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

Care home resident died after unqualified nurse administered wrong medication

A nurse with no qualifications gave a care home resident a fatal dose of the wrong drug, leading to her death before she then tried to cover up her mistake.
Katherine Hutchinson gave Fiona Jayne Thorne a fatal overdose of a powerful anti-psychotic drug, which was meant for another patient, an inquest heard.
She then tried to cover up her errors which contributed to the death of the 36-year-old with learning difficulties, Derbyshire Live reported .
Ms Hutchinson had, at the time, been the nurse in charge at Whitwell Park Care Home, in Whitwell, Derbyshire despite not having any qualifications.
She gave Miss Thorne clozapine, which had been intended for another resident, on October 6, 2010.
Instead of owning up to what she did, Ms Hutchinson then tried to cover up her mistake by taking Miss Thorne to bed and leaving her there until she was discovered, Senior Coroner Dr Robert Hunter said.
Miss Thorne was "found by the care support worker around midnight, when undertaking routine checks on residents”, the inquest heard.
And then Ms Hutchinson’s mistake was only discovered after an audit was carried out of the medication trolley and a dosage of clozapine was found.
Read full story
Source: Mirror, 8 April 2022
Patient Safety Learning

This Easter will be worse than any winter for the NHS

Two years ago the first wave of the covid pandemic reached its peak. The NHS had reacted with impressive speed to prepare for an influx of patients with an infectious disease that few knew much about, had no cure for, and for which there was no known vaccine.
However, now the NHS goes into the Easter break in a more fragile state than in any previous winter since, at least, the 1990s.
This is not just the direct result of covid hospitalisation, of course – although the distracting narrative of ‘with rather than because of covid’ has obscured how hugely damaging any kind of infectious disease that is as widespread in the community as covid is now can be to effective hospital care.
For someone who has just undergone an operation, for example, the greatest threat is not from catching covid itself, but from the impact the virus may have on how quickly their wound may heal.
Perhaps covid’s greatest continuing impact is on growing staff absences and the pernicious impact it is having on the long-term health of those who had the disease – even in some cases where it has been relatively mild. For the tens of thousands who have been hospitalised with covid, the consequences for their long-term health look more serious every day.
Much of this new workload is ending up at the doors of primary and community care – and displacing other needs and services just when they are most required after two years of coping with the pandemic.
There is usually one thing you can confidently say about the NHS, which is that in any crisis it will make sure the life-saving decisions are made on time.
However, in the South West, and probably other regions too, that is not happening. People are dying because the NHS cannot – despite its best efforts – save them.
Read full story (paywalled)
Source: HSJ, 8 April 2022
Patient Safety Learning

Thousands of ventilators pulled as electrical faults put UK patients’ lives at risk

Two thousand ventilators being used in UK hospitals are at risk of suddenly shutting down due to electrical faults that have led to a global safety alert.
Hospitals have been ordered to source replacement ventilators after Philips Respironics said its breathing support devices could suddenly stop working, in some cases without activating a warning alarm.
The Medicines and Healthcare products Regulatory Agency (MHRA) said the problem related to “a number of electrical faults in the devices, which can result in an unexpected shutdown, leading to loss of ventilation”.
It said there had been five reported cases of shutdowns in the UK so far, none of which involved patient harm. Globally, there have been 389 reports of failures, including one where the patient died and four where they were seriously injured. In six of the total cases, the warning alarm didn’t sound.
Philips Respironics is one of several manufacturers that increased production of ventilators during the pandemic. The MHRA brought in a fast approval process for ventilators and other medical devices in response to Covid-19.
The MHRA said the root cause of the problem was not yet known and remained under investigation, but that Philips Respironics currently had “no permanent solution” to correct it.
Helen Hughes, chief executive of Patient Safety Learning, said there was a “significant patient safety concern” that some Philips devices could remain in use until replacements were sourced.
Read full story
Source: The Guardian, 9 April 2022
National Patient Safety Alert: Philips Health SystemsV60, V60 Plus and V680 ventilators – potential unexpected shutdown leading to complete loss of ventilation
Patient Safety Learning

“Implementation gap” renders reviews of patient safety incidents ineffective, finds charity

Patients continue to experience avoidable harms from unsafe care because the NHS fails to learn from its mistakes, a report that tracked what actions the NHS took following safety reviews over several decades has found.
Patient Safety Learning looked at the findings of a variety of investigations, including widespread public inquiries, Healthcare Safety Investigation Branch (HSIB) reports, Prevention of Future Deaths reports, incident reports, and complaints and legal action by patients and their families.
It found an “implementation gap” in learning lessons and taking action to prevent future harms. It highlighted an absence of a systemic and joined up approach to safety; poor systems for sharing learning and acting on that learning; lack of system oversight, monitoring, and evaluation; and unclear patient safety leadership.
Helen Hughes, chief executive of Patient Safety Learning, said, “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 learnt’ and ‘action will be taken to prevent future avoidable harm to others.’ The healthcare system needs to understand and tackle the barriers for implementing recommendations, not just continually repeat them.”
The report calls for “systemwide commitment and resources, with effective and transparent performance monitoring” for patient safety inquiries and reviews and HSIB reports to ensure that the accepted recommendations translate into action and improvement.
Read full story
Source: BMJ, 8 April 2022
Patient Safety Learning

Ambulance chief calls out acute trust over ‘lack of action’ on handover delays

An ambulance service has raised concerns over the record number of ‘hours lost’ to handover delays at an acute hospital on its patch, which it says is happening despite the number of arrivals being at its lowest level in seven years.
West Midlands Ambulance Service University Foundation Trust has said the situation at Royal Stoke Hospital presents a “significant risk to patient safety”, but “we don’t currently see actions being taken that are reducing this risk”.
It comes amid rising frustrations from ambulance chiefs around the country at a perceived lack of support from acute hospitals around handover delays. Ambulance response times for some of the most serious 999 calls have ballooned in recent months, in part due to lengthy handover delays at emergency departments.
In a letter sent to a member of the public on 31 March, Mark Docherty, director of nursing at WMAS, said: “WMAS [is] experiencing difficulties as a direct result of delays in patient handovers at acute hospitals. We have been highlighting our concerns for over six years as the situation has become progressively worse every year."
Read full story (paywalled)
Source: HSJ, 10 April 2022
 
Patient Safety Learning

GP numbers in England down every year since 2015 pledge to raise them

The number of GPs in England has fallen every year since the government first pledged to increase the family doctor workforce by 5,000, a minister has admitted.
There were 29,364 full-time-equivalent GPs in post in September 2015, when the then health secretary, Jeremy Hunt, first promised to increase the total by 5,000 by 2020.
However, by September 2020 the number of family doctors had dropped to 27,939, a fall of 1,425, the health minister Maria Caulfield disclosed in a parliamentary answer. And it has fallen even further since then, to 27,920, she confirmed, citing NHS workforce data.
In the 2019 general election campaign, Boris Johnson replaced Hunt’s pledge with a new commitment to increase the number of GPs in England by 6,000 by 2024. However, Sajid Javid, the health secretary, admitted last November that this pledge was unlikely to be met because so many family doctors were retiring early.
Organisations representing GPs say their heavy workloads, rising expectations among patients, excess bureaucracy, a lack of other health professionals working alongside them in surgeries, and concern that overwork may lead to them making mistakes are prompting experienced family doctors to quit in order to improve their mental health and work-life balance.
The British Medical Association (BMA) said the figures Caulfield cited showed that the lack of doctors in general practice was “going from bad to worse for both GPs and patients”, and it warned that patients were paying the price in the form of long waits for an appointment.
“Despite repeated pledges from government to boost the workforce by thousands, it’s going completely the wrong way,” said Dr Kieran Sharrock, the deputy chair of the BMA’s GP committee. “As numbers fall, remaining GPs are forced to stretch themselves even more thinly, and this of course impacts access for patients and the safety of care provided.”
Read full story
Source: The Guardian, 11 April 2022
Patient Safety Learning

The US is trying to fix medical devices’ big cybersecurity problem

Medical devices are one major weak point in health care cybersecurity, and both the US Congress and the Food and Drug Administration took steps towards closing that gap this week —Congress with a proposed bill and the FDA with new draft guidelines for device makers on how they should build devices that are less likely to be hacked.
Devices like infusion pumps or imaging machines that are connected to the internet can be targets for hacks. Those attacks can siphon off patient data or put their safety directly at risk. Experts consistently find that devices in use today have vulnerabilities that could be exploited by hackers.
The new document is still just a draft, and device makers won’t start using it until it’s finalised after another round of feedback. But it includes a few significant changes from the last go-around — including an emphasis on the whole lifecycle of a device and a recommendation that manufacturers include a Software Bill of Materials (SBOM) with all new products that gives users information on the various elements that make up a device. An SBOM makes it easier for users to keep tabs on their devices. If there’s a bug or vulnerability found in a bit of software, for example, a hospital could easily check if their infusion pumps use that specific software.
The FDA also put out legislative proposals around medical device cybersecurity, asking asking Congress for more explicit power to make requirements. “The intent is to enable devices to be that much more resilient to withstand the potential for cyber exploits or intrusion,” Schwartz says. Manufacturers should be able to update or patch software problems without hurting the devices’ function, she says.
Read full story
Source: The Verge, 8 April 2022
Patient Safety Learning

Washington State Nurses Association: Joint statement on the conviction of RaDonda Vaught

On 25 March2022, a Tennessee jury convicted RaDonda Vaught, a nurse at Vanderbilt University Medical Center, of criminally negligent homicide and impaired adult abuse in a 2017 medication administration error that tragically resulted in a patient death. The Washington State Nurses Association have issued a joint statement adamantly opposed to criminalization of patient care errors. 
"Focusing on blame and punishment solves nothing. It can only discourage reporting and drive errors underground. It not only undermines patient safety; it fosters an environment of fear and lack of respect for health care workers."
"The Vaught case has drawn intense national attention and concern. We join with health care workers and patient safety experts around the country and the world in rejecting the criminalization of medical errors. Further, we are committed to redoubling our efforts to achieve health care environments that are safe for patients and health care workers alike. This includes the ongoing, critical fight to achieve safe staffing standards in Washington state."
Read full statement
Source: Washington State Nurses Association, 8 April 2022
Patient Safety Learning

Trusts with the biggest falls in staff confidence in care provided

Several large teaching hospitals are among those which saw the steepest declines in the proportion of staff who would recommend the care of their organisation, according to the NHS staff survey results.
Norfolk and Norwich University Hospitals Foundation Trust, University Hospitals Birmingham, Liverpool University Hospitals FT and Nottingham University Hospitals Trust saw declines of 12 percentage points or more in 2021 — for the proportion of staff saying they would be happy for a friend or relative to be treated at their organisation. This was double the average drop in the acute sector.
In a message to staff, Sue Musson, chair of Liverpool University Hospitals Trust, said about her trust’s overall results: “On behalf of the trust board, I want to apologise to everyone that the experience of working at the trust is so deeply unsatisfactory for so many colleagues.
“It would be wrong to suggest that there are quick fixes to these issues. The promise I can give you today is a genuine commitment to listen and learn; we particularly need to understand what would make the difference for colleagues across the trust, recognising that there may well be different answers in different parts of the organisation.
“We will seek to learn from the trusts that have demonstrated the best staff experience scores and to implement best practices at pace. We will also be seeking support and input from national and staff side colleagues.”
Read full story (paywalled)
Source: HSJ, 11 April 2022
Patient Safety Learning

NHS whistleblowers still face consequences

Criticism of NHS managers over the treatment of whistleblowers has been reignited by Donna Ockenden’s damning review of maternity services at Shrewsbury and Telford Hospital Trust.
Her findings come seven years after the “Freedom to speak up?” report from Sir Robert Francis QC, which found that NHS staff feared repercussions if they blew the whistle on poor practice. He recommended reforms to change the culture and support whistleblowers.
The Public Interest Disclosure Act 1998 makes it unlawful to subject workers to negative treatment or dismiss them because they have raised a whistleblowing concern, known as a “protected disclosure”. But critics say little has changed since the Francis review.
According to Protect, a whistleblowing charity, 64% of those contacting it for advice said that they had been victimised, dismissed or forced to resign. Shazia Khan, founding partner at Cole Khan Solicitors, says that instead of being afforded protection, whistleblowers are “targeted as a form of retaliation by trust senior management and disciplined on trumped up charges to shut them down”.
Those seeking to vindicate their rights before an employment tribunal, Khan adds, will often be “priced out of justice” by well-resourced NHS trust lawyers who at public expense “deploy a menu of tactics” to defend cases. 
When Peter Duffy, a consultant urologist at University Hospitals of Morecambe Bay Foundation NHS Trust, reported on allegedly unsafe practices by colleagues in 2016, he was demoted, falsely accused of financial irregularities, and threatened with a six-figure adverse costs order by Capsticks, the hospital’s law firm.
“All my witnesses dropped out after the medical hierarchy told them that the department might be dissolved if the case went badly,” Duffy says, which meant there was no one to rebut the trust’s evidence.
Read full story (paywalled)
Source: The Times, 7 April 2022
Patient Safety Learning

Trusts to stop routine Covid tests for new patients amid ‘brutal’ NHS pressures

Overstretched hospitals are stopping routine Covid tests for new patients as “brutal” pressures mount on doctors and nurses, The Independent understands.
On Monday there were 1,702 new Covid admissions to hospitals in England as of 9 April – with 16,442 positive patients occupying beds – the NHS leaders warn their ability to tackle the backlog in planned care is at risk.
Despite pleas from NHS chiefs to measures such as mask-wearing back into force, ministers said there were no plans to change guidance.
The Independent understands at least two major hospitals, in Newcastle and York, have dropped testing of all patients without symptoms in order to alleviate pressure on beds – raising fears that Covid could spread on unchecked wards. Other hospitals are also likely to do the same as bed pressures worsen.
Sources have told The Independent some trusts have begun to drop “red” Covid only wards, while some are considering not separating patients in A&E.
One expert, critical care doctor Tom Lawton, who analyses hospital-acquired infection data, said that stopping patient testing in hospitals was “worrying” and that the NHS would be putting “blinkers on” just as in-hospital infections were “as high as they’ve ever been”.
Read full story
Source: The Independent, 11 April 2022
Patient Safety Learning

Governance scandal trust failing to manage complaints

A trust which is facing major governance issues is failing to respond to hundreds of complaints properly, with patients and families waiting more than twice as long as the NHS target for responses to their concerns, an external review has found.
Cornwall Partnership Foundation Trust, which is subject to regulatory action by NHS England, was found to be “not classifying complaints, concerns and comments accurately”, while staff had “no formal training”, meaning complaints were “not investigated appropriately”.
Last year, the trust was embroiled in a governance scandal in which NHSE investigated multiple allegations of finance and governance failings, resulting in the departure of former CEO Phil Confue.
Rachel Power, chief executive of the advocacy group Patients Association, told HSJ  patient complaints often contain “vital intelligence” on how trusts can improve services and “essential warnings about any area where things might be going wrong”.
According to the review, the backlog had stemmed from several factors. These included more work being needed on investigations that had not been thorough enough, and the relevant service teams not responding to enquiries by the complaints team.
Additionally, there was a “lack of formal monitoring and review” to ensure complaint points were reported appropriately and consistently, and an “apparent lack of accountability by local teams for complaints” triaged through the trust’s patient liaison and complaints team.
Read full story (paywalled)
Source: HSJ, 12 April 2022
Patient Safety Learning

Covid threat being ignored in England for ideological reasons, say NHS leaders

Ministers should reconsider England’s “living with Covid” plans, health leaders have said, while accusing the government of ignoring the ongoing threat for ideological reasons.
The NHS Confederation, which represents organisations across the healthcare sector, has accused No 10 of having “abandoned any interest” in the pandemic, despite a new Omicron surge putting pressure on an already overstretched NHS.
“The brutal reality for staff and patients is that this Easter in the NHS is as bad as any winter,” said Matthew Taylor, the chief executive of the NHS Confederation.
"We do not have a living-with-Covid plan, we have a living-without-restrictions ideology.
“But instead of the understanding and support NHS staff received during 2020 and 2021, we have a government that seems to want to wash its hands of responsibility for what is occurring in plain sight in local services up and down the country. No 10 has seemingly abandoned any interest in Covid whatsoever.
“NHS leaders and their teams feel abandoned by the government and they deserve better.”
Taylor later told BBC Breakfast: “In our view, we do not have a ‘living with Covid’ plan, we have a ‘living without restrictions’ ideology, which is different. We need to put in place the measures that are necessary to try to alleviate the pressures on our health service while this virus continues to affect [it].”
Read full story
Source: BBC News, 11 April 2022
Patient Safety Learning

‘I feel so let down’: long waits for ambulances in south-west England

More than four hours after an ambulance was called, Richard Carpenter, 71, who had had a suspected heart attack, began to despair. “Where are they?” he asked his wife, Jeanette. “I’m going to die.”
She tried to reassure her husband that the crew must surely be close. Perhaps they were struggling to find their rural Wiltshire home in the dark. “But I could see I was losing him,” she said. She gave her husband CPR and urged him: “Don’t leave me.” But by the time the paramedics arrived another hour or so later, it was too late.
Jeanette Carpenter, 70, a stoical and reasonable person, accepts it might have been impossible to save her husband. “But I think he would have had more of a chance if they had got here sooner,” she said.
It is the sort of sad story that is becoming all too common. Across England, but in particular in the south-west, ambulances are too often not getting to patients in a timely manner.
Before Covid, said one ambulance worker – who asked not to be named – he would do between six and 10 jobs in a shift. Now if the first person he is called to needs to go to hospital, he expects this will be his one job for the whole shift.
“At some hospitals we are waiting outside hospitals for 10, 11 or 12 hours,” he said. “There’s nothing more demoralising than hearing a general broadcast going out for a cardiac arrest or road accident and there’s no resources to send. It’s terrible to think someone’s loved one needs help and we can’t do anything because we’re stuck at a hospital.”
Read full story
Source: The Guardian, 10 April 2022
Patient Safety Learning

Mums covered in bodily fluids, begging for pain relief and scared their babies will die

Mums who have given birth at Sheffield's largest maternity unit have revealed all about the "horrible" conditions, with some parents saying they feared for their baby's lives.
One mum - a midwife herself - was so concerned about her unborn baby's welfare that she and her partner temporarily moved to London just weeks before her due date. "I felt like my son and I might have died if we had the pregnancy in Sheffield," she said.
Several mums have spoken to Yorkshire Live about their stories after a scathing report uncovered the scale of the issues on the Jessop Wing. CQC inspectors highlighted all manner of major issues about the care given at Sheffield Teaching Hospital's specialist maternity unit, including examples of emergency help not arriving when staff called for it.
Distraught mums said they were left naked and covered in bodily fluids while others complained about being ignored for hours despite begging for pain relief. Dangerously low staffing levels exposed patients to the risk of serious harm, while midwives themselves revealed a toxic environment of a "bullying and intimidating culture" from senior management.
As a Trust spokesperson said "we are very sorry" and vowed to make big improvements, we spoke to some of the families worst affected by the problems as they explained how "basic dignity and care have gone out the window".
Read full story
Source: 12, April 2022, Yorkshire Live
Patient Safety Learning

UK officials investigate 74 child hepatitis cases

Health officials are investigating 74 cases of hepatitis - or liver inflammation - in children across the UK since the start of this year.
They say one potential cause of the illness could be adenoviruses, but they have not ruled out Covid-19 as a cause.
Officials are examining 49 cases in England, 13 in Scotland and 12 across Wales and Northern Ireland. The UK Health Security Agency (UKHSA) said parents should be on the lookout for symptoms such as jaundice.
Dr Meera Chand, director of clinical and emerging infections at UKHSA, said officials were looking at a wide range of possible factors which could be causing children to be admitted to hospital with liver inflammation.
"One of the possible causes that we are investigating is that this is linked to adenovirus infection. However, we are thoroughly investigating other potential causes," she said.
Other possible explanations being investigated include Covid-19, other infections or an environmental trigger.
Read full story
Source: BBC News, 13 April 2022
Patient Safety Learning
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