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

Nearly half of trust’s beds filled by patients fit to be discharged

A chief executive has described her ‘considerable regret’ that growing difficulty in discharging patients has resulted in nearly half of her trust’s inpatients being clinically ready to leave.
Debbie Richards, who leads Cornwall Partnership Foundation Trust, a community and mental health provider, highlighted the issue at the trust’s board meeting last month, amid a “dearth of adult social care provision” across the country.
In her update to the board, Ms Richards said delays in finding onward care for patients awaiting discharge meant “almost 50 per cent of our community hospital beds are occupied by patients who have no medical need to be in hospital”.
In her report to the board, Ms Richards said: “Despite having over 5,000 care home beds in Cornwall, the majority of these are full, or care home providers are unable to offer beds because of a lack of staffing.
“Where there is capacity, this tends to be for lower-level residential beds where unfortunately there is much less demand.”
Siobhan Melia, chair of the NHS Community Network and CEO of Sussex Community FT, said the “dearth of adult social care provision” was the biggest limiting factor in discharging delayed patients home, followed by high staff vacancies and sickness absence."
She called for a national long-term funding settlement for social care and reform of the sector to address the key challenges.
Read full story (paywalled)
Source: HSJ, 10 May 2022
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‘Hepatitis in children: Any delays in diagnosis could lead to negligence claims, say lawyers

Parents whose children have mysteriously fallen ill with hepatitis and received a delayed diagnosis could be entitled to negligence claims, lawyers believe.
Officials are no closer to explaining a recent and unusual outbreak in cases of liver inflammation recorded among young children across the UK.
To date, a total of 163 children have been diagnosed. Eleven of these have received liver transplants, while 13 are currently in hospital. Globally in recent months, 300 children have been struck down by the illness, which has no clear cause.
Because the UK cases have been identified retrospectively, there is potential that doctors and medics may have “missed signs” which would have led to earlier hepatitis diagnoses and treatment, lawyers say.
“There are a significant number of these diagnoses which are actually retrospective,” said Jonathan Peacock, a partner at VWV specialising in clinical negligence.
“The obvious issue there from a negligence point of view is if you have missed signs, which ought to have led you to a diagnosis of hepatitis earlier, as a result of which it’s gone untreated and the outcome is worse, then potentially you’re negligent.
“There’s two stages: was the care diagnosis, treatment, intervention, was that of a reasonable standard? If the answer is no – there was clearly a negligent delay, or a breach of duty of care, then the second question that then arises is has the individual been harmed by that delay?”
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Source: The Independent, 10 May 2022
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Leapfrog Group: Patients report worse hospital experiences during COVID-19 pandemic, raising safety concerns

The latest batch of hospital patient safety ratings from America's Leapfrog Group shows a general decline among “several” hospital safety measures concurrent with the onset of the COVID-19 pandemic, according to the healthcare safety watchdog.
Released Tuesday, the scores are accompanied by a report from Leapfrog that highlights a “significant” decline in the experiences of adult inpatients at acute care hospitals during the pandemic, with many areas “already in dire need” prior to the pandemic deteriorating even further.
“The healthcare workforce has faced unprecedented levels of pressure during the pandemic, and as a result, patients' experience with their care appears to have suffered,” Leah Binder, president and CEO of the Leapfrog Group, said in a statement.
Leapfrog’s twice-annual reports assess more than 30 patient safety measures and component measures compiled from the Centers for Medicare & Medicaid Services (CMS) and Leapfrog’s hospital surveys between July 2018 and March 2021. The most recent release assigns letter grades to nearly 3,000 US general hospitals and is the second collection of scores to incorporate safety and experience data from the COVID-19 pandemic.
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Source: Fierce Healthcare, 10 May 2022
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Families dismay at interim report plans despite review ‘chaos’

Families involved in a major review into maternity failings at Nottingham University Hospitals Trust (NUH) have criticised the decision of the review team to press ahead with the publication of an interim report, despite serious concerns about its terms of reference and methodology.
A “thematic review” into NUH was first announced last year after reports that dozens of babies died or were brain damaged after errors were made at the trust over the last decade. More than 460 families have since contacted the review team.
The review has been overseen by NHS England and local commissioners, but, in April, the families called for an independent inquiry and asked for it to be carried out by Donna Ockenden, the senior midwife who chaired the high-profile review of Shropshire maternity services, which reported in March.
Last month, NHSE chief operating officer Sir David Sloman wrote to families and said former strategic health authority chair Julie Dent would be brought in to chair the review. However, Ms Dent stepped down from the role weeks later, citing “personal reasons”. A new chair is yet to be appointed.
Despite these uncertainties, families have been told by the review team that an interim report will be issued shortly.
Gary Andrews, whose daughter Wynter died after being delivered by caesarean section at NUH’s Queens Medical Centre in 2019, said to issue an interim report “seems at odds with the current situation” and risked causing “significant distress” to families.
He added: “We need government to get to grips with this review. Put the brakes on, ensure its structure and design and objectives are fully supported by families, before any interim report can be issued.”
Read full story (paywalled)
Source: HSJ, 19 May 2022
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Alarm after EHRC says long Covid should not be treated as disability

People suffering from long Covid have reacted with alarm to comments by government’s equalities watchdog that the condition should not be treated as a disability.
Under the Equalities Act, anyone with a physical or mental impairment that has lasted for longer than 12 months and substantially impacted their ability to carry out normal day-to-day activities qualifies as disabled and is entitled to protection to ensure that they aren’t discriminated against in the workplace. This includes requesting that their employer makes “reasonable adjustments”, such as flexible working hours or home working, to ensure that they can continue working.
In a tweet posted on Sunday night, the Equalities and Human Rights Commission (EHRC), which was set up to promote and enforce equality and non-discrimination laws said: “Discussions continue on whether ‘long Covid’ symptoms constitute a disability. Without case law or scientific consensus, EHRC does not recommend that ‘long Covid’ be treated as a disability.”
The statement prompted immediate concern and confusion from long Covid support groups and unions.
Dr Jenny Ceolta-Smith, an employment advocate for Long Covid Support and co-founder of Occupational Therapy for Long Covid, said: “There is already disbelief of workers’ long Covid symptoms within the workplace, and this harmful announcement by the EHRC may make it much harder for workers to gain the support that they need from colleagues and line managers. It may even mean more jobs are lost.”
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Source: The Guardian, 9 May 2022
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Chronic pain treatments are failing millions, say experts

Relentless. Unbearable. Overwhelming.
These are just some of the words used by the thousands of people who have revealed their battle with long-term, persistent pain.
An exclusive survey of over 4,000 adults aged 16-75 for BBC News, carried out by research company Ipsos, suggests that a quarter of people in the UK are living with chronic pain - an often hidden and misunderstood condition.
And pain specialists warn the health service is not set up to deal with such complex conditions. They say the treatments on offer are decades behind the science, leaving millions of patients without the support they need to manage their pain.
Jen Proudler says chronic pain has left her grieving for "the person she was".
It started four years ago with sporadic back pain. After several incorrect diagnoses, Jen was eventually told by a neurosurgeon that she had a "pretty massive" far lateral disc herniation in her spine. The pain has now spread around her body - Jen has burning pins and needles sensations down her leg, as well as sharp pain, as if being cut by a razor. Sometimes it's so bad, she can't even bear any fabric to touch it.
"Our nervous system becomes more and more protective, it feels danger and sends warning signals - and those warning signals contribute to the pain," explains Dr Chris Barker, clinical director of an NHS community pain service in Ainsdale, Merseyside.
He says such pain can be hard to diagnose, and the difficulty of getting the correct treatment can make things worse. "Incorrect diagnoses, delayed diagnoses, poor experiences in and out of the health system, not being believed - all of these can contribute to a more intense experience of pain."
Dr Barker says the NHS is not set up to deal with such a complex condition, despite the fact it is so common. "The prevalence of pain is huge. It dwarfs most other conditions."
Read full story
Source: BBC News, 11 May 2022
Further reading: Is pain a patient safety issue? Blog from Patient Safety Learning
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Covid vaccines are ‘safe for pregnant women and cut stillbirth risk’, study says

Covid-19 vaccines are safe for pregnant women to take and can even reduce the risk of stillbirths, according to a new study.
Researchers at St George’s University of London and the Royal College of Obstetricians and Gynaecologists collated data from studies and trials involving over 115,000 vaccinated pregnant women.
They found that pregnant women – who are more likely to become serious ill if they catch Covid-19 – are 15% less at risk of stillbirth if vaccinated.
“We wanted to see if vaccination was safe or not for pregnant women,” said Asma Khalil, professor of obstetrics and maternal fetal medicine at London’s St George’s Hospital in London to The Guardian.
“It is safe, but what’s surprising, and it’s a positive finding, is that there was a reduction in stillbirths.”
“So far, most of the data on vaccines in pregnancy have been about protecting the pregnant woman herself from Covid. Now we have evidence that the vaccines protect the baby too,” she added.
Read full story
Source: The Independent, 10 May 2022
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Staff warn of ‘worsening’ culture at beleaguered trust

The culture at a long-troubled ambulance trust is ‘worsening, not improving’, its staff have told a health watchdog.
Concerns about culture and patient safety at East of England Ambulance Service Trust (EEAST) were raised to inspectors at the Care Quality Commission (CQC) during an inspection of the trust last month, according to public documents.
In a feedback letter to the trust following the inspection, the CQC said staffing at EEAST’s control room was below planned levels, and the inspectors were “not assured that staffing levels met the demands within the service and this may impact on patient safety when managing the high volume of calls”.
The trust, which is in the equivalent of special measures and currently rated “requires improvement” by the CQC, has had long-standing cultural problems and last year signed a legal agreement with the Equality and Human Rights Commission on how it would protect staff from sexual harassment.
According to the feedback letter, staff described a “worsening, not improving, culture” and said the workforce was “tired” and not receiving mandatory training, one-to-ones with managers or appraisals.
The letter, published in the trust’s latest board papers, also reported inspectors raising concerns about potential risks to patients over the management of the trust’s call stack and a lack of consistency over “standard operating procedures”.
Additionally, some staff in the control room on an accelerated training programme were unable to undertake full patient assessments and had to call for assistance from others.
Read full story (paywalled)
Source: HSJ, 11 May 2022
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Crowded A&Es mean Scottish paramedics play the waiting game

Paramedic Moira Shaw is eyeing the frantic activity at the front doors of Edinburgh's emergency department.
She is waiting for the go-ahead to hand over her patients to medics and answer the next 999 call. It can be a long wait.
Last week, 1 in 10 ambulances across Scotland took more than 80 minutes to drop patients at an emergency department.
BBC Scotland joined Moira and colleague Blair Paul at the Royal Infirmary of Edinburgh where they were among seven ambulances waiting to drop off patients.
"At the moment we can be an hour waiting, we sit in the ambulance and we wait until there is a space to go in," explains Moira, who has been with the service for nearly a decade.
"This is pretty much an everyday occurrence now.
"It's that domino effect, so if patients are waiting to move to other areas, A&E gets clogged up and they can't take any more patients in because they are waiting to move people on."
Moira said she has noticed they are attending more calls where people have not been able to get through to their GP so phone 999 instead.
Another theme picked up by Moira and her colleague Blair is helping younger sicker patients who need urgent hospital treatment.
"I've seen actually quite a lot of people maybe in their 40 or 50s who have got now stage four cancer and they've just not been able to get access to any treatments or anything just due to the pressures on the NHS at the moment," explained Blair.
Read full story
Source: BBC News, 11 May 2022
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Website to show NHS delays

A website that tells patients how long they are likely to wait for NHS treatment will be made available in Scotland this summer.
Humza Yousaf, the Scottish health secretary, said people queuing for tests and procedures and their doctors would be able to access information about any delays in their area using the software.
Many patients living in pain are waiting years to have common operations such as hip and knee replacements. In theory, the SNP guarantee hospital treatment within 12 weeks of patients joining the waiting list, but this law was broken extensively before the pandemic and has now been breached hundreds of thousands of times.
One orthopaedic surgeon, who did not wish to be named, said he was operating on patients whose joints had entirely collapsed after a two-year wait for a limb replacement made their case an emergency. Other patients who did not reach crisis faced even longer delays, he said.
Dr Sandesh Gulhane, a GP and health spokesman for the Scottish Conservative Party, asked Yousaf, during a meeting of the Scottish Parliament’s health committee yesterday: “Why can’t we have in the future, in the [recovery] plan, indicative waiting times which are relatively live so we can all go on a website and see how long we need to wait.”
Yousaf said it was fair for patients and NHS staff to expect to have information on waiting times, and that a website to provide this was being developed. 
“We are working closely with Public Health Scotland, we are working closely with boards to develop the infrastructure in order to collate and publish this data,” he said. “It’s an ambition of ours to have that available in a way that is easy to find, easy to understand, both for the patient but for the health professional too.”
Read full story (paywalled)
Source: The Times, 11 May 2022
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Nurse who filmed unconscious patients at hospital jailed for 12 years

A nurse who filmed up the gowns of unconscious women patients and recorded staff using the toilet at a large teaching hospital has been jailed for 12 years by a judge who said he had "brought shame on an honourable profession".
Paul Grayson, 51, was also told by the judge he must serve an extended licence period of 4 years when he is eventually released.
The judge described how four patients were targeted as they recovered from surgery at Sheffield's Royal Hallamshire Hospital – one of whom has never been identified from the footage.
Sentencing Grayson on Tuesday, Judge Jeremy Richardson QC said: "You have betrayed every ounce of trust reposed in you.
Earlier this week, the court heard one victim, who was secretly filmed in the shower by Grayson over a number of years, face him directly in court as she told him his "sick and disgusting perversions" and "evil actions" were crimes that "have torn me into pieces".
The court heard that one victim was unconscious after an eye operation when Grayson filmed her up her gown, and could be seen moving her underwear.
The woman told police she had "put her trust in staff at the hospital to keep her safe".
The victim said that she has since been due to have an operation at another hospital but she "can't bring myself to go".
Read full story
Source: Medscape UK, 11 May 2022
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‘Smart socks’ to keep dementia carers on their toes by tracking patients’ stress levels

“Smart socks” that track sweat levels, heart rate and motion are being given to dementia patients to alert carers if they are becoming distressed.
The unintrusive technology was developed by Dr Zeke Steer, of Bristol Universit. Dr Steer wanted to find a way to spot the early warning signs of distress, so carers or relatives could intervene with calming techniques to de-escalate the situation. 
The hi-tech hosiery - which look and feel like normal socks - use e-textiles to transmit data in real time to an app, which alerts carers when stress levels are rising.
The socks are now being trialled among mid to late stage dementia patients. Researchers think they will also help people with autism and other conditions that affect communication. 
Fran Ashby, manager from Garden House Care Home, in Bristol, said: “We were really impressed at the potential of assisted technology to predict impending agitation and help alert staff to intervene before it can escalate into distressed behaviours. 
“Using modern assistive technology examples, like smart socks, can help enable people living with dementia to retain their dignity and have better quality outcomes for their day to day life.”
Read full story (paywalled)
Source: The Telegraph, 9 May 2022
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‘Unfounded’ NHS criticism and investigation caused unnecessary deaths at London heart surgery unit

Heart surgery patients in London have died “unnecessarily” and faced increased risk of death as botched NHS investigations into dozens of deaths reduced a hospital’s ability to treat people, a coroner has warned.
“Unnecessary” patient deaths have occurred as a result of heart surgery at St George’s University Hospital Trust being restricted and emergencies diverted to other “over stretched” hospitals, following investigations by national NHS bodies.
The warning that deaths have occurred and may occur in the future, comes following the conclusion of a series of inquest hearings in March, during which it was found the NHS’ wrongly blamed a team of cardiac surgeons for the deaths of dozens of patients.
Coroner Fiona Wilcox, in a report published on Wednesday, has now said the “inadequate” NHS led investigations, which criticised the care of 67 patients, led to people being put increased risk of death.
The NHS’ investigations into the deaths of 67 patients ruled there were “shortcomings” in care. It led to complex operations being diverted elsewhere and doctors being referred to the General Medical Council. Two doctors have sinced been exonerated following GMC hearings.
According to the coroner’s findings, capacity within cardiac surgery at the unit is down by 60% and staff are becoming “deskilled.”
Read full story
Source: The Independent, 11 May 2022
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Concerns flagged over exploitation and poor treatment of overseas nurses

A “shocking” number of nurses from overseas are winding up “in trouble” or sanctioned within their first few months of working in the UK partly because of a lack of induction and support, a conference has heard.
The issue was raised during a panel session at the Unison health conference in April discussing the importance of ethical recruitment practices in nursing and midwifery.
According to Unison, it is supporting “many” overseas nurses who have been “exploited, unfairly treated and subject to racism” since their move.
Among the panel was Gamu Nyasoro, a clinical skills and simulation nurse manager in the NHS and an elected member of Unison’s nursing and midwifery occupational group committee.
Ms Nyasoro, who is from Zimbabwe and has been working in the NHS for the past two decades, said she herself had been discriminated against and had faced several challenges during her migration.
She raised concern that overseas nurses were not given enough information about how to live and work in the UK, including about how to access healthcare services themselves, or about country specific rules and regulations.
There was also the issue that UK employers “don’t look at their skills beforehand”, which means nurses were being put in roles or areas they were not confident in.
She cited examples of staff who had been specialising in neonatal services before moving, who were then being asked to work with older people, and those who had been practising as a midwife in their home nations and then being required to work in emergency departments in the UK.
Read full story
Source: Nursing Times, 28 April 2022
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Ambulance wait times endangering patients, doctors say

Doctors and paramedics have told the BBC that long waits for ambulances across the UK are having a "dangerous impact" on patient safety.
BBC analysis found a 77% rise in the most serious safety incidents logged by paramedics in England over the past year, compared to before the pandemic.
In Wales, Scotland and Northern Ireland, the 999 system is also under "tremendous pressure", doctors say.
NHS England said the safety of patients is its "absolute priority".
In October, nine-year-old Willow Clark fell off her bike on a country path in Hertfordshire, cracking her helmet and leaving her with a fractured skull and a nine-inch laceration across her leg.
"I could see it was a really bad accident and I was 20 minutes away from home screaming for help," said her mother Sam. "These really nice people who were passing by phoned 999.
"They explained she had a severe head injury and her leg was badly hurt but we were told it would be a 10-hour wait for an ambulance and we'd have to get her to hospital ourselves."
When they got to A&E, Willow was immediately transferred to the trauma department. Doctors told her family that she should not have been moved because of her back and neck injuries.
She later found out that Willow had been classified as an "urgent" category three case, meaning an ambulance should have arrived within 120 minutes.
Coroners and lawyers have highlighted recent cases including:
Staffordshire's assistant coroner issued a 'prevention of future deaths' warning after a patient in Stoke died after waiting eight hours for an ambulance. The family of a man who died after waiting nine hours for treatment has issued a legal challenge against the Northern Ireland Ambulance Service over a "chronic shortage" of ambulances. The London Ambulance service is investigating after a man died when paramedics took almost 70 minutes to respond to a suspected heart attack. Dr Katherine Henderson, an A&E consultant and president of the Royal College of Emergency Medicine, told the BBC's Today programme the problem with ambulance waits was "more serious than we've ever seen it".
Read full story
Source: BBC News, 12 May 2022
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Blowing whistle on trust CEO ‘hardest thing I’ve had to do’, says his successor

A trust chief who blew the whistle on her predecessor’s ‘aggressive’ behaviour and lack of interest in patient safety says it was the hardest thing she has had to do in her career.
Janelle Holmes, who is now chief executive of Wirral University Teaching Hospital Foundation Trust, was among four Wirral University Teaching Hospital Foundation Trust senior executives who wrote to regulators in 2017 about the behaviour of the trust’s then CEO David Allison.
They said he would react with “dismay and aggression” to concerns being raised about service quality, and staff were afraid to speak up as a result. The intervention led to Mr Allison’s departure and a subsequent independent investigation found “deep systemic cultural issues”. Mr Allison always denied his behaviour was inappropriate.
In an interview with HSJ, Ms Holmes talked of the difficulties in taking those actions, and the subsequent efforts to overhaul the trust’s culture.
She said: “From a personal integrity perspective, it was the right thing to do…and I [also] felt I had a personal responsibility to make it right afterwards.
“But yes, it was the most difficult thing I’ve ever had to do.”
She said: “I remember watching Sir David Dalton (the ex-Salford CEO) probably more than 10 years ago… say ‘we are harming patients’.. it was like ’you can’t say that’.
“But actually [there was a] complete sea change and [it became] an organisation where [speaking out] was the right thing to do. That’s the only way you can ensure you’re delivering good quality high standard services. If you’re acknowledging mistakes happen, you’re learning from them, you’re correcting things… I think that then starts to shape how our clinicians and staff feel.
Read full story (paywalled)
Source: HSJ, 12 May 2022
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