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

Death toll of autism and learning disability patients revealed

Fourteen patients with autism or learning disabilities have died since 2015 while detained in psychiatric facilities in Scotland, figures reveal. 
The statistics were released for the first time by Public Health Scotland (PHS) following a parliamentary question by Scottish Conservative MSP Alexander Burnett, who has campaigned to end the “national scandal” of otherwise healthy people being locked up for months or years due to a lack of community-based support. 
The PHS report does not detail the causes of death, but does show that seven of the deaths occurred in patients who had been resident at an inpatient psychiatric facility for between 91 and 365 days, with six (43%) in patients whose stay had exceeded at least one year. 
Rob Holland, acting director of the National Autistic Society Scotland, said the data was a “step forward in understanding the experience of autistic people and people with a learning disability within inpatient psychiatric facilities”.
He added: “While it does not shine a light on the reasons for the deaths it does highlight how almost all of those that died had been within institutional care for more than 30 days with 6 people having been there for more than a year.
“Hospitals are not homes and it adds further impetus to the Scottish Government’s ‘Coming Home’ strategy to reduce delayed discharge and support people to live in homes of their own choosing.”
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Source: The Herald, 18 May 2022
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Cancer recovery target will be missed, says national leader

The NHS will miss its target to return cancer treatment waits to pre-covid levels by next March, a national cancer leader has said.
When asked at the HSJ Cancer Forum whether the service would be back to “business as usual” performance by next spring, Liz Bishop, who sits on NHS England’s national cancer board, said: “I think it depends on what you mean by ‘business as usual’.
“If you mean hitting the 62-day numbers, and the 104-day numbers, by next March, then no. If I am honest, I don’t think we will.
“Do I know when that date will be? No, I don’t know. But what I do know is that everyone is working really hard to do it and get there.”
NHSE initially said the number of patients waiting longer than 62 days for treatment following an urgent referral would return to pre-pandemic levels by March this year, but has since pushed this back to March 2023.
Read full story (paywalled)
Source: HSJ, 18 March 2022
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Shrewsbury and Telford NHS Trust admits failures after two patients die

A hospital trust has pleaded guilty to failures in care that contributed to the deaths of two patients.
One of the charges related to the death of patient Mohammed Ismael Zaman in 2019 at the Royal Shrewsbury Hospital.
The 31-year-old died of severe blood loss while undergoing dialysis, Telford Magistrates' Court heard.
Max Dingle, in his 80s, died after his head became trapped between a mattress and bed rail while he was being treated at the Royal Shrewsbury Hospital.
Shrewsbury and Telford Hospital NHS Trust (SaTH) admitted three counts of failing to provide treatment and care in a safe way, resulting in harm or loss, between October 2019 and May 2020.
Representing the CQC, Ryan Donoghue said the failures in Mr Zaman's care "were the legal cause of his death, for which the trust is responsible".
He said Mr Dingle, who had been admitted with chronic lung disease, died from a cardiac arrest after he was freed.
"The basis [of the guilty plea] is that the failures exposed him to a significant risk of avoidable harm," Mr Donoghue said.
As well as the two deaths, the CQC accused the trust of exposing other patients to significant risk of avoidable harm.
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Source: BBC News, 18 May 2022
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Study aims to make food allergy deaths history

The parents of a teenage girl who died from an allergic reaction to a Pret a Manger baguette have set up a clinical trial to make "food allergies history".
Nadim and Tanya Ednan-Laperouse's daughter Natasha, 15, died in 2016 after eating a baguette containing sesame, to which she was allergic.
The trial will investigate if everyday food products can be used as treatment.
It is a unique opportunity to establish immunotherapy as a practical treatment, according to an expert.
The trial, set up by the family from Fulham in west London, will see whether commonly available food products, such as milk and peanuts, can be used under medical supervision to treat those with food allergies.
After a 12-month desensitisation period, those involved will be tracked for two further years.
Mr and Mrs Ednan-Laperouse's daughter died in 2016 after she ate an artichoke, olive and tapenade baguette containing sesame seeds, bought from a Pret a Manger at Heathrow Airport.
The wrapper did not have any allergy information, and, as it was made on the premises, this was not required by law at the time.
In October, "Natasha's Law" was brought in, making allergy information a requirement for food made on site.
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Source: BBC News, 18 May 2022
Related articles on the hub
Why allergies are the Cinderella service of the NHS – a blog by Tim McLachlan
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60,000 NHS workers living with PTS after battling pandemic

Around 60,000 NHS staff members have post-traumatic stress after working through the Covid-19 pandemic, new research suggests.
Nine out of 10 health workers say it will take them years to recover from the ordeal and one in four had lost a colleague to coronavirus, according to NHS Charities Together
The charity, NHS staff and mental health experts are now calling for more support from the health service and UK government to support those struggling in the aftermath of the pandemic.
“I think it’s quite clear there hasn’t been enough support to help NHS workers recover from their experiences during the pandemic. As a result, a lot of people are feeling incredibly jaded,” said Dr Ed Patrick, an NHS anaesthetist who worked in a Covid-19 intensive care unit from the beginning of the pandemic.
On his experiences of working on the front lines of the health service, Dr Patrick said: “Like everyone else in the world, we lost our outlets for release. Everything was shut down and for NHS workers, our lives just became the hospital."
He described the long and gruelling hours and the emotional burden of working at the height of the pandemic: “We all had an overwhelming feeling of powerlessness. There was also a deep sadness because everything you would normally do to help patients just wasn’t working.
Read full story
Source: The Independent, 17 May 2022
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Numbers of nurses and midwives leaving NHS highest for four years

More than 27,000 nurses and midwives quit the NHS last year, with many blaming job pressures, the Covid pandemic and poor patient care for their decision.
The rise in staff leaving their posts across the UK – the first in four years – has prompted concern that frontline workers are under too much strain, especially with the NHS-wide shortage of nurses.
New figures show the NHS is also becoming more reliant on nurses and midwives trained overseas as domestic recruitment remains stubbornly low.
In a report on Wednesday, the Nursing and Midwifery Council (NMC) discloses that the numbers in both professions across the UK has risen to its highest level – 758,303.
However, while 48,436 nurses and midwives joined its register, 27,133 stopped working last year – 25,219 nurses, 1,474 midwives and 304 who performed both roles. That was higher than the 23,934 who did so during 2020 after Covid struck, and 25,488 who left in 2019.
Andrea Sutcliffe, the NMC’s chief executive, said that while the record number of nurses and midwives was good news, “a closer look at our data reveals some worrying signs”. She cited the large number of leavers and the fact that “those who left shared troubling stories about the pressure they’ve had to bear during the pandemic”.
Read full story
Source: The Guardian, 18 May 2022
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Dementia cases missed amid struggle to see GP in Covid pandemic

Difficulties seeing GPs during the pandemic have hampered efforts to tackle dementia, with thousands missing out on a diagnosis, Sajid Javid has said.
Announcing a ten-year strategy aimed at preventing four in ten cases of the disease, the health secretary said that delays had “stemmed the tide of progress”. GPs must play a “crucial role” in referring patients, he said.
NHS leaders went further, saying a drop in face-to-face GP appointments had meant “opportunities have been lost” to spot signs of dementia. Only 62% of consultations in March were face to face, compared with 80% before the pandemic.
Javid said: “By 2025, one million people in the UK are expected to have dementia, and this is expected to rise to 1.6 million by 2040. I know the Alzheimer’s Society has estimated over 30,000 people didn’t receive a diagnosis because of the pandemic. Tens of thousands are still missing out on a dementia diagnosis each year because they confuse key symptoms with getting old.”
About 325,000 in England have dementia but are undiagnosed, meaning they cannot get treatment or social care support.
Speaking at the Alzheimer’s Society conference, Javid said the government would publish a strategy this year, which would be “as bold as we’ve been with our ten-year plan for cancer”, focusing on prevention and research.
Read full story (paywalled)
Source: The Times, 18 May 2022
This week is Dementia Action Week - see our Top picks: 5 key resources about patient safety for people with dementia
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Injured women face discrimination over life-saving drugs, say researchers

Injured women are experiencing sex discrimination in the administration of a life-saving drug that cuts the risk of bleeding to death by 30%, researchers have warned.
They found that female trauma victims were half as likely to receive tranexamic acid (TXA) as injured men – even though the treatment is equally effective regardless of sex.
“These results are very concerning. TXA is the only proven life-saving treatment for traumatic bleeding. Women were treated less frequently than men regardless of their risk of death from bleeding or the severity of their injuries,” said Prof Ian Roberts of the London School of Hygiene and Tropical Medicine (LSHTM), who was involved in the study.
“This looks like sex discrimination, and there is an urgent need to reduce this disparity, so all patients who need the drug have the chance to receive it.”
“Whatever of the mechanism of injury, and whatever the bleeding risk we looked at, women were statistically less likely to receive tranexamic acid than men, apart from road traffic collisions with a very high risk of bleeding,” said Tim Nutbeam, whose research was published in the British Journal of Anaesthesia. “However, when we looked at mechanisms of injury which we tend to associate less with major trauma, such as falls from standing, women and particularly older women were much less likely to receive it.”
As striking as these results are, they are not necessarily surprising, he added: “It is already known that women with chest pain are less likely to receive aspirin, less likely to be resuscitated for out of hospital cardiac arrest, and less likely to be taken to hospital by an ambulance using lights and sirens.”
Read full story
Source: The Guardian, 18 May 2022
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Hospital admissions for eating disorders up 84% in five years, NHS data shows

Hospital admissions for people with eating disorders in England have risen 84% in the last five years, official NHS figures reveal.
There were 11,049 more admissions for illnesses such as bulimia and anorexia in 2020-21 than in 2015-16, with 24,268 admissions in total. Experts described the increase as “alarming”.
The number of children and young people admitted to hospital with eating disorders grew from 3,541 to 6,713, with a 35% increase in the last year alone as the Covid pandemic hit, according to the analysis by the Royal College of Psychiatrists.
A particularly stark rise in admissions – 128% – was seen in boys and young men, from 280 hospital admissions in 2015-16 to 637 in 2020-2021.
The college has published guidelines to help health professionals identify people whose eating disorders have become life-threatening and get them the right care. It said the signs that somebody was dangerously ill could be missed at GP surgeries and in A&E due to a lack of guidance and training.
Dr Dasha Nicholls, who chaired the development of the medical emergencies in eating disorders guidelines, said: “Eating disorders such as anorexia, bulimia and binge eating don’t discriminate, and can affect people of any age and gender.
“They are mental health disorders, not a ‘lifestyle choice’, and we shouldn’t underestimate how serious they are. Even though anorexia nervosa is often referred to as the deadliest mental health condition, most deaths are preventable with early treatment and support. Full recovery is possible if spotted and treated early.”
Read full story
Source: The Guardian, 19 May 2022
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Urgent patient safety warning at hospital facing police probe

A private hospital facing a police investigation following a patient’s death has been given an urgent warning by the care regulator due to concerns over patient safety.
The Huntercombe Hospital in Maidenhead, which treats children with mental health needs, was told it must urgently address safety issues found by the Care Quality Commission (CQC) following an inspection in March.
The CQC handed the hospital a formal warning due to concerns over failures in the way staff were carrying out observations of vulnerable patients.
The move comes as The Independent revealed police are investigating the hospital in relation to the death of a young girl earlier this year.
In a report published last week, the care watchdog said it had received “mainly negative” feedback from young people at the hospital’s Thames ward, a psychiatric intensive care unit which treats acutely unwell children.
Commenting on the hospital overall, the report said: “Young people told us that staff did not follow the care plans in relation to their level of observations. They told us that if there was an incident the staff stopped doing intermittent observations. Staff in charge of shifts on wards asked new staff members to do observations before they understood how to do it. Staff had to ask the young person how to carry out their observations as they did not always understand what was expected of them in carrying out different levels of observations.”
Read full story
Source: The Independent, 19 May 2022
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Government failed health staff in pandemic, says BMA

The UK government failed in its duty of care to protect doctors and other healthcare staff from avoidable harm and suffering in its management of the covid-19 pandemic, a major review by the BMA has concluded.
Two reports published on 19 May document the experiences of thousands of UK doctors throughout the pandemic, drawing on real time surveys carried out over the past two years, formal testimonies, data, and evidence sessions. The reports will form part of a wider review by the BMA into the government’s handling of the pandemic, with three further instalments to come.
The evidence lays bare the devastating impact of the pandemic on doctors and the NHS, with repeated mistakes, errors of judgment, and failures of government policy amounting to a failure of a duty of care to the workforce, the BMA said.
Chaand Nagpaul, BMA chair of council, said, “A moral duty of government is to protect its own healthcare workers from harm in the course of duty, as they serve and protect the nation’s health. Yet, in reality, doctors were desperately let down by the UK government’s failure to adequately prepare for the pandemic, and their subsequent flawed decision making, with tragic consequences.
“The evidence presented in our reports demonstrates, unequivocally, that the UK government failed in its duty of care to the medical profession.”
Read full story
Source: BMJ, 19 May 2022
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Regulator suggests ways to prevent choking deaths

The body which regulates health and social care services in Northern Ireland has made recommendations aimed at preventing choking deaths.
It follows the deaths of 31 people since 2016 - 10 of whom died in the last 15 months.
The Regulation and Quality Improvement Authority (RQIA) review found a "clear and urgent" need to improve the "quality and safety" of care.
People at higher risk of choking include those who have had a stroke. It also includes older people and those with mental health or learning disabilities.
The key recommendations include enhanced training for staff, shorter waiting times for assessment by speech and learning therapy and better communication between staff.
RQIA chief executive Briege Donaghy said the vast majority of people who died from choking were known to have a swallowing issue and many had a care plan in place.
"However, choking incidents may occur due to failures in communication of the care plan and when people are inadvertently provided with, or are able to access food and drink that is not suitable or safe for them."
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Source: BBC News, 19 May 2022
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Blackpool death: Abortion sepsis risk training inadequate

Doctors are receiving "inadequate" training about the risk of sepsis after a mother-of-five died following an abortion, a coroner has warned.
Sarah Dunn, 31, died of "natural causes contributed to by neglect" in hospital on 11 April 2020, an inquest found.
Assistant coroner for Blackpool and Fylde, Louise Rae, said Ms Dunn had been treated as a Covid patient even though the "signs of sepsis were apparent".
Her cause of death was recorded as "streptococcus sepsis following medical termination of pregnancy".
In her record of inquest, the coroner noted Ms Dunn was admitted to Blackpool Victoria Hospital in Lancashire on 10 April 2020. She was suffering from a streptococcus infection caused by an early medical abortion on 23 March, which had produced sepsis and toxic shock by the time she was admitted to hospital.
The coroner said "signs of sepsis were apparent" before and at the time of Ms Dunn's hospital admission but she was instead treated as a Covid-19 patient.
"Sepsis was not recognised or treated by the GP surgery, emergency department or acute medical unit and upon Sarah's arrival at hospital, the sepsis pathway was not followed," she added.
Read full story
Source: BBC News, 19 May 2022
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Respiratory syncytial virus kills 100,000 under-fives every year

Respiratory syncytial virus is killing 100,000 children under the age of five every year worldwide, new figures reveal as experts say the global easing of coronavirus restrictions is causing a surge in cases.
RSV is the most common cause of acute lower respiratory infection in young children. It spreads easily via coughing and sneezing. There is no vaccine or specific treatment.
RSV-attributable acute lower respiratory infections led to more than 100,000 deaths of children under five in 2019, according to figures published in the Lancet. Of those, more than 45,000 were under six months old, the first-of-its-kind study found.
More children are likely to be affected by RSV in the future, experts believe, because masks and lockdowns have robbed children of natural immunity against a range of common viruses, including RSV.
“RSV is the predominant cause of acute lower respiratory infection in young children and our updated estimates reveal that children six months and younger are particularly vulnerable, especially with cases surging as Covid-19 restrictions are easing around the world,” said the study’s co-author, Harish Nair of the University of Edinburgh. “The majority of the young children born in the last two years have never been exposed to RSV (and therefore have no immunity against this virus).”
Read full story
Source: The Guardian, 19 May 2022
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The trusts making least progress in improving maternity services

The trusts that have made the most and least progress on urgent recommendations set out by the Ockenden review have been revealed
Published in December 2020, the interim Ockenden review set out 12 immediate and essential actions for all trusts with maternity provision, grouped into seven themes, and in its latest board papers NHS England has set out the progress they have made.
The actions which trusts are struggling with most include “risk assessment throughout pregnancy” and clearly describing pathways of care in written information and posted on the trust websites.
According to the data, Sheffield Teaching Hospitals Trust is the least compliant provider in England to date, as it is only fully compliant on one action.
Last summer Sheffield’s maternity service plunged to “inadequate” from “outstanding” following a Care Quality Commission inspection, with concerns raised about staffing numbers, training and a lack of an open culture.
Mid and South Essex Hospitals and York and Scarborough Teaching Hospitals were compliant on five actions each. MSE is rated “requires improvement” by the CQC for maternity care, whereas YSTH is “good”.
Read full story (paywalled)
Source: HSJ, 20 May 2022
 
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Obese adults set to outnumber those at healthy weight in UK within five years, report warns

Obese adults in Britain are on course to outnumber those who are a healthy weight within five years, a stark report has revealed.
Experts have warned there will be a “tipping point” in 2027 when one third of adults will be obese if current trends continue.
By 2040, they predict there will 21 million people classed as obese in the UK, and 19 million deemed to be overweight.
The analysis by Cancer Research UK shows seven in 10 (71%) people will be overweight or obese by 2040. Of this, almost four in 10 (36%) adults will be obese.
At present, 64% of adults are overweight or obese, with figures rising every year.
Being overweight or obese increases the risk of at least 13 different types of cancer and also causes other conditions such as high blood pressure and Type 2 diabetes.
The new data comes after former Conservative leader William Hague attacked the government for postponing a ban on “buy one get one free” deals for foods high in fat, salt and sugar for a year because of the cost-of-living crisis.
Read full story
Source: The Independent, 19 May 2022
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