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

Public health ‘at risk’ as leading Covid surveillance programme ends

Ministers will be left in the dark on Covid spikes just as case numbers reach unprecedented levels if a “world-beating” surveillance programme is scrapped, scientists have warned.
The React-1 study, which played a crucial role in detecting and tracking the spread of the Alpha variant in December 2020 ahead of the second lockdown, has been stopped as part of the government's plan to cut its Covid costs.
But in its last report, the study found 6.37% of the population was infected between 8 and 31 March – the highest figure since it began in May 2020. More worryingly, the scientists behind the research said the prevalence rate has also reached new highs for people aged 55 and over, at 8.31 per cent.
The Royal Statistical Society (RSS) said dismantling the project while cases were at record levels damaged preparedness and put public health at risk.
The spread of Covid within hospitals is also fuelling staff shortages, bed closures and delayed discharges in multiple regions of the country. This is coinciding with delays in ambulance handovers and response times, NHS sources say.
Information seen by The Independent revealed hundreds of beds are currently out of use at Newcastle upon Tyne Hospitals trust due to Covid outbreaks. A senior clinician said the “hospital is coming apart at the seams” and that, across the northeast, even “high” performing emergency departments were “crashing” and “stacking ambulances outside of hospital”.
Read full story
Source: The Independent, 6 April 2022
Patient Safety Learning

Covid had devastating toll on poor and low-income communities in US

The devastating impact of the Covid-19 pandemic on poor and low-income communities across America is laid bare in a new report that concludes that while the virus did not discriminate between rich and poor, society and government did.
As the US draws close to the terrible landmark of 1 million deaths from coronavirus, the glaringly disproportionate human toll that has been exacted is exposed by the Poor People’s Pandemic Report. Based on a data analysis of more than 3,000 counties across the US, it finds that people in poorer counties have died overall at almost twice the rate of those in richer counties.
Looking at the most deadly surges of the virus, the disparity in death rates grows even more pronounced. During the third pandemic wave in the US, over the winter of 2020 and 2021, death rates were four and a half times higher in the poorest counties than those with the highest median incomes.
During the recent Omicron wave, that divergence in death rates stood at almost three times.
Such a staggering gulf in outcomes cannot be explained by differences in vaccination rates, the authors find, with more than half of the population of the poorest counties having received two vaccine shots. A more relevant factor is likely to be that the poorest communities had twice the proportion of people who lack health insurance compared with the richer counties.
“The findings of this report reveal neglect and sometimes intentional decisions to not focus on the poor,” said Bishop William Barber, co-chair of the Poor People’s Campaign which jointly prepared the research. “The neglect of poor and low-wealth people in this country during a pandemic is immoral, shocking and unjust.”
Read full story
Source: The Guardian, 4 April 2022
Patient Safety Learning

NI Health: Quarter of cancer patients diagnosed in A&E

More than a quarter of cancers in Northern Ireland are being diagnosed in hospital emergency departments, according to Cancer Research UK.
The study, published in The Lancet Oncology, was supported by NI Cancer Registry at Queen's University Belfast.
It looked at 857,068 cases diagnosed between 2012 and 2017 in six countries including Australia, Denmark and the UK.
Clare Crossey, 35, from Lurgan was diagnosed with acute myeloid leukaemia in February 2018 after being admitted to hospital as an emergency.
The 35-year-old mother-of-two, who is a domiciliary care assistant, suddenly became very unwell with symptoms including tiredness and bruising.
She told BBC News NI she had contacted her local health centre, where a GP told her she was being overly anxious.
Ms Crossey said she had panicked, fearing she may have leukaemia after looking up her symptoms on the internet.
"I had a feeling that things weren't right," she said.
"The doctor did not agree with my suspicions as they passed me the number of the Samaritans helpline, a prescription for beta blockers and told me to wait a week for blood tests."
She said: "I went to Craigavon's A&E, they did blood tests and within hours a consultant broke the news to me that I might have leukaemia."
The medical team told her that had she waited any longer to come to the emergency department, she could have died, said Ms Crossley.
Barbara Roulston, from Cancer Research UK, said the study confirmed too many people were only being diagnosed with cancer once their health had deteriorated to a point when they needed to go to their emergency department.
"We need to reduce the number of cancer diagnoses that are happening in this way," she said.
"That means renewed focus on early diagnosis and prevention through things like better awareness of symptoms, better uptake of screening programs and the way to do that is to get funding for the cancer strategy which was published recently.
"If we don't, the risk is that we will start to see cancer survival going backwards."
Read full story
Source: BBC News, 7 April 222
Patient Safety Learning

Increase in hepatitis (liver inflammation) cases in children under investigation

The UK Health Security Agency (UKHSA) has recently detected higher than usual rates of liver inflammation (hepatitis) in children. Similar cases are being assessed in Scotland.
Hepatitis is a condition that affects the liver and may occur for a number of reasons, including several viral infections common in children. However, in the cases under investigation the common viruses that cause hepatitis have not been detected.
UKHSA is working swiftly with the NHS and public health colleagues across the UK to investigate the potential cause. In England, there are approximately 60 cases under investigation in children under 10.
Dr Meera Chand, Director of Clinical and Emerging Infections, said:
"Investigations for a wide range of potential causes are underway, including any possible links to infectious diseases. We are working with partners to raise awareness among healthcare professionals, so that any further children who may be affected can be identified early and the appropriate tests carried out. This will also help us to build a better picture of what may be causing the cases."
"We are also reminding parents to be aware of the symptoms of jaundice – including skin with a yellow tinge which is most easily seen in the whites of the eyes – and to contact a healthcare professional if they have concerns."
Read full story
Source: UK Health Security Agency, 6 April 2022
Patient Safety Learning

Patients continue to die and be harmed by the failure to learn from unsafe care

Press release: 7 April 2022
Today the charity Patient Safety Learning has published a new report, ‘Mind the implementation gap: The persistence of avoidable harm in the NHS'.
The report is an evidence-based summary of the failures over decades to translate learning into action and safety improvement.  It highlights that avoidable unsafe care kills and harms thousands of people each year in the UK and costs the NHS billions of pounds for additional treatment, support, and compensatory costs.  The report highlights how we fail to learn lessons from incidents of unsafe care and are not taking the action needed to prevent harm recurring.
The report focuses on six sources of patient safety insights and recommendations, ranging from inquiry reports into patient safety scandals, such as the recent Ockenden report into maternal and neonatal harm at Shrewsbury and Telford Hospital, to the findings of Coroner’s Prevention of Future Deaths reports. It calls on the Government, parliamentarians, and NHS leaders to take action to address the underlying causes of avoidable harm in healthcare and proposes recommendations in each policy area. Patient Safety Learning is calling for system-wide action in healthcare to transform our approach to learning and safety improvement.
Helen Hughes, Chief Executive of Patient Safety Learning, said:
“Today’s report highlights the all too frequent examples of where healthcare organisations fail to learn lessons from incidents of unsafe care and not taking the action needed to prevent future harm. Time and time again there is a lack of action and coordination in responding to recommendations, an absence of systems to share learning and a lack of commitment to evaluate and monitor the effectiveness of safety recommendations.”
“This is a shocking conclusion that is an affront to all those patients and families who have been assured that ‘lessons have been learned’ and ‘action will be taken to prevent future avoidable harm to others’. The healthcare system needs to understand and address the barriers for implementing recommendations, not just continually repeat them. Hope is not a strategy.”
This report has been published as part of the Safety for All Campaign, which calls for improvements in, and between, patient and healthcare worker safety to prevent safety incidents and deliver better outcomes for all. The campaign is supported by Patient Safety Learning and the Safer Healthcare and Biosafety Network.
Notes to editors:
Patient Safety Learning is a charity and independent voice for improving patient safety. We harness the knowledge, insights, enthusiasm and commitment of health and social care organisations, professionals and patients for system-wide change and the reduction of avoidable harm. Safer Healthcare and Biosafety Network an independent forum focused on improving healthcare worker and patient safety and has been in existence more than 20 years. It is made up of clinicians, professional associations, trades unions and employers, manufacturers and government agencies with the shared objective to improve occupational health and safety and patient safety in healthcare. COVID-19 pandemic has provided a stark reminder of the vital role healthcare professionals play in providing care to those in our society who need it most and this was recognized in the WHO Patient Safety Day in September 2020: only when healthcare workers are safe can patients be safe. In 2020, the Network launched a campaign called ‘Safety for All’ to improve practice in, and between, patient and healthcare worker safety to prevent safety incidents and deliver better outcomes for all.
Patient Safety Learning

‘Big personalities’ accused of bullying thought to be ‘bullet proof’, finds review

Doctors at an acute trust believe their clinical leaders have failed to tackle the ‘big personalities’ accused of being aggressive bullies, a review has found.
The probe at University Hospitals of North Midlands Trust was prompted by a survey carried out last year by the British Associations of Physicians of Indian Origin, after concerns were raised by its members.
The review was undertaken by Birmingham-based equalities charity Brap, and Roger Kline, a research fellow at Middlesex University Business School. It found the trust was not an outlier in statistical measures of bullying and harassment, but suggested the situation was still worse than leaders would wish.
They said: “The most common reason people cited for bullying/harassment they experienced was the personality, attitude, and disposition of their managers and colleagues… it is felt senior clinical leaders have, in the past, failed to tackle these ‘big personalities’.
“It is worth noting feedback from interviews suggesting many doctors feel they have endured poor behaviour – talking over people during meetings, criticising work in public, aggressive questioning – for years, and have simply become inured to it.
The reviewers found that as a consequence, certain people within the organisation were perceived to be “bullet proof”, and added: “We would suggest the trust needs a big, long-term plan to ‘rehumanise’ the organisation.
“The trust’s existing culture has permitted, and continues to permit infringements in behaviour… While this is not condoned by senior leaders in the trust, the lack of a plan to proactively tackle a legacy of overlooking poor behaviours has allowed them to persist.”
Read full story (paywalled)
Source: HSJ, 6 April 2022
Patient Safety Learning

Families asked to take in Covid-positive loved ones as NHS faces ‘perfect storm’

NHS chiefs have issued an extraordinary plea for families to help them discharge loved ones even if they are Covid-19 positive as the health service faces a “perfect storm” fuelled by heavy demand, severe staff shortages and soaring Covid cases.
Hospitals and ambulance services across England are under “enormous strain”, health leaders have warned, after NHS trusts covering millions of patients declared critical incidents or issued stark warnings to residents.
Dr Layla McCay, director of policy at the NHS Confederation, which represents the whole healthcare system, said the situation had become so serious that “all parts” of the health service were now becoming “weighed down”. This will have a “direct knock-on effect” on the ability of staff to tackle the care backlog, she added, as well as the current provision of urgent and emergency care.
On Wednesday evening, the crisis became so acute in Hampshire and the Isle of Wight that its chief medical officer urged relatives of patients well enough to be discharged to collect them immediately – even if they were still testing positive for coronavirus.
Dr Derek Sandeman, of the Hampshire and Isle of Wight Integrated Care System, revealed that almost every hospital in the two counties was full, and said the number of people with Covid-19 being cared for in hospitals across the area was 650 – more than 2.5 times higher than in early January. He added that 2,800 staff working for local NHS organisations were off sick, half of which absences were due to Covid-19.
“With staff sickness rates well above average, rising cases of Covid-19 and very high numbers of people needing treatment, we face a perfect storm – but there are some very specific ways in which people can help the frontline NHS and care teams,” said Sandeman.
Read full story
Source: The Guardian, 6 April 2022
Patient Safety Learning

My body caught on fire halfway through surgery – my insides were scorched and it took a year to recover

A patient was left traumatised when his body caught on fire halfway through surgery - leaving his insides scorched.
Mark, 52, went to hospital for a routine abscess removal - but woke up to the news that a freak accident in theatre had sparked an horrific blaze.
A diathermy machine, used to stop bleeding, caused a swab to catch fire - before flames burnt their way through his exposed flesh, Mark explained.
It took over a year for Mark - not his real name - to recover from his dreadful injuries - and the emotional scarring it caused.
Between 2008 and 2018, 37 cases were acknowledged by NHS trusts across Britain. But from 2009 to 2019, it has paid out nearly £14 million in compensation settlements and legal fees.
Fires such as these are often fuelled by leaking oxygen - and are caused by faulty machinery or sparking equipment.
Campaigners are concerned that UK hospitals are lagging behind other countries in recording surgical fires and introducing protocols to reduce both their frequency and severity.
Theatre scrub nurse Kathy Nabbie has spent the past five years trying to make colleagues more aware of the threat of surgical fires.
In 2017 - after hearing how a woman in Oregon, USA, had suffered severe burns when her face was set alight in surgery - she made a  simple safety checklist. 
Her Fire Risk Assessment tool allowed colleagues to check for the presence of elements that together might cause a fire to break out.
But senior staff failed to implement the initiative and - when a surgical fire actually took place three months later - Kathy learned that her laminated checklist had simply been put in a drawer.
 “I couldn’t believe it,” she said. “After that they did start using it, but why on earth should it have taken an actual fire to persuade them?”
Read full story
Source: The Sun, 7 April 2022
Further reading
What can we do to improve safety in the theatre? Reflections from theatre nurse Kathy Nabbie
How I raised awareness of fires in the operating theatre - Kathy Nabbie
 
Patient Safety Learning

Leading clinicians ‘horrified’ as NHSE slashes community funding without warning

Senior medics have reacted in horror to NHS England’s decision to ‘dramatically’ cut the funding of a key long-term plan commitment designed to improve older people’s community services and deliver more care at home.
British Geriatrics Society president Jennifer Burns told HSJ the professional body was “horrified” that the budget for the Ageing Well programme for 2022-23 would be £70m instead of the £204m originally promised in the long-term plan for the NHS.
“We are dismayed that the promised funding for the Ageing Well programme as set out in the NHS long-term plan is being so dramatically cut at this time,” Dr Burns said.
NHSE said: “The NHS is also investing an additional £200m in funding for virtual wards across the country by March 2023, delivering more care to patients safely in the comfort of their own home which will directly benefit older patients.”
But Dr Burns said that although virtual wards would go “some way to helping with hospital admissions”, they were “no substitute” for the original commitments.
“Older people suffered a devastating toll during the pandemic. Now is the time for systems to ensure the right services are in place and there is sustainable planning for the healthcare needs of an ageing population.”
Read full story (paywalled)
Source: HSJ, 7 April 2022
Patient Safety Learning

Patients asked to travel 200 miles in push to cut elective waits

Long waiting times at Devon’s acute hospitals have forced commissioners to offer patients treatment 200 miles away in London in a bid to reduce the elective backlog.
Devon Clinical Commissioning Group has secured extra capacity for patients requiring complex orthopaedic surgery under a new deal with the South West London Elective Orthopaedic Centre, located at Epsom General Hospital.
The NHS-run orthopaedic centre is around 170 miles from Exeter in east Devon and 210 miles from Plymouth in west Devon. Many patients have declined to go, despite the CCG offering to cover their travel costs.
It is the longest publicly reported distance patients are being sent for elective treatment in the NHS, with patients usually referred to neighbouring hospitals or integrated care systems if there is no capacity at their local provider.
Nearly 1,500 patients in the Devon ICS have waited longer than two years for treatment. The latest national data for England showed nearly 23,000 patients had been waiting longer than two years in January.
Read full story (paywalled)
Source: HSJ, 8 April 2022
Patient Safety Learning

Nurse suspended after forcing medication into patient’s mouth

A nurse has been suspended for three months by the Nursing and Midwifery Council (NMC) after forcing medication into a person with dementia's mouth.
An NMC Fitness to Practise (FtP) panel found Reni Kirilova had forced medicine into the patient’s mouth, held her mouth closed and shouted ‘take your tablets’ while working at the Chocolate Quarter Care Home in Bristol, run by the St Monica Trust.
Patient was reportedly distressed, waving her hands and shouting
The incident occurred on 30 May 2019, seven days after Ms Kirilova began working at the care home on 23 May. She was suspended on 7 June pending a police investigation and she resigned the same day.
One witness told the NMC hearing that they saw the nurse’s fingers go over the patient’s mouth for around 30 seconds while the patient was ‘flapping her hands’ and ‘trying to spit them out’.
They added the patient was distressed and was ‘waving her hands everywhere’ and shouting ‘no, no, no’.
Ms Kirilova denied the allegations and said that she had given the patient some water and then tilted the patient’s chin to help her swallow.
The panel found that the allegation she held her hand over the patient’s mouth was not true but that she had held it closed in some way, after three witnesses corroborated this.
The panel said they were not satisfied that she had considered how she would cope with stressful situations in the future and there was a risk it could happen again.
Read full story
Source: Nursing Standard, 7 April 2022
Patient Safety Learning

Leaders ‘pay lip service’ to public engagement, NHSE director says

Health leaders ‘pay lip service’ to engaging with patients and "do not look like or live the lives of the people they are making decisions about", an NHS England director has said.
Olivia Butterworth, NHSE’s deputy director of people and communities, told a public event hosted by the New Local think tank there is a “whole load of work” going on around reforming patient-reported outcome measures.
But she said that “none” of this work “starts with conversations with people about what do they value and what they want to measure.”
Asked whether NHS England’s top leadership is “paying lip service” to patient engagement, Ms Butterworth said: “I think often everybody pays lip service to it. We all use the right words. But whether it’s local government, whether it’s the NHS we know the words to use, but do we really live that in our actions in the way that we really like to change things?
“Or do we just blame the system for being too complex and it is the system that won’t let us, without recognising that we are the system, we make the system, we run the system, the system is people.”
Elsewhere in the session, Ms Butterworth said that “our decision makers do not look like or live the lives of the people they are making decisions about.”
She added that health services need to “join up around people” and that integrated care systems and partnerships offer the opportunity to “cut the crap of the organisational boundaries that stopped us doing things”.
Read full story (paywalled)
Source: HSJ, 8 April 2022
Patient Safety Learning

Thousands have PTSD symptoms after miscarriage

Tens of thousands of women in the UK may be experiencing symptoms of post-traumatic stress disorder (PTSD) after miscarriages each year, a leading researcher warns.
Prof Tom Bourne estimates the number affected could run to 45,000 annually.
But he says most are not given prompt psychological support that could help prevent PTSD developing.
The Miscarriage Association says there is an urgent need for better access to talking and other psychological therapies for those affected. At present, most women have to ask for help themselves rather than support being in place.
Prof Bourne believes there needs to be more research into other ways of helping people experiencing loss. His team is trying out a variety of new approaches - including virtual reality - to help address the issue.
One idea his team is experimenting with is offering women virtual reality headsets during miscarriage procedures.
It builds on previous work that shows VR headsets can help reduce pain during some medical procedures.
Researcher Dr Nina Parker says the aim is "to transport them to sort of a more calm, virtual reality world for distraction from the pain and anxiety during the procedure".
She adds: "There is nothing that we are ever going to be able to do that takes away from the loss and the trauma of losing pregnancy and having a miscarriage.
"But if we can do everything that we can to minimise any additional trauma we might be adding to in the interactions that are had within the hospital, then we are obligated to do that."
Read full story
Source: BBC News, 8 April 2022
Patient Safety Learning

Families in Nottingham maternity inquiry hit out at review

Dozens of families have written to the government expressing concern over a review into failing maternity units in Nottingham.
A probe into Nottingham University Hospitals Trust is under way after dozens of babies died or were injured.
But families say the review is "moving with the viscosity of treacle".
They have called for Donna Ockenden, who led the inquiry into the UK's biggest maternity scandal, to take charge of a review.
In a letter to Health Secretary Sajid Javid, a group of 100 people raised concerns with the current thematic review, which has been commissioned by the local clinical commissioning group (CCG) and NHS England, and NHS Improvement.
According to the CCG, the review will look at themes and trends and put in "place detailed and measurable actions so improvements can be made fast".
But families have questioned the independence of the review and the experience of the team to handle a probe of this magnitude.
It is chaired by Cathy Purt, a long-time NHS manager who the families believe has no experience of running complex inquiries or maternity services.
The letter states: "If families are to be safeguarded, real intervention is required."
Read full story
Source: BBC News, 7 April 2022
Patient Safety Learning

NHS regulator ‘not fit for purpose’ for dismissing baby deaths scandal warnings

The healthcare regulator has been branded “not fit for purpose” after dismissing warnings of the biggest maternity scandal in NHS history, The Telegraph can reveal.
Letters seen by this newspaper show that the Care Quality Commission (CQC) told grieving parents it would not support an independent inquiry into baby deaths, just months before such an investigation was ordered.
Rhiannon Davies wrote to the watchdog in Dec 2016, alerting the regulator to 19 avoidable deaths of mothers and babies at the Shrewsbury and Telford Hospital NHS Trust, as well as a string of cases where lives were put at risk.
However, the head of the CQC at the time assured Ms Davies that the culture was “changing for the positive”, rebuffing her calls for an independent inquiry.
Ms Davies had provided the watchdog with details of a string of deaths, which she and fellow bereaved parents had found from publicly available information.
The information was contained in a letter to Jeremy Hunt, the health secretary at the time, and shared with the regulator, setting out why families believed an inquiry was required.
On Tuesday night, Ms Davies said that the refusal of the CQC to back an investigation, and the false assurances given by its most senior figure, showed how it “never scratched beneath the surface” despite death after death.
Ms Davies said that she had “absolutely no faith” in its current ability to regulate and spot future scandals, saying it had “pushed back” every effort made by families to expose the failings at Shrewsbury.
“They are not fit for purpose because we cannot trust them to be doing their job properly,” she told The Telegraph.
Read full story (paywalled)
Source: The Telegraph, 5 April 2022
Patient Safety Learning

Why nurses are raging and quitting after the RaDonda Vaught verdict

Emma Moore felt cornered. At a community health clinic in Portland, Oregon, USA, the 29-year-old nurse practitioner said she felt overwhelmed and undertrained. Coronavirus patients flooded the clinic for two years, and Moore struggled to keep up.
Then the stakes became clear. On 25 March, about 2,400 miles away in a Tennessee courtroom, former nurse RaDonda Vaught was convicted of two felonies and facing eight years in prison for a fatal medication mistake.
Like many nurses, Moore wondered if that could be her. She'd made medication errors before, although none so grievous. But what about the next one? In the pressure cooker of pandemic-era health care, another mistake felt inevitable.
Four days after Vaught's verdict, Moore quit. She said Vaught's verdict contributed to her decision.
"It's not worth the possibility or the likelihood that this will happen," Moore said, "if I'm in a situation where I'm set up to fail."
In the wake of Vaught's trial ― an extremely rare case of a health care worker being criminally prosecuted for a medical error ― nurses and nursing organizations have condemned the verdict through tens of thousands of social media posts, shares, comments, and videos. They warn that the fallout will ripple through their profession, demoralizing and depleting the ranks of nurses already stretched thin by the pandemic. Ultimately, they say, it will worsen health care for all.
Read full story
Source: Kaiser Health News, 5 April 2022
Patient Safety Learning
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