshire Hospitals NHS Trust and Barking, Havering and Redbridge University Hospitals NHS Trust performed worse.
Read full story
Source: The Independent, 31 March 2022
 
Patient Safety Learning

GP practices training receptionists to do blood tests

A number of London GP practices are training their receptionists to do blood tests, Pulse has learned.
Professor Sir Sam Everington, a GP and chair of Tower Hamlets CCG, told Pulse that ‘lots of practices’ in the area have taken the step, including his own.
Training a receptionist to carry out blood tests – which can be done in just six weeks – provides much-needed support to pressured practices, he said.
Dr Everington told Pulse: ‘A lot of our receptionists have signed up to be phlebotomists and they love it because actually, phlebotomy is not just about taking blood. 
"You get to know all the patients with long-term conditions and so our phlebotomists know all these patients."
He added that reception teams are a ‘fertile recruitment ground’ for a phlebotomist. They can ‘manage even the most terrified patients’ and have ‘amazing’ clinical skills.
Dr Everington suggested that training receptionists as phlebotomists can help build trust with patients who are suspicious about having to describe their symptoms for triage by reception staff.
But he said that the extra role just ‘acknowledges’ that all members of practice staff are ‘part of the clinical team’.
He told Pulse: "In our practice, we all train together. We have meetings together, the whole team, and it’s acknowledging in this modern world that actually every member of your staff is a clinician – part of the clinical team – because there are always things they will do or can do that will have an impact clinically."
"There isn’t a hidden supply of GPs out there in the next few years. It takes 10 years to train GPs so actually help is going to come from a wider team base."
Read full story
Source: Pulse, 31 March 2022
Patient Safety Learning

Artificial pancreas to revolutionise diabetes care in England

Nearly 900 patients with type 1 diabetes in England are testing a potentially life-changing artificial pancreas.
It can eliminate the need for finger prick tests and prevent life-threatening hypoglycaemic attacks, where blood sugar levels fall too low.
The technology uses a sensor under the skin. It continually monitors the levels, and a pump automatically adjusts the amount of insulin required.
Six-year-old Charlotte, from Lancashire, is one of more than 200 children using the hybrid closed loop system.
Her mother, Ange Abbott, told us it has made a massive impact on the whole family.
"Prior to having the loop, everything was manual," she said. "At night we'd have to set the alarm every two hours to do finger pricks and corrections of insulin in order to deal with the ups and downs of Charlotte's blood sugars."
Prof Partha Kar, NHS national speciality adviser for diabetes, said: "Having machines monitor and deliver medication for diabetes patients sounds quite sci-fi like, but technology and machines are part and parcel of how we live our lives every day.
"It is not very far away from the holy grail of a fully automated system, where people with type 1 diabetes can get on with their lives without worrying about glucose levels or medication."
Read full story
Source: BBC News, 1 April 2022
Further reading on the hub
How safe are closed loop artificial pancreas systems?
Patient Safety Learning

Stroke and heart patients routinely waiting over an hour for ambulance

Stroke and heart attack victims are now routinely waiting more than an hour for an ambulance, after a further fall in performance in recent weeks, and with hospital handover delays hitting a new high point, HSJ reveals.
Figures for ambulance performance this week, seen by HSJ, showed average response times for category two calls at more than 70 minutes for successive days. 
3,000 patients may have suffered “severe harm” from delays in February, ambulance chief executives say.
Several well-placed sources in the sector said response times had deteriorated further this month, and that more than half of ambulance trusts were this week seeing average category two responses of longer than an hour. 
Some cited an average category two response last week of around 70 minutes, with the services under huge pressure from a combination of demand, long handover delays, and covid-related sickness.
Category two calls include patients with suspected heart attacks and strokes, and the national target for reaching them is 18 minutes.
The figures seen by HSJ for this week showed average response times for category one calls — the most serious, including cardiac arrests and other immediately life threatening emergencies — of more than 10 minutes on Wednesday, against a target of just 7 minutes. Monthly average performance for category one has never reached 10 minutes.
Read full story (paywalled)
Source: HSJ, 1 April 2022
Patient Safety Learning

Sajid Javid: Doctors too often ‘ignore’ women’s pain

Doctors too often "ignore" women's pain, Sajid Javid said as he called for change in the wake of the Shrewsbury maternity scandal.
Writing for The Telegraph, the Health Secretary said the wider NHS needed to do much more to listen to women, adding that too many are left in pain and ignored by clinicians.
On Wednesday, the Ockenden report revealed that the deaths of 201 babies and nine mothers at Shrewsbury and Telford NHS Trust could have been avoided, citing a failure to listen to women.
Mr Javid wrote: "This week we have seen the tragic reality of what can happen when women's voices are not listened to when it comes to their care. 
"Donna Ockenden's report into maternity failings at Shrewsbury and Telford Hospitals raises specific concerns for maternity services, but more widely we must address issues across the whole of the health and care system when it comes to listening to women's concerns and recognising their pain."
In the joint piece with Maria Caulfield, the minister for women’s health, Mr Javid welcomed a "shift in the way we talk about women's health", with more open discussions about areas once seen as taboo.
But the pair said more needed to be done – specifically to improve the treatment of endometriosis, an extremely painful gynaecological condition.
"We must ensure all women feel confident in going to their GP when they experience symptoms of endometriosis and, when they do, that they are listened to," they said. Too many were "spending too long in pain waiting for a diagnosis, often feeling ignored by clinicians", they warned.
Later this year the Government will publish a women's health strategy, which will examine issues including fertility, menopause, and prevention and treatment of diseases.
Read full story (paywalled)
Source: The Telegraph, 31 March 2022
Patient Safety Learning

Guilty verdict for nurse RaDonda Vaught’s dosing mistake could cost lives

Patient safety and nursing groups around the country are lamenting the guilty verdict in the trial of a former nurse in Tennessee, USA.
The moment nurse RaDonda Vaught realised she had given a patient the wrong medication, she rushed to the doctors working to revive 75-year-old Charlene Murphey and told them what she had done. Within hours, she made a full report of her mistake to the Vanderbilt University Medical Center.
Murphey died the next day, on 27 December 2017. On Friday, a jury found Vaught guilty of criminally negligent homicide and gross neglect.
That verdict — and the fact that Vaught was charged at all — worries patient safety and nursing groups that have worked for years to move hospital culture away from cover-ups, blame and punishment, and toward the honest reporting of mistakes.
The move to a “Just Culture" seeks to improve safety by analyzing human errors and making systemic changes to prevent their recurrence. And that can't happen if providers think they could go to prison, they say.
“The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent,” the American Nurses Association said. “Health care delivery is highly complex. It is inevitable that mistakes will happen. ... It is completely unrealistic to think otherwise.”
Read full story
Source: The Independent, 31 March 2022
Patient Safety Learning

Experts warn of racial disparities in the diagnosis and treatment of Long Covid

It has long been clear that Black Americans have experienced high rates of coronavirus infection, hospitalisation and death throughout the pandemic.
But those factors are now leading experts to sound the alarm about what will may come next: a prevalence of Long Covid in the Black community and a lack of access to treatment.
Long Covid — with chronic symptoms like fatigue, cognitive problems and others that linger for months after an acute coronavirus infection has cleared up — has perplexed researchers, and many are working hard to find a treatment for people experiencing it. But health experts warn that crucial data is missing: Black Americans have not been sufficiently included in Long-Covid trials, treatment programmes and registries, according to the authors of a new report released on Tuesday.
“We expect there are going to be greater barriers to access the resources and services available for Long Covid,” said one of the authors, Dr. Marcella Nunez-Smith, who is the director of Yale University’s health equity office and a former chair of President Biden’s health equity task force.
“The pandemic isn’t over, it isn’t over for anyone,” Dr. Nunez-Smith said. “But the reality is, it’s certainly not over in Black America.”
In the first three months of the pandemic, the average weekly case rate per 100,000 Black Americans was 36.2, compared with 12.5 for white Americans, the authors write. The Black hospitalisation rate was 12.6 per 100,000 people, compared with 4 per 100,000 for white people, and the death rate was also higher: 3.6 per 100,000 compared with 1.8 per 100,000.
“The severity of Covid-19 among Black Americans was the predictable result of structural and societal realities, not differences in genetic predisposition.” 
"Many Black Americans who contracted the coronavirus experienced serious illness because of pre-existing conditions like obesity, hypertension and chronic kidney disease, which themselves were often the result of “differential access to high-quality care and health promoting resources,” the report says.
Read full story (paywalled)
Source: New York Times, 29 March 2022
Patient Safety Learning

RCM response to Ockenden review into maternity services at Shrewsbury and Telford

Poor culture and leadership must be addressed if we are to make our maternity services the safest place to give birth. This statement from the Royal College of Midwives (RCM) came as the final report of the largest ever review of NHS maternity services was published. The RCM acknowledged that the pain and suffering of the families had been worsened by having to fight for answers and vowed to work with NHS bodies and other professional organisations to ensure lessons are learned from these tragic failings.
Today the RCM has pledged to continue its work to be part of the solution to safety improvements and support its members to do the same not only at Shrewsbury and Telford NHS Trust, but throughout all maternity services across the UK.
Commenting, the Royal College of Midwives’ (RCM) Chief Executive, Gill Walton said:
“It is heartbreaking that this report only came about because of the determination of the families. We owe them a debt that I fear can never be repaid. What we can do - all of us who are involved in maternity services – is work together to ensure we listen, and we learn from this and ensure that women and families have trust in their care."
“This review must be a turning point for all those working in maternity services. The actions recommended are measured and sensible and reflect much of what the RCM has been calling for. We hope that those in a position to enact them – NHS England and the Department for Health & Social Care – will do so in partnership with organisations like ours and with haste.”
"A poor working culture, where staff were afraid to raise concerns, has been cited by the report as a key factor in many of the cases. Earlier this year the RCM called for a seismic NHS cultural shift to improve maternity safety as it published guidance for its members to raise concerns about maternity care which outlined steps staff can take and what to do if they feel they are not being listened to or their concerns are ignored."
Read full story
Source: Royal College of Midwives, 30 March 2022
Patient Safety Learning

Bullying among top surgeons sparks two national investigations

‘Horrifying and upsetting’ reports of bullying in prestigious heart units are being probed by national officials and professional leaders, HSJ can reveal.
Health Education England told HSJ it was “undertaking a national thematic review of training in cardiothoracic surgery”, while the Society for Cardiothoracic Surgery separately revealed it was investigating concerns about “bullying, harassment and undermining behaviour” in the specialty following high-profile recent cases in Newcastle and Wales.
Society president consultant surgeon Simon Kendall, who is based at James Cook University Hospital in Middlesbrough, told HSJ he has been made aware of wider problems beyond those identified in the North East and Wales.
Mr Kendall revealed allegations reported to the society have included people being shouted at in public, problems resulting from a “legacy culture of sarcasm and public humiliation”, and more personal disputes between individuals.
The consultant surgeon told HSJ: “The job is hard enough for all of us, without picking on each other and making it worse."
He added: “It’s the extended team that is affected by these behaviours and it will have an impact on patient safety and patient care.
Read full story (paywalled)
Source: HSJ, 1 April 2022
Patient Safety Learning

Patient care and safety put at risk in A&E at brand new £350m hospital

Patients visiting Wales' newest emergency department were likely to have been put at risk of harm due to the lack of processes and systems in place, inspectors found. Healthcare Inspectorate Wales (HIW) carried out an unannounced inspection of The Grange University Hospital in Cwmbran between 1 and 3 November last year and published its findings on 29 March.
On the day of their arrival inspectors said The Grange was at full capacity with no empty beds in A&E or in the hospital in general. Despite the best efforts of staff who were "working hard under pressure" the report stated the emergency department had several issues which could have compromised the privacy and dignity of patients. This included problems with the physical environment of the waiting room, which was described as a "major cause of anxiety" for visitors, as well as with the flow of patients through the hospital in general.
It found that patients were not triaged and medically managed in A&E in a timely fashion with many being placed on uncomfortable chairs or in corridors for hours on end. Between 1 April 2021 and 1 November 2021, the average waiting time in the department was six hours and seven minutes.
The report said some issues required immediate action including the fact patients in the waiting area were often left to "deteriorate without being overseen". There were also infection control failures which could have led to the cross-contamination of Covid-19. "We were not assured that all the processes and systems in place were sufficient to ensure that patients consistently received an acceptable standard of safe and effective care," the report stated.
Read full story
Source: Wales Online, 1 April 2022
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